The best surgery is that which can reconstruct what has been damaged, without affecting what is still healthy.

Natalia Gennaro, expert gynecologist, specialised in laparoscopic surgery and the pelvic floor.

Types of surgery

There are two major recognised classifications of pelvic organ prolapse surgery.

Reconstructive surgery aims to restore or reconstruct the pelvic floor to its original position. Some procedures are performed through vaginal route and others through abdominal laparoscopic route. The most important step for defining the best surgery is the analysis of the pelvic floor’s condition.

Obliterative surgery  consists of closing the vagina and stitching the vaginal walls in place in order to support the prolapse. With this type of surgery, sex is not possible. This surgery is used for severe cases of prolapse seen in very old patients who can’t tolerate a pessary or major surgery.

What types of reconstructive surgery are there?

Before mentioning the various types of surgery, it’s important to know that the patient shouldn’t only deal with the bulge that appears through the vagina. Common belief is that this is the only issue. The patient must undergo a profound analysis of the entire pelvic floor structure and its injuries, both obvious and not obvious, anatomical and functional, in order to be prescribed the best surgery.

There are, of course, simple cases that only require a simple surgical procedure, but prolapse is often a complex condition and in many cases, the damage is underestimated.

Modern reconstructive surgery is based on:

• Exhaustive knowledge of the anatomy and function of each pelvic floor structure.

• This allows us to give a better anatomical and functional diagnosis and therefore choose the best possible treatment.

•  Ensure minimal amount of damage to the healthy tissue and the smallest insertion of prosthetic material possible for the best anatomic and functional restoration.

When the structures that support the vagina (rear of vagina, cervix, uterus and/or vaginal vault) elongate, these structure fall and protrude out of the vulva. We call this apical prolapse and can be approached either vaginally or laparoscopically.

In many cases, a complete vaginal hysterectomy is considered unnecessary. The main complication with this procedure is the loss of cushioning against abdominal pressure that falls on the cervix and the consequent lack of force transmission on the endopelvic fascia, whose main function is muscular activation, along with weakness produced by the section of fibrous tissue, nerves and vessels of the apical end, that can, on occasions, produce iatrogenic bladder dysfunctions.

Although vaginal hysterectomies are used for this treatment, due to the fact that apical reconstruction through vaginal route is very simple without the uterus, it’s not always the best approach.

Natalia Gennaro, expert gynecologist, specialised in laparoscopic surgery and the pelvic floor.

 

For apical reconstruction (reconstruction of the bottom of vagina), the following can be done:

  • Uterosacral ligament plication with or without a vaginal hysterectomy.
  • Apical fixation to sacrospinous ligaments with or without uterus.
  • Insertion of apical sling with or without uterus through the vagina.
  • Apical laparoscopic fixation with or without uterus or with a subtotal hysterectomy to the unilateral or bilateral sacral.

 

 

I am a pioneer in the introduction of minimally invasive and maximum reconstruction techniques in Spain, such as apical sling procedures via the vaginal route and all unilateral and bilateral colposacral suspension procedures via laparoscopy.

There is a wide range of procedures for apical fixation, but it’s recognised that:

 

Apical injuries are often underestimated and their treatment is not only the most complex of procedures, but also the most important, as it gives support to the rest of the pelvic floor compartments.

The laparoscopic route is the most adequate way to maintain a high quality of life, with more improvement seen regarding the anatomic and functional treatment of prolapse.

To reconstruct the vaginal walls, the following can be done:

When the anterior walls of the vagina (the ones that separate the vagina from the bladder) and/or the posterior walls (the ones that separate the rectum/intestines from the vagina) elongate and form bulges that protrude from the vulva, we call this cystocele, rectocele or rectoenterocele. These can be approached via the vaginal route (reconstruction with tissue and, occasionally, the insertion of a vaginal sling) or via laparoscopy, where it can be treated with stitches and, occasionally, prosthetic material.

For cystocele surgery, the following can be done:

  • Anterior-central vaginal repair with intramucosal sutures.
  • Anterior paravaginal repair with intramucosal sutures.
  • Vaginal sling insertion with intramucosal sutures.
  • Correction of laparoscopic anterior or paravaginal defect with or without mesh.

To treat rectocele, enterocele or rectoenterocele,
there exist the following options:

  • Posterior vaginoplasty with specific defect repair.
  • Insertion of vaginal sling.
  • Correction of laparoscopic defect with or without mesh.
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