From the earlier sections on Assessment and Main Diagnoses, there may be abnormal descent down the vagina of the:
- Uterus (Uterine prolapse)
- Bladder (Anterior vaginal wall prolapse or cystocele)
- Rectum (Posterior vaginal wall prolapse or rectocoele)
- Vaginal vault (Apical vaginal prolapse or enterocoele)
Surgery Is Generally Required If:
- There are Symptoms of discomfort due to the prolapse.
- Prolapse has descended to or through the vaginal entrance.
- Bladder conditions such as urinary incontinence or voiding dysfunction cannot be effectively treated without prolapse surgery.
It is most common for more than one type of prolapse to be present. In the following discussion of the four or five different types of repairs, it is common for all four to be necessary to achieve an effective prolapse cure. Professor Haylen adopts a vaginal approach for most of his prolapse surgery. This requires no external incisions.
1. Uterine Prolapse:
a) Vaginal hysterectomy:
Most women will react with surprise and concern when this is suggested. It does mean the removal of the uterus and cervix but not the ovaries, so no hormonal changes are involved.
The uterus is often the main part of the prolapse and drags the vaginal walls down with it.
Effective cure of the prolapse may be much more difficult without vaginal hysterectomy. Most women will notice no change after vaginal hysterectomy apart from the relief of prolapse symptoms and cessation of periods for women undergoing hysterectomy prior to menopause.
b) Manchester Repair:
This is occasionally performed for women in their thirties, with severe uterine prolapse, unsure of whether they will have further children. It requires the partial amputation of the lower part of the uterus (cervix), shortening of the uterine support ligaments (uterosacral) and other repairs.
The use of the Manchester repair, as a uterine preservation prolapse surgery, has now largely been replaced by uterosacral ligament surgery, performed in conjunction with an anterior vaginal repair, and without the need for partial amputation of the cervix.
c) Abdominal Hysterectomy:
In cases of prolapse of a large fibroid uterus, an abdominal approach to the hysterectomy can occasionally be required. Sometimes this will be associated with an abdominal continence procedure (colposuspension).
2: Anterior Vaginal Repair:
This procedure, normally performed with other repairs, addresses bladder prolapse (anterior vaginal wall prolapse or cystocele). The front vaginal wall is opened, the bladder is pushed back in a 2 or 3 layer repair and the stretched vaginal wall is reduced to normal size.
Relief of prolapse symptoms and improved bladder emptying generally follow this repair.
3: Posterior Vaginal Repair:
Traditionally, the posterior vaginal repair has been performed in a similar fashion to the anterior vaginal repair. The back vaginal wall is opened, the rectum is pushed back in a 2 or 3 layer repair and the stretched vaginal wall is reduced to normal size.
Prof Haylen has introduced posterior repair quantification (PR-Q) or taking measurements to determine where the anatomical weaknesses are found. Surgery can then be appropriate to the weaknesses found. These measurements, known as Key Anatomical Indicators (KAI) look at the vaginal entrance (introitus – KAI 1 – Perineal Gap); vaginal vault (top of the vagina – KAI 2 – posterior vaginal vault descent); mid-vaginal skin laxity – KAI 3 – mid-vaginal laxity; mid-vaginal fascial laxity – KAI 4 – recto-vaginal facial laxity.
These measurements are made at the time of surgery and do involve some traction on the tissues in and around the vagina. The measurements allow for surgical precision and the creation of a consistently extremely satisfactory surgical result.
Prof Haylen research has indicated that the biggest weakness is at the vaginal vault (mean KAI 2 of 6.0cm). this will require much more use of sacrospinous ligamentous (hitch) support to the vault (see section 4). The second main weakness is at the vaginal introitus (mean KAI 1 of 3.0cm). This area, which in 88% of cases involves thinned out and microscopically abnormal tissue (scarring, inflammation) is removed and refashioned with healthy normal tissue, providing comfort, extra support and a much improved cosmetic result.
Contrary to traditional theory, the mid-vaginal weaknesses were quite small (mean KAI 3 – 1.3cm, mean KAI 4 – 1.0cm). This means less dissection and repair is necessary for this area.
- Perineal gap (prior to excision);
- Perineal gap (after excision);
- Reconstituted perineum.
These KAI are illustrated below:
KAI 1: Perineal Gap (PG) – Thinned out media area of the anterior perineum.
KAI 2: Posterior Vaginal Vault descent (PVVD): Measurement bottom figure subtracted from measurement top figure.
KAI 3: Mid-vaginal laxity: Laxity of the mid-vaginal skin.
KAI 4: Recto-vaginal fascial laxity: Laxity of the mid-vaginal fascia.
4: Sacrospinous Colpopexy (Hitch – Picture below):
This procedure is performed when vaginal vault support is lost. As Prof Haylen’s research in Section 3 has shown, this can occur far more often than previously believed. Around 80% posterior vaginal repairs will need an accompanying sacrospinous colpopexy. Vaginal vault prolapse can occur in the longer term after hysterectomy or previous prolapse surgery. A successful overall prolapse repair is unlikely unless this area of weakness (if present) is repaired.
The sacrospinous colpopexy (hitch) attaches the top (vault) of the vagina to the strong sacrospinous ligaments on the sidewall of the pelvis using one or two permanent sutures.
Sacral (period-like) backache due to vaginal vault prolapse as well as the obvious lump from a larger prolapse, will be relieved by this procedure.
Prof Haylen uses minimally invasive techniques including the Capio device (Boston Scientific) to facilitate suture placement and reduces tissue trauma.
Appropriate retraction aids SSL suture placement.
5: Uterosacral Ligament Surgery:
With anatomists Dzung Vu and Kelly Tse, Prof Haylen has re-mapped the anatomy of the key supports of the uterus and vaginal vault, the uterosacral ligament (Reference 66) and the cardinal ligament (Reference 71).
This knowledge has been applied to the safe use of the uterosacral ligaments outside the abdominal cavity (extraperitoneal) to provide vaginal vault support. Prof Haylen has also developed the Midline Uterosacral Plication Anterior Colporrhaphy Combo (MUSPACC Procedure – reference 72). This procedure strengthens the anterior vaginal repair by the addition of vaginal vault support using the uterosacral ligaments.
6: Surgery Using Mesh for Recurrent Prolapse:
Prof Haylen does not use mesh for prolapse surgeries. He is confident in the use of the patient’s own (native) tissues using the measurement and surgical techniques he has developed. These give consistent and reliable anatomical results as weaknesses (“defects”) are measured and corrected at the time of surgery.
Prof Haylen has seen (for over 14 years) many patients with problems from prior mesh insertion. Symptoms include pain, mesh exposure, bleeding and discharges. In a high percentage of these women, there is a recurrence of the original or a new prolapse problem. He is confident in being able to manage these issues as well as restoring vaginal anatomy and function in most cases. He understands that women with these complications have, at times, have suffered long term physical and emotional distress.
7: Vaginal Mesh Removal:
Prof Haylen has an extensive experience (over 14 years) in removing vaginal mesh. He welcomes new patients who have incurred complications from vaginal mesh surgery.