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Bladder Surgery

Surgery for Prolapse

Vaginal Hysterectomy
Anterior Repair
Posterior Repair
Tension Free Vaginal Tape
General Information About Surgery

Vaginal Hysterectomy for “Fallen Uterus”

A vaginal hysterectomy with suspension of the “top” of the vagina is a surgery performed to the removal of the uterus. The ovaries do not need to be removed, but can be removed, if decided or if they are abnormal. This surgery is done in the event that the uterus has “dropped” and is causing symptoms such as pain or pressure or the feeling that “something is coming out,” which may or may not be associated with leaking of urine. The uterus must be removed in order to “put up” the vagina. Benefits of removing the uterus are that it should resolve the symptoms and permit “fixing” the leaking of urine (if you have leaking of the urine).

Alternatives to this procedure are Pessary use. A pessary is like a strong diaphragm. It fits in the vagina and can be left in for up to 4-6 weeks. The pessary can be removed as often as every night. It Holds Up the uterus, cervix and bladder without surgery. Some women like using a pessary because it fixes the symptoms (pain, pressure, leaking of urine) without surgery. Some women do not like the pessary, even if it works. No one likes a pessary that does not work.

Surgical Options for this surgery are that it can be done through the vagina OR through the abdomen. Recovering from vaginal surgery is quicker than recovering from abdominal surgery. The abdominal surgery usually relies upon a “mesh” to connect the vaginal walls to the sacrum (the large triangular bone at the base of the spine). The “mesh to bone” attachment is the strongest fix available, but it is not always necessary. The vaginal surgery connects the fallen vagina to the strongest ligaments of the pelvis. The vaginal surgery fixes symptoms for most women.

Limitations for this procedure are mainly that any tissue that falls can fall again. After the abdominal surgery, which uses mesh attached to bone, the vagina is LEAST likely to fall again. “Putting things up” with vaginal surgery relies upon re-attaching the vagina to ligaments with sutures that do not dissolve. The specifics ligaments used to “put up” the vagina are ultimately determined at the time of surgery, and are based upon specific findings at the time of surgery. Sometimes mesh or a “graft” is used.

Long Term Success of this operation is limited by the strength of the tissues. Nature can find a weak spot in the tissue to “push through.” Also, heavy lifting, straining, constant coughing and constipation with straining to have a bowel movement can ALL put the surgery at risk.


Anterior Repair to Put Up the Bladder

This anterior repair surgery is done to “put up” a dropped bladder. It is performed if the bladder has fallen AND it is causing symptoms such as pain, pressure, the feeling as if “something is coming out.” Benefits of this surgery are the relief of your symptoms.

Alternatives to this procedure are Pessary use. A pessary is like a strong diaphragm. It fits in the vagina and can be left in for up to 4-6 weeks. The pessary can be removed as often as every night. It Holds Up the uterus, cervix and bladder without surgery. Some women like using a pessary because it fixes the symptoms (pain, pressure, leaking of urine) without surgery. Some women do not like the pessary, even if it works. No one likes a pessary that does not work.

Limitations for this procedure are mainly that any tissue that falls can fall again. After the abdominal surgery, which uses mesh attached to bone, the vagina is LEAST likely to fall again. “Putting things up” with vaginal surgery relies upon re-attaching the vagina to ligaments with sutures that do not dissolve. The specifics ligaments used to “put up” the vagina are ultimately determined at the time of surgery, and are based upon specific findings at the time of surgery. Sometimes mesh or a “graft” is used.

Bladder Function After Surgery for some women are the inability to urinate on their own after this surgery. The bladder may “go on strike” while it is recovering from the surgery that moved things around. The inability to urinate is usually limited to one week. If you can not empty your bladder completely by the time you are discharged from the hospital you will go home with a catheter in your bladder AND a leg bag. The nurses will teach you how to care for yourself and the catheter. You will then come to the office approximately 5-7 days after surgery to have the catheter removed. We will make sure you can completely empty your bladder at that time.

Activity should be limited with NO STRAINING for 8 weeks. This means no lifting anything heavier than a gallon of milk for 8 weeks. You must not strain. This may mean taking medicine to keep your bowel movements soft as well. This is ESSENTIAL to the success of the surgery.


Posterior Repair for Fixing the Rectum

A Posterior Repair surgery is performed to put back a bulging rectum at the bottom of the vagina. This is a solution for when the rectum is “pushing up,” especially when having a bowel movement AND it is causing symptoms such as pain, pressure, the feeling as if “something is coming out.” Also, many women have to “push down” on the bulging tissue in order to actually “finish” the bowel movement.

Alternatives to surgery are few for “fixing” the problem without surgery. One could “live with it,” and simply push down on the vagina when it is time to have a bowel movement. Pessaries are generally Less Effective at fixing the rectum than they are at fixing the bladder. Kegel exercises do not help much in patients with a significant posterior defect.

Limitations for this procedure are that the “cause” of the prolapsed rectum is weak tissue. We use permanent stitches to “put back together” the defect in the tissue. Unfortunately, it is possible for the “fixed tissue” to weaken again. Sometimes it is necessary to use something to bridge the opening of the weakened tissue. There are many types of graft material available, including fabrics, meshes AND porcine tissue. Sometimes we can not be sure what will be necessary until we are actually doing the surgery.

Constipation should be avoided. You must not strain to have a bowel movement during the recovery time from this surgery, or after. Extra straining can  risk undoing the surgical fix. Docusate Sodium 100 mg twice each day is useful for keeping your stools soft.  If twice a day pills make the stools too soft, use it once per day.

Pain should be considered as recovery from this surgery to the rectum is quite painful. The post surgery pain of this surgery is considerably MORE than the same surgery done to the bladder.

Activity should be limited and consist of NO STRAINING for 8 weeks. This means no lifting anything heavier than a gallon of milk for 8 weeks. You must not strain. This may mean taking medicine to keep your bowel movements soft.  This is ESSENTIAL to the success of the surgery.


TVT to Prevent & Treat Leaking Urine

The TVT (tension free vaginal tape) is the placement of a sling or hammock under the urethra to lift it up. There is a small incision in the vagina AND two very small incisions just above your pubic bone in the middle. The primary goal for this procedure is to fix leaking of urine because the urethra has “fallen.”  As well as to prevent leaking of urine in conjunction with surgery to “put up” the vagina (hysterectomy to fix a fallen uterus, or surgery to fix a fallen vagina. The benefits of this surgery are the prevention of leaking urine while coughing and sneezing and lifting and straining. This leaking can begin after surgery for a “fallen uterus.”

Alternatives to this surgery can include 1) “living with” the leaking and/or do Kegel exercises to strengthen the pelvic muscles; 2) timed voiding – reduce the amount of leaking by drinking less AND emptying the bladder on a set schedule; 3) Pessary use – there is a special pessary designed to HOLD UP the urethra, to decrease or prevent leaking of urine.

There are no medicines currently on the market which reliably help leaking. Kegel exercises help, but may not be enough if the urethra is fallen.

Surgical Options include a number of different surgeries to “put up” the urethra. The medical phrase to describe this surgery is “urethropexy,” which literally means to hold up the urethra. The operations done for this purpose, over time, have included:

  1. Different “approaches,” either through the vagina or the abdomen or the belly-button (laparoscopy).
  2. Different “holders,” either stitches, or slings (like a hammock), or a combination of stitch and sling.
  3. The slings vary in material:  fabrics and mesh material, like gore-tex and polyester; as well as tissue (fascia) from one’s own body.

The final choice of which surgery AND which material depends upon BOTH the success rates found in the published literature and the specifics of the individual patient. The TVT appears to combine the best success rates with the least invasive, with few material-based complications.

Limitations to this surgery can include:

  1. Re-learning to urinate: The sling works by Holding In the urine when you strain or push. Many patients have to learn to relax to urinate, because pushing to urinate will NOT work well.
  2. Success in fixing the leaking: The literature suggests that 90% of women are “cured” with this surgery.
  3. Medium/Long term bladder function: Some women have a NEW problem after this surgery called overactive bladder. This condition is also known as Detrusor Instability. It is a nerve problem of the bladder, and usually responds to a medication which can relax the bladder.  [medications:  Detrol and Ditropan]
  4. Can not urinate on your own, six weeks later: As many as 1/20 women have a real problem emptying their bladder, even SIX WEEKS after surgery. In most of these cases the sling is working too well, and instead of just preventing leaking it is preventing urinating. The fix for this problem is to cut or remove the TVT, which is another smaller operation, with quicker recovery. This sling revision fixes 2/3 of women with this problem, allowing them to urinate normally. The other 1/3 women may actually leak again, however this is Rare.

General Information About Surgery

Type of Anesthesia: Our surgeries are done in the hospital and the most common type of anesthesia used during is a general anesthesia, which will result in you going all the way to sleep.

Risks of Surgery: The following information is very detailed, and is simply meant to be complete. All surgery has the risk of bleeding, infection and damage to internal organs. Anything that is damaged during the procedure will be fixed either by the doctor performing the operation, or by a specialist, if necessary. This is rare. Complications can extend the time you need to stay in the hospital OR slow your recovery.

Typical Time in Hospital: Recovery is usually 1-2 days after the vaginal surgery, and 2-3 days after abdominal surgery for most women. By the time you go home you are taking pills for pain, and you can take care of yourself: eat, walk, get out of bed, shower, go up and down the stairs, and do other things necessary to go about your daily life.

Bladder function after surgery: Bladder function is different for everyone. Some women are NOT able to urinate on their own after this surgery. The bladder may go on strike while it is recovering from the surgery that “moved things around.” The inability to urinate is usually limited to one week. If you can not empty your bladder completely by the time it is time for discharge from the hospital you will go home with a catheter in your bladder AND a leg bag. The nurses will teach you how to care for yourself and the catheter. You will then come to the office approximately 5-7 days after surgery to have the catheter removed. We will make sure you can completely empty your bladder at that time.

Activity: Activity should be limited and consist of NO STRAINING for 8 weeks. This means no lifting anything heavier than a gallon of milk for 8 weeks. You must not strain. This may mean taking medicine to keep your bowel movements soft.  This is ESSENTIAL to the success of the surgery.

Typical Recovery Time: This varies by person but is marked more by fatigue than pain. You may be tired for 4-6 weeks after the surgery: This usually means you find yourself needing a nap at 2-3 pm each day.

Back to Regular Activity/Work: For most patients is around 6-8 weeks. Paperwork for an employer will say “back to work” 6 weeks after surgery.  If you feel ready to return to work earlier we can write you a letter OR modify/re-do the paperwork.