Enhanced surgical prolapse repair technique can stave off early menopause

Pelvic organ prolapse patients can now avoid hysterectomy  

Wednesday, June 28 2017

An enhanced technique in performing minimally invasive pectopexy surgery to correct severe pelvic organ prolapse without having to remove the uterus has shown excellent results in the first patient to have undergone the procedure in South Africa.

“We recently performed the new procedure at Netcare Garden City Hospital, and I have heard that our patient, who is in her 40s, is doing very well. As there was no medical need to remove her uterus, we elected to perform the first pectopexy operation without an accompanying hysterectomy in South Africa,” says Dr Paul Blaauwhof, a gynaecologist who practises at Netcare Rosebank and Netcare Garden City hospitals.

Pic: Dr Paul Blaauwhof, a gynaecologist who practises at Netcare Rosebank and Netcare Garden City hospitals, recently performed South Africa's first pectopexy operation without an accompanying hysterectomy.

Pelvic organ prolapse (POP) is a condition whereby the internal pelvic organs of a woman descend from their usual positions in the body as a result of the pelvic muscles and tendons no longer holding the organs in position. In severe cases, a bulge may be felt inside the vagina or the organs may even descend to such an extent that they 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 the sagging organs.

Dr Blaauwhof performed the first pectopexy procedure in South Africa two years ago. A pectopexy involves a laparoscopic procedure for supporting the internal organs with the aid of an intra-abdominal mesh, which is made of polyvinylidene fluoride (PVDF).

A number of the pectopexies Dr Blaauwhof has performed involved the mesh being sutured to the stump of the uterus, which had been partially removed, in order to support the internal organs. With the new technique, however, the uterus can be completely preserved.

“Leaving the uterus intact is an option if there are no other foreseeable medical problems. We usually perform a pap smear beforehand, and if the result is normal it is possible, and often desirable, to preserve the uterus.

“Removal of the uterus can restrict blood flow to the ovaries, which can in turn compromise ovarian function and this may negatively impact hormone production – often resulting in earlier onset of menopause. With this enhanced pectopexy procedure, we are able to avoid this in patients who qualify for this option.

“In addition to less time under anaesthetic and reduced costs, this solution incurs less risk of surgical complications. For younger patients in particular, retaining the uterus means that their hormonal balance will usually not be affected,” Dr Blaauwhof explains.

POP can be caused by a number of factors, including vaginal birth, obesity, asthma, hormonal changes and genetic factors weakening the tissues holding the internal organs in place.

“It can be corrected by supporting the uterus and other organs with the pectopexy procedure. A hysterectomy is a major operation, and can be damaging to the support of the bladder. This may lead to a higher chance of recurrence of POP because the bladder and neighbouring uterus share supporting tissues.

“If a hysterectomy can be avoided, there may be significant advantages for the patient’s physiological and psychological wellbeing, particularly for women who have not yet been through ‘the change of life’.”

Menopause is often accompanied by hot flushes, night sweats, reduced libido, and discomfort during sexual intercourse. It can also result in long-term changes in muscle mass and bone density. Women experiencing sudden onset menopause, which can be triggered by a hysterectomy, often experience the symptoms more acutely.  
“Another benefit of the pectopexy procedure over the standard sacral colpopexy operation, in which a sling of mesh is used to secure the organs inside the pelvic bowl by attaching it to the back of the pelvis on the sacrum, is that less mesh is required.

“With pectopexy we can use a minimal amount of mesh, which can help to avoid erosion of surrounding tissues, and as we use a lateral repair technique we can avoid the sacrum, which is a complicated area to operate on due to the major blood vessels and nerves that run over it,” Dr Blaauwhof observes.

“Often in correcting POP surgically, we are dealing with a more complex issue than the uterus alone being prolapsed. Often the bladder and back passage are prolapsed, and all of these can be addressed in a single operation.

“Women will also appreciate the fact that there is no scarring of the vagina, as the pectopexy is performed laparoscopically, requiring small incisions in the belly button and on the panty line. It is usually not possible to reach all of the tendons when operating through the vagina, and the laparoscopic repair is more complete while incurring significantly less risk of infection.”

While approximately 50% of women will develop pelvic organ prolapse to some degree, surgical interventions are reserved for severe cases. Often the pelvic floor muscles can be strengthened with Kegel exercises in women experiencing less serious POP.

“Many women do not realise that they have a prolapse and in many cases doctors only diagnose it during an examination,” Dr 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.”

“Although it is premature to conclude that pectopexy should be considered routinely instead of sacral colpopexy, as more studies – particularly longitudinal studies – are needed, the technique is now a very valuable addition to surgical treatment options available for patients with severe POP,” Dr Blaauwhof observes.

“While most patients in need of this kind of surgery are past childbearing age, for those who have not gone into menopause the procedure will not hasten the onset thereof. It should be noted, however, that women who have the pectopexy operation should still avoid falling pregnant, as there could be complications.”

Women who undergo pectopexy must avoid weight-bearing exercise and sexual intercourse for approximately six weeks while the area heals, but thereafter can resume normal activities.

“Surgical repair of POP should only be a last resort. With early detection and appropriate physiotherapy it is often possible to prevent the condition from reaching a stage where it needs to be surgically corrected.

“The great advantage of this enhanced pectopexy technique is that an already minimally-invasive procedure can now be performed with greater surgical efficiency, not only preserving healthy functioning of the hormones involved in the reproductive system, but also improving and extending quality of life. This is particularly important for younger women,” Dr Blaauwhof concluded.

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Issued by:    Martina Nicholson Associates (MNA) on behalf of Netcare Garden City and Netcare Rosebank Hospitals
Contact    :    Martina Nicholson, Graeme Swinney, Meggan Saville or Pieter Rossouw
Telephone:    (011) 469 3016
Email:    [email protected], [email protected], [email protected] or [email protected]