Pelvic Floor Surgery
What is vaginal hysterectomy?
Vaginal hysterectomy is an alternative surgical procedure to abdominal hysterectomy. In this procedure, the uterus is removed through the vagina rather than through the incision in the abdomen.
What are the advantages of the vaginal hysterectomy over abdominal hysterectomy?
Recovery in vaginal hysterectomy is much faster than abdominal hysterectomy. You may be discharged from the hospital in a day or two and you can return to your daily activities within a few weeks after the surgery.
Who are the good candidates for vaginal hysterectomy?
Individuals with the following conditions and those who don’t have enlarged uterus are considered as eligible candidates for vaginal hysterectomy,
Uterine prolapse: It is the protrusion of the uterus from the pelvic cavity into the vaginal canal due to weakening of the muscles and connective tissues that hold the uterus in place. It is often seen in women who had one or more vaginal births.
Endometriosis: It is abnormal growth of endometrium, the membrane lining the uterus, on surfaces of other organs in the pelvis such as ovaries, fallopian tubes, outer surface of the uterus, pelvic cavity lining, vagina, cervix, vulva, bladder or rectum.
Cervical dysplasia: It is the premalignant condition of the cells lining the cervix.
Uterine fibroids: They are the non-cancerous growths in the uterus. If the fibroids are large, abdominal hysterectomy is required.
How is vaginal hysterectomy performed?
You may be given general or regional anaesthesia. An incision is made in the vagina and the uterus is removed through it. The incision in the vagina is then closed with absorbable stitches.
What are the risks of the vaginal hysterectomy?
Vaginal hysterectomy is generally safe. Complications may include infection, blood loss, blood clot usually in the leg vein or damage to the nearby organs in the abdomen and pelvic region such as urinary bladder, ureter or bowel. Obesity, diabetes and high blood pressure increase the chances of complications due to surgery.
What to expect after the vaginal hysterectomy?
Recovery after vaginal hysterectomy is fast. Medicines are prescribed for pain and to prevent infection.
Bleeding from the vagina is normal and will last for a few weeks after the surgery. Use of sanitary pads should be preferred as tampons increase the risk of infection. You will not have periods and cannot conceive after the vaginal hysterectomy.
If ovaries and fallopian tubes are removed along with uterus in vaginal hysterectomy you may have vaginal dryness or hot flashes, the symptoms of menopause.
These may be treated with medicines, if required. You will be able to do normal activities in around two weeks after the surgery, but should not lift heavy objects or have vaginal intercourse until the sixth week or till the complete healing occurs.
What if I come across any problem during the recovery period?
You should seek immediate medical attention if you experience any of the below mentioned conditions:
Offensive vaginal discharge or heavy bleeding
Severe nausea or vomiting
Inability to empty your bladder or bowels
TOTAL LAPAROSCOPIC HYSTERECTOMY
WHAT IS TOTAL LAPAROSCOPIC HYSTERECTOMY?
Total laparoscopic hysterectomy is a surgical procedure for the removal of the uterus. In this technique, the uterus is separated from inside of the body and is removed in small pieces through small incisions or through the vagina. A hysterectomy is a major surgical procedure and has both psychological and physical consequences.
WHY IS IT PERFORMED?
Total laparoscopic hysterectomy is done to treat conditions such as painful or heavy menstrual periods, pelvic pain, fibroids or may be performed as a part of cancer treatment. You should clearly understand the reason for this surgery.
ARE THERE OTHER ALTERNATIVES TO THIS TREATMENT?
There are other conservative interventions which may be appropriate for your particular condition. Hysterectomy may be performed vaginally, abdominally or laparoscopically. Laparoscopic hysterectomy has benefits such as shorter recovery period, reduced postoperative pain, but it may be associated with a greater risk of complications, particularly urinary tract injury.
HOW IS A LAPAROSCOPIC HYSTERECTOMY PERFORMED?
The procedure is done under general anesthesia in the operating room. A small incision is made just below your umbilicus. The abdomen is inflated with gas and a fiber-optic instrument called laparoscope is inserted to view the internal organs.
Further, small incisions may be made on your abdomen through which tiny surgical instruments are passed. Then, the uterus and cervix are removed along with or without both ovaries and tubes.
WHAT PRECAUTIONS SHOULD BE TAKEN BEFORE THE PROCEDURE?
You can continue taking your regular medications, unless Dr Alexander advises otherwise. You may need to have a bowel preparation which will empty your bowel before the surgery. For this, you should be on a liquid diet (soups, jellies, juices or similar drinks) for 24 hours before the surgery. Avoid smoking and if you develop signs of illness prior to your surgery, please contact Dr Alexander immediately.
WHAT CAN BE EXPECTED DURING THE RECOVERY PERIOD?
You will be in the recovery room when you wake up from anesthesia. You may feel sleepy for the next few hours. You may have pain in the shoulder or back which is because of the gas used in the procedure. It resolves within a day or two. You may have some discomfort or feel tired for a few days after the procedure. Contact Dr Alexander if pain and nausea does not go away or is becoming worse. You should avoid strenuous activities or exercise until you recover completely.
You may have some vaginal discharge for several days after the procedure. You can return to normal activity in three months time, but complete recovery may take longer. After the procedure, you will no longer be menstruating or be able to conceive.
You may experience bladder and bowel dysfunction and an increased risk of urogenital prolapse.
WHAT ARE THE POSSIBLE RISKS AND COMPLICATIONS OF THIS PROCEDURE?
As with any surgical procedure, there are associated risks and complications which include:
Problems due to the anesthesia
Injury to the internal organs
Bleeding and infection
Any specific risks and complications will be discussed prior to the procedure.
WHAT IF I COME ACROSS ANY PROBLEM DURING THE RECOVERY PERIOD?
You should seek immediate medical attention if you experience any of these conditions:
Offensive vaginal discharge or heavy bleeding
Severe nausea or vomiting
Inability to empty your bladder or bowels
VAGINAL NATIVE TISSUE PELVIC FLOOR SURGERY
The pelvic floor is made up of pelvic muscles, ligaments, connective tissues, nerves and arteries. It contains organs such as the rectum, uterus, vagina, and bladder.
Causes of Pelvic Floor Problems
Several factors such as vaginal birth, trauma during childbirth, repeated lifting of heavy objects and chronic disease or surgery may weaken or stretch the pelvic floor.
When the pelvic floor can no longer hold the pelvic organs in place, the pelvic organs come down and bulge into the vagina. This condition is referred to as pelvic organ prolapse.
Pregnancy and childbirth are the most important risk factors for prolapse. Pelvic organ prolapse is asymptomatic in most patients. However, in a small percentage of patients it causes symptoms that vary from vaginal discomfort to difficulties in sexual, urinary and defecatory activities.
Symptoms of Pelvic Floor Problems
Asymptomatic patients do not require treatment.
Symptoms in most of the symptomatic patients can usually be managed by pelvic floor exercises and use of removable vaginal inserts (pessaries).
Treatments for Pelvic Floor Prolapse
In rare cases, when even after conservative treatment the symptoms are unmanageable and result in significant impairment of the quality of life of the patient, surgery is advised.
The aim of the surgery is to correct the prolapse and maintain urinary and faecal continence and preserve coital and reproductive function.
Native Tissue Surgery
Pelvic organ prolapse was traditionally treated surgically using native vaginal tissue (NT). It involved the use of the patient’s own tissue and sutures to restore the vagina to a natural position by reattaching it to the various supportive structures.
Reports in the literature of high recurrence rates associated with vaginal native tissue repair led to the development of alternative techniques, such as synthetic mesh.
However, the newer current data obtained from large population studies with long term follow up periods show that the recurrence rate with NT is much lower than was earlier predicted.
Native tissue repairs have similar outcomes to synthetic mesh without the risks inherent in mesh use.
Native Tissue Surgery Complications
The most common complication associated with mesh repair is erosion or protrusion of the mesh from the soft tissues in the vaginal wall leading to discomfort in intercourse and blood spotting and may require additional surgery. Thus, newer isn’t always better. Native vaginal tissue repair is still the standard of care for the typical patient with pelvic organ prolapse.
Surgery for pelvic organ prolapse is optional. Decision about the surgery should be made only after proper discussion of the risks and benefits of the possible procedure with your Urogynecologist.
Myomectomy is a surgical procedure to remove uterine fibroids, benign or noncancerous growths appearing in your uterus.
Uterine Fibroid Symptoms
Many women with uterine fibroids do not experience any symptoms. However, some women may experience symptoms that are
mild and they include heavy and prolonged menstrual bleeding,
bleeding between periods,
lower back pain,
pain during intercourse and
In rare cases, some women may
have difficulty emptying the bladder,
difficulty moving the bowels,
anaemia due to heavy menstrual bleeding and
reproductive problems such as infertility.
Treatment for Uterine Fibroid
Myomectomy is the treatment of choice in women with fibroids who are planning to have children in the future. Myomectomy removes only the fibroids and leaves your uterus intact and increases your chances of pregnancy.
Before your surgery, gonadotropin-releasing hormone analogue (GnRH-a) therapy which lowers oestrogen levels may be used to shrink the uterine fibroids, thus reducing the risk of excessive bleeding during the surgery.
Depending on the size, location and number of fibroids, Dr Alexander may choose one of three surgical approaches to remove the fibroids:
Hysteroscopy: This is an outpatient surgical procedure and is performed under general anaesthesia or spinal anaesthesia. Dr Alexander uses a tiny viewing tool called a hysteroscope which is passed through your vagina and cervix into your uterus to look inside the uterus. Dr Alexander can see the inside of the uterus to examine the lining of the uterus (endometrium) and remove the fibroids. Dr Alexander may also take tissue samples for biopsy. Fibroids located on the inner wall of the uterus that have not gone deep within the wall of the uterus can be removed using this technique.
Laparoscopy: A laparoscopic myomectomy procedure is a minimally invasive surgery during which a laparoscope, a long thin instrument attached with a camera is used. A small incision is usually made below the navel and a laparoscope is inserted through this incision. Carbon dioxide gas is injected into the abdominal cavity using a special needle to create more space to work. Dr Alexander identifies and removes the fibroids. During the procedure, tissue samples can also be taken for biopsy. This procedure is the preferred option to remove one or two fibroids up to 5.1 cm across that grow on the outside of the uterus.
Laparotomy: A laparotomy is the surgical removal of fibroids through a large incision in the lower abdomen. If the fibroids are large and many in number or have grown deep into the uterine wall Dr Alexander may opt for laparotomy. Urinary or bladder problems can be corrected using laparotomy.
When is a Myomectomy Required?
Myomectomy is a treatment option if
you have anaemia and pain or pressure not relieved with medications.
the fibroids have changed the uterus so as to cause infertility or
repeated miscarriages as this method improves your chances of becoming pregnant even after the procedure.
Recovery from Myomectomy
After myomectomy surgery, your pelvic pain and bleeding from fibroids are reduced and your chances of having a baby are improved. If the fibroids are large and are more in number, they can re-grow after surgery.
Complications with Myomectomy
The possible complications of myomectomy include
scar tissue formation,
damage to the bladder or bowel, and
rupture of the uterine scars in late pregnancy or during labour.
Rarely, a myomectomy causes uterine scarring that can lead to infertility.
Fibroids and Pregnancy
Because fibroids can grow back, those women who are planning to become pregnant in the future must try to conceive as early as possible after the myomectomy procedure. However, following surgery, Dr Alexander will advise you to wait for 4 to 6 months until the uterus heals.
Before undergoing any treatment for infertility, Dr Alexander may recommend a hysterosalpingogram, an X-ray test to check the uterus and fallopian tubes.
The incisions made in the wall of the uterus to remove fibroids may cause placental problems and improper functioning of the uterus during labour may need a caesarean delivery. In rare cases, a hysterectomy may be needed if the uterus has grown too large with fibroids.
A cystoscopy is an examination of the inside of the bladder and urethra, the tube that carries urine from the bladder to the outside of the body.
The doctor performing the examination uses a cystoscope, a long, thin instrument with an eyepiece on one end and a tiny lens and a light on the other end that is inserted into the bladder.
The doctor inserts the cystoscope into the patient’s urethra and the small lens magnifies the inner lining of the urethra and bladder allowing the doctor to see inside the hollow bladder. Many cystoscopes have extra channels within the sheath to insert other small instruments that can be used to treat or diagnose urinary problems.
Why have a Cystoscopy?
Dr Alexander may perform a cystoscopy to find the cause of many urinary conditions, including:
Frequent urinary tract infections
Blood in the urine, called haematuria
Frequent and urgent need to urinate
Unusual cells found in a urine sample
Painful urination, chronic pelvic pain, or interstitial cystitis/painful bladder syndrome
Urinary blockage caused by prostate enlargement or some other abnormal narrowing of the urinary tract
Stone in the urinary tract, such as a kidney stone
Unusual growth, polyp, tumor, or cancer in the urinary tract
People scheduled for a cystoscopy should ask their doctor about any special instructions.
The doctor gently inserts the tip of the cystoscope into the urethra and slowly glides it up into the bladder. A sterile liquid salt water called saline flows through a channel in the scope to slowly fill the bladder and stretch it so the doctor has a better view of the bladder wall.
As the bladder is filled with liquid, patients feel some discomfort or pressure and the urge to urinate. The doctor may then release some of the fluid, or the patient may empty the bladder as soon as the examination is over.
Possible risks of a cystoscopy include:
- Rupture of the bladder wall
WHAT IS COLPOSCOPY?
Colposcopy is a procedure in which a special magnifying instrument called a colposcope is used to look into the vagina and into the cervix. The colposcope gives an enlarged view of the outer portion of the cervix.
Why would a Colposcopy be necessary?
Colposcopy is done when there are abnormal changes in the cells of the cervix as seen on a Pap test. Further, it may be done to assess problems such as genital warts on the cervix, inflammation of the cervix, benign growths or polyps, pain and bleeding.
How is the Colposcopy procedure done?
During a colposcopy, you will lie on your back with feet raised just as you do when you have a regular pelvic examination. The doctor uses an instrument called a speculum to hold the walls of the vagina apart. Then the colposcope is placed at the opening of your vagina.
A mild solution may be applied to the vagina and cervix with a cotton swab. This makes abnormal areas to be seen easily. The doctor will look inside the vagina to locate any problem. If there are any abnormalities, the doctor may take a small tissue sample called a biopsy.
You may feel a mild pinch or cramp while the biopsy sample is taken. The tissue is then sent to a laboratory for further study.
What to expect after the Colposcopy procedure?
Your gynaecologist will talk to you about any problems detected during colposcopy. If a sample of tissue was taken from your cervix (biopsy), the laboratory results should be ready in 2 to 3 weeks.
Most women feel fine after colposcopy. You may feel a little lightheaded and if you have had a biopsy, you may have some mild bleeding. Talk to your gynaecologist about how to take care of yourself after the procedure and when you need to return for a check-up.
What are the risks of colposcopy?
There may be a risk of infection when you have a colposcopy. Mild pain and cramping during the procedure and mild bleeding afterwards are common. This most often happens when a biopsy is done. If there is heavy bleeding, fever, or severe pain after the procedure, contact your gynaecologist immediately.