Prolapse Surgery in NYC

Female pelvic organ prolapse (POP) is the protrusion of the pelvic organs into or out of the vaginal canal. The patient typically notices a mass or a protrusion from the vagina. Some patients with prolapse may be symptom- free, but others may experience pelvic pressure, backache, urinary incontinence, urinary retention, sexual dysfunction, and difficulty with bowel movements.

Surgery for Prolapse in New York City

Surgery for prolapse becomes necessary if the use of pessary or conservative measures fails. The goal of surgery is to reduce the prolapse and in many cases restore normal anatomy and function. Many types of procedures are available, each addressing a specific prolapse condition.
We do not use synthetic mesh for our prolapse repair unless absolutely necessary, such as in the case of severe recurrent prolapse. The synthetic mesh, if needed, will be placed laparoscopically or robotically, never vaginally.

  • Uterine prolapse:  The treatment of choice is the laparoscopic uterine suspension. No hysterectomy is necessary unless uterine pathology is detected. Laparoscopic uterine suspension is usually performed in conjunction with a vaginal vault suspension -- this procedure attaches the apex of the vagina to strong ligaments toward the back of pelvis to support the vagina. The surgery is a quick and relatively simple procedure with a short recovery time. For severe uterine prolapse, laparoscopic or robotic sacro-utero-colpopexy can be performed using synthetic mesh.
  • Vaginal prolapse: Vaginal vault suspension, a technique attaching the apex of the vagina to ligaments toward the back of the pelvis to support the vagina, is a very quick and effective procedure. For severe recurrent vaginal prolapse, laparoscopic or robotic sacro-colpopexy maybe performed using synthetic mesh.
  • Cystocele: Three different types of cystoceles exist.

    1. Paravaginal defect cystoceles account for 80-85% of all cystoceles.
    2. Transverse defect cystoceles account for 10–15% of all cystoceles.
    3. Midline defect cystoceles represent 5% of cystoceles.
    The midline defect cystocele is primarily treated by anterior colporrhaphy (bladder tack done through the vagina). The paravaginal defect and the transverse defect type of cystocele can be more effectively repaired and with excellent outcomes when performed laparoscopically by an experienced laparoscopic surgeon. No synthetic mesh is necessary for cystocele repair
  • Rectocele: A posterior colporrhaphy procedure repairs or closes the defect in the strong tissue overlying the rectum. A new surgical technique that uses principles of site-specific defect repair has evolved with less discomfort for the patient and better long-term results.
  • Enterocele: An enterocele repair procedure closes the defect in the strong tissue on the top of the vaginal wall and restores the integrity of the fibromuscular structure of the vagina. Enterocele repair enjoys better long-term successful outcomes when performed laparoscopically because of enhanced visibility.

In 1991, Dr. Liu pioneered the laparoscopic Burch Colposuspension for the treatment of urinary stress incontinence and, in the following year, the laparoscopic utero and vaginal suspension for utero/vaginal prolapses by using uterosacral ligaments at the level of the ischial spine. Also to his credit are the innovative laparoscopic repair of enteroceles and the laparoscopic paravaginal suspension for the repair of cystoceles. Dr. Liu is frequently called upon by other physicians to rectify complications from their own prolapse/incontinence surgeries and/or to reconstruct previously failed surgeries.
Holding the world record for performing one of the highest numbers of laparoscopic surgeries for female pelvic organ prolapse, Dr Liu is in great demand for lecturing and performing live surgeries at major national and international medical conferences (see Dr.Liu’s CV). This ensures the dissemination of his female organ prolapse surgical techniques to other surgeons worldwide.

Photos of Different Types of Prolapse

Prolapse Surgery - Frequently Asked Questions

Q: In order to have a more successful repair of my uterine prolapse, is it necessary for me to have a hysterectomy performed at the same time as my repair surgery?

Answer: A hysterectomy at the same time of prolapse repair surgery has no impact on the outcome of repair surgery, because the uterus plays no role of pelvic floor support. The two supporting systems for the female pelvic floor are the active support of the levator ani muscles and the passive support of the pelvic endopelvic fascia (cardinal and utero-sacral ligaments, pubocervical fascia, rectovaginal septum, uro-genital diaphragm and perineal body). 

The reason that many gynecologists to recommend a hysterectomy at the same time of vaginal repair surgery for prolapse is that the normal position of the uterus usually interferes with the visibility of the repair work.  However, we do not routinely recommend a hysterectomy concurrent withlaparoscopic/robotic  prolapse repair surgery except when there is concomitant uterine pathology or the patient desires to have her uterus removed.

Q: What are the advantages of laparoscopic surgery for female organ prolapse?

Answer: There are numerous advantages of having a laparoscopic repair surgery for pelvic organ prolapse. A few of the many advantages include the following:

Laparoscopy provides a superb magnified view of the pelvic floor and its supporting defects through a very sophisticated video camera and high resolution monitor.  The good visualization leads to much more precise and complete suture placements to repair the defects. 

Unlike the traditional vaginal approach to repair the prolapse, the laparoscopic approach permits the surgeon to not only see the supporting defects well, but to also feel the defects by performing a vaginal examination under direct laparoscopic view before, during and after the repair.  This permits the surgeon to place the sutures precisely and effectively. With the traditional vaginal repair surgery for prolapse, the surgeon is almost totally dependent upon tactile feeling to guide the surgery which unfortunately can result in either over-repair or under-repair of the defects.

Photos of the surgery can be taken or the entire surgery can be videotaped for future reference and for the patient to see the actual surgery later. The patient is visually well informed by what was wrong with her pelvic floor before surgery, how the repair surgery was performed, and how her pelvis appears at end of surgery.

The minimally invasive nature of laparoscopic surgery results in greatly reduced the postoperative pain and discomfort and shortened hospitalization and recovery period.

Q: What about the robotic surgery for female organ prolapse?

First of all, we need to demystify the mystic surrounding robotic surgery. To better understand the recent hype surrounding robotic surgery, one needs to realize that only one company manufactures surgical robots and consequently markets its product heavily. Robots and various lasers are merely surgical tools, no more so than a scalpel or any other surgical instrument. The most important factor is a knowledgeable, competent, and experienced surgeon. A robot or the most expensive laser in the hands of an unskilled or inexperienced surgeon will have disastrous outcomes.

Any surgical instrument has its advantages and disadvantages, and the robot is no exception.  The greatest advantage of using robot to do surgery is that it provides a 3- dimensional view of the surgical field, and it also enables the surgeon to perform long distant surgery. Robotic surgery was initially developed by the military for use on the battlefield to eliminate long distance transportation of severely wounded soldiers. This advantage of performing distant surgery has also become a disadvantage. During robotic surgery, the surgeon is sitting in a console apart from patient and therefore loses all tactile feeling of the surgery. Tactile feeling of tissue strength is extremely important for successful repair of female organ prolapse.  Therefore, I do not routinely recommend robotic surgery for prolapse except for a sacro-colpopexy with synthetic mesh which replaces the weak part of native tissue.
With the current sophistication of technology, including the camera and high definition, high resolution TV monitors, the advantage of a robotic 3-D view over the traditional laparoscopy is no longer so important. The surgeon’s ability for tactile feeling of the defects of the pelvic floor and the strength of the tissues to be repaired is of paramount importance for a successful surgery. Additionally, continued tactile feeling in pelvic examination by the surgeon before and after suture placements is one of the key factor for the good long term result of the surgery.

Q: What are the disadvantages of laparoscopic repair for female organ prolapses?

In addition to the extensive knowledge of the functional anatomy and the pathophysiology of the female pelvic floor supporting system, the surgeon must possess  advanced laparoscopic surgical skills with proficient laparoscopic suturing ability. The learning curve for the surgeon is steep and, unfortunately, very few surgeons in the country meet this requirement.  Without advanced surgical skills and experience, the outcomes of the laparoscopic surgical repair for prolapse are less than desirable. Always ask your surgeon the number of cases he/she has performed and the long-term results of these cases before you commit yourself for surgery.

My own extensive experience in laparoscopic surgery for female organ prolapse over the past 22 years with outstanding results convinces me of the importance of the surgeon’s knowledge of the anatomy and pathophysiology of genital prolapse and his/her advanced laparoscopic surgical skills.

Q: Can prolapse reoccur after surgery?    

Even with increased understanding of the functional anatomy and pathophysiology of the pelvic floor supporting system and with advances in surgical techniques, challenges yet remain. One of the challenges is the improvement of the quality of inherently weakened fascial tissue within the pelvic floor supporting system. Another challenge is for patients to learn how to effectively avoid conditions causing increased pelvic pressure. 

The two basic supporting systems of the pelvic floor are 1) the active supporting system from levator ani muscles, and 2) the passive supporting system from endopelvic fascia. Prolapse is the result of breakdown of both active and passive supports of the pelvis.  Surgery can only restore the integrity of endopelvic fascia, but not the levator ani muscle.  The dysfunction of levator ani muscle is the result of injured pudendal nerves that innervate the muscle. These nerves can be damaged during childbirth, especially with prolonged second stage of labor or difficult forceps delivery. These nerves can also be damaged in conditions such as chronic constipation, chronic respiratory problems such as asthma, emphysema, and other problems causing chronic coughing, and chronic heavy lifting. Dysfunctional levator ani muscles eventually result in prolapse of pelvic organs. 

With current surgical technology, the pelvic floor can be restored to its normal anatomic position by repairing defects in the endopelvic fascia. However, some prolapses may still reoccur after the repair surgery for the following reasons: 1) Injured pudendal nerves that control the levator ani muscles of the pelvis cannot be rejuvenated. No matter how well the endopelvic fascia and other supporting structures are repaired, if the nerves are unable to carry the signals from the brain to the muscles, the muscles will not work properly. 2) Some women are born with weak supporting tissue. If the endopelvic fascia is inherently weak, no amount of repair work will prevent it from falling again. With aging, the quality and strength of the supporting tissues naturally weaken. 3) If the medical conditions that caused chronic elevation of pelvic pressure in the first place cannot be corrected, then the repair may not be sustained. Hence, some women undergoing repair for their prolapses may require additional surgery later in their life. 

No long-term outcomes of any surgery can be guaranteed. But we have found that a well done surgery by a proficient, experienced laparoscopic surgeon who has repaired all defects, coupled with meticulous postoperative care and life style changes such as the avoidance of constipation and heavy lifting and the practice of pelvic muscle exercise, the majority of our patients do enjoy long-term results with satisfaction.

Q: What about using synthetic mesh for the repair of female organ prolapse?

On July 13, 2011, the FDA issued a safety communication and update to inform patients and health care providers that “serious complications associated with surgical mesh for transvaginal repair of pelvic organ prolapse are not rare.”

Mesh used in pelvic organ prolapse is made of synthetic, non-absorbable  material, which means it will stay in the body permanently.  Mesh is a “foreign body” to which our bodies will have reaction. Our reactions to the mesh could be mild or strong, depending on our constitutions (genetic make up) and the environment around the mesh such as the degree of surgical trauma to the surrounding tissue and the presence of blood and bacteria. In addition to the surgical risk of injuring the organs near the mesh placement, side effects or complications of mesh include infection (foreign body reaction plus tissue trauma plus presence of blood and bacteria), mesh rejection, exposure, contraction, erosion, and extrusion.  The patient may exhibit clinical manifestations of pain, urinary and defecatory dysfunction, bloody or purulent mal-odored discharge, and painful sexual intercourse. The patient may require additional surgery to remove the mesh and repair the prolapse again. The following statement was recently issued by the American College of Obstetricians and Gynecologists. 

Unfortunately, some women will continue having pain even after corrective surgery because complete removal of the mesh may not be possible. For this reason, it’s important to understand that, in many cases, POP can be successfully treated without mesh and women and their doctors really need to weigh the risks and benefits before deciding on a course of action.

Although studies suggest benefit from the use of synthetic vaginal mesh for anterior compartment prolapse, data are limited on the use of mesh for posterior and apical prolapse when compared with native tissue repair. The benefits of a more durable repair must be weighed against risks such as the development of de-novo stress incontinence, visceral injury, dyspareunia, pelvic pain and mesh contraction, exposure and extrusion requiring reoperation. Furthermore, the success rates of native tissue repairs are higher than previously considered using updated validated composite outcomes that incorporate both subjective relief of bulge and objective cure defined as prolapse above the hymenal ring.

However, some cases may require mesh repair for female organ prolapse. This includes cases such as procidentia in which the native supporting fascia (endopelvic fascia) is so deteriorated that no more tensile strength is left in those fascia and the organ protrudes out of opening of the vagina (see photo), or recurrent severe prolapse after previous reparative surgery that the native fascia is tensely scarred.  Only in these two extreme conditions would I use mesh repair.

Q: Isn’t sacro-colpopexy the most popular surgery for POP? And, doesn’t this surgery requires the use of synthetic mesh?

Yes, abdominal, robotic, or laparoscopic sacro-colpopexy is the most popular surgery for POP and it requires the use of permanent synthetic mesh.  In view of the possible severe adverse effects of mesh, I reserve sacro-colpopexy for the procidentia and severe recurrent prolapses after previous failed repair surgery.  I have developed laparoscopic repair of POP by using deep uterosacral ligaments at the level of ischial spine with permanent sutures.  I have been doing this surgery for the past 22 years with excellent results.   

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