About 50% of women will develop pelvic organ prolapse (POP), a condition whereby internal organs are no longer held in position by the pelvic muscles and tendons. Women who have had at least one vaginal birth, are obese, or belong to the Caucasian ethnic group are most at risk of developing this condition.
A new procedure to correct severe cases of POP can now be done in South Africa, with gynaecologist Dr Paul Blaauwhof having successfully performed the country’s first laparoscopic pectopexy operation at Netcare Rosebank Hospital in Johannesburg recently.
“Many women do not realise that they have a prolapse and in many cases doctors only diagnose it during an examination,” Blaauwhof explains. “For women who have severe POP, on the other hand, there may be some anxiety and embarrassment about the physical symptoms. Often women do not complain about the discomfort that accompanies the condition and, for various reasons, delay seeking treatment.”
POP is a condition where the internal pelvic organs of a woman descend from their usual positions in the body. In severe cases, a bulge may be felt inside the vagina or the organs may descend to protrude from the vagina.
Women who experience POP may have a predisposition to urinary tract infections because of residual urine remaining in the bladder. Other symptoms include a feeling of pressure or fullness in the pelvic area, pain during sexual intercourse, lower backache and a sensation of heaviness or pulling associated with organs sagging into, or out through the vagina.
The standard procedure to correct severe POP is known as sacral colpopexy, in which a piece of mesh – known as a sling – is used to secure the organs inside the pelvic bowl, attaching it to the back of the pelvis on the sacrum, which is part of the lower spine. Over the sacrum run major blood vessels and nerves, which are important for normal bowel and bladder function, therefore surgery on this part of the body can incur risks, particularly in obese patients, as operating space is limited.
The pectopexy procedure performed by Blaauwhof involved an intra-abdominal mesh, which is made of polyvinylidene fluoride (PVDF), being sutured to the stump of the uterus, which had been partially removed, in order to support the internal organs.
“The sacrum and lower spine is avoided completely, as the pectineal ligament on the sidewall of the pelvis is used for the suspension of the prolapsed uterus stump. Alternatively, the top of the vagina can also be used for suspension in patients who have had a hysterectomy. In this way, all complications associated with surgery on the sacrum are avoided by the pectopexy procedure.”
“A further benefit of the pectopexy procedure over the sacral colpopexy is that it is more anatomically natural in that it occupies less space internally, as the mesh is not traversing the entire pelvis from front to back. Instead, the mesh stays in the front of the pelvis, suspending the prolapsed organs like a hammock. The pectopexy can be combined with bladder prolapse repair without the use of mesh, thereby avoiding the potential complications associated with mesh. With sacropexy on the other hand, mesh is standardly used for bladder prolapse repair,” Blaauwhof explains.
According to Blaauwhof, an ongoing randomised prospective European trial, conducted by Dr Karl-Günter Noé, comparing the two procedures when performed by experts, found that the pectopexy is associated with reduced chance of bowel dysfunction and vaginal side wall prolapse recurrence. All other parameters tested were comparable for both procedures.
“Although it is premature to conclude that pectopexy should be considered routinely instead of sacral colpopexy, as more studies are needed it is at least for now a very valuable addition to surgical treatment options for patients with severe POP,” Blaauwhof observes.
“The position and degree of the prolapse, obesity and whether the patient wishes to have more children are all factors that need consideration when choosing which of these two procedures is most appropriate in any given case. For example, if the woman still wants to have children the pectopexy procedure cannot be performed, however most patients in need of this kind of surgery are past childbearing age.”
This is because the condition often affects women during or after menopause, when there is a drop in oestrogen levels, which can have an effect on the tissue quality. It may also arise as a result of weakened pelvic muscles, tendons and connecting tissue following vaginal childbirth. POP can also be a congenital condition, in other words a person may be born with it, Blaauwhof notes.
“I recently saw the first patient who underwent this surgery, for her last post-operative check-up. She reports that she is happy with the result. There were no complications and the procedure left the vagina unscarred,” Blaauwhof observes.
Women who have this surgery must avoid weight-bearing exercise and sexual intercourse for approximately six weeks while the area heals, but thereafter can resume normal activities.
“While there are advances in the surgical techniques available to treat this common condition, it is important to remember that surgery is a last resort. With early detection, and appropriate physiotherapy, it is often possible to prevent pelvic organ prolapse from getting to the stage where it needs to be surgically corrected,” he says.
“This highlights just one of the many reasons why it is imperative that women should have regular gynaecological check-ups,” Blaauwhof concluded.Netcare material