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1 University College Hospital Surgery for prolapse Helping you to make the right choice Urogynaecology and Pelvic Floor Unit, Women s Health Contents Page 1. What type of surgery should I choose? 2 2. What are the alternatives to surgery? 2 3. What are the complications of surgery? 3 4. Will I need a hysterectomy? 3 5. Which operation is best for womb prolapse? 4 6. When might hysterectomy be a better choice? 5 7. Is using mesh to lift the womb up safe? 5 8. How is prolapse of the vaginal walls treated? 6 9. How is vaginal wall prolapse after hysterectomy treated? Will I need more than one operation? Can I have surgery if I want more children? Where can I get more information? References Contact details How to find us 9

2 2 1 What type of surgery should I choose? There are a number of different operations for prolapse. Your choice of surgery will depend on the type of prolapse you have, but there are other important factors. A desire for future pregnancy is one such consideration. We might also recommend a particular operation for medical reasons. Although you will make the final decision, we will provide you with all the information you need to help you make your choice. This leaflet has been produced to help you decide whether surgery is the right treatment for you. It contains basic information about the operations that we offer. It also provides answers to frequently asked questions from patients. We have also produced a range of detailed information booklets for each operation. For this reason, we have tried to keep the information in this leaflet as simple as possible. Once you have read this leaflet, you may decide to read about one or more surgical procedures in more detail. We also provide additional information for the non-surgical treatments we discuss below. 2 What are the alternatives to surgery? Before you consider surgery, you should think about other options: Carrying on as you are Pelvic floor physiotherapy The use of a vaginal pessary If you decide not to have treatment, you will continue to be troubled by your symptoms. However, you are very unlikely to come to any harm. Physiotherapy is an effective treatment, especially if your prolapse is not too severe. Around half of women who engage in physiotherapy will find that their symptoms improve. Physiotherapy appears to continue working provided that you do not stop practicing your exercises. If your prolapse is quite severe, we are not sure how well physiotherapy works. Vaginal pessaries are an alternative treatment. A pessary is a removable device that is placed in your vagina. Most are made of soft plastic or silicone and shaped like a ring. There are different types of pessary and they come in different sizes. Pessaries relieve prolapse symptoms by keeping the womb and vaginal walls in their normal position. A specialist nurse or doctor will fit your pessary for the first time. After this, you can be taught to insert and remove your pessary yourself. Pessaries can be used as a long-term treatment or as a temporary measure. A small number of women might experience some bleeding or discharge when they use a pessary. Rarely, a minor infection might develop. These problems are usually easy to treat.

3 3 3 What are the complications of surgery? All operations can be associated with complications. These are undesirable or unwanted effects that happen as a result of surgery. If a complication affects you, it does not mean that something must have gone wrong during the surgery. The risk of having a complication varies depending on the type of surgery you have. Complications that can be associated with surgery include: Bleeding and blood transfusion Infections Blood clots in the legs travelling to the lungs. Damage to the bowel, bladder, and other organs New or worsening bowel or bladder symptoms Painful sexual intercourse Long-term problems with pain Problems with implanted mesh used to repair prolapse Failure of the operation to cure the prolapse Although the risk of most complications is low, we recommend that patients try non-surgical treatments before surgery. This is because non-surgical alternatives are generally not associated with serious complications. More details about the complications of surgery can be found in our information booklets on each surgical procedure. 4 Will I need a hysterectomy? If you have prolapse of the womb, you could try physiotherapy or a vaginal pessary to help with your symptoms. If these treatments are ineffective or unsuitable, you could consider an operation. If you are affected by prolapse of the womb you could choose to have a hysterectomy or a hysteropexy. Hysterectomy is an operation to remove the womb Hysteropexy is an operation to lift the womb up Traditionally, hysterectomy has been recommended to treat prolapse of the womb. Although hysterectomy is very commonly performed, removal of the womb is not necessary to treat the prolapse. We recognise that many women express a preference to keep their womb, even if their family is complete.

4 4 If you prefer not to have your womb removed as part of your treatment, you could choose a hysteropexy operation. We offer three different types of hysteropexy surgery. Two procedures are performed using keyhole surgery through your abdomen. The third is performed through a cut in the vagina: Laparoscopic mesh sacrohysteropexy is a keyhole procedure that uses a soft plastic mesh to hold the womb up. Laparoscopic suture sacrohysteropexy is a keyhole operation that lifts the womb up using permanent stitches. Sacrospinous hysteropexy attaches the womb to a strong ligament in the pelvis using stitches. The stitches are placed through a cut in the vagina. Laparoscopic mesh sacrohysteropexy seems to be the most effective procedure. This is probably because the mesh holds the womb in place better than stitches. Laparoscopic suture hysteropexy and sacrospinous hysteropexy seem to be less effective. Some complications seem to be more common after sacrospinous hysteropexy than the other procedures. These include painful sexual intercourse and urinary leakage. Despite these problems, there are some circumstances in which we recommend sacrospinous hysteropexy. This is often when keyhole surgery through your abdomen might risk significant complications. This might be the case if: You have had complicated surgery in your abdomen before. You have serious heart or lung disease. 5 Which operation is best for prolapse of the womb? Hysterectomy is one of the options if you are affected by prolapse of the womb, although it is not the only option. You could decide that you want to keep the womb and have it lifted up with one of our hysteropexy operations. Many people assume that removing the womb must be the best treatment if the womb has prolapsed. This would seem to make sense because if the womb has been removed, it cannot prolapse again. Unfortunately, even with the womb gone, it is possible that the vagina itself can prolapse after hysterectomy. During hysterectomy, the womb is cut away and removed. The very end of the vagina, where the womb used to be connected, is stitched closed. The closed end of the vagina is then held in place by attaching it to ligaments in the pelvis using stitches. After hysterectomy, the end of the vagina can prolapse in out of 100 women after surgery. This happens despite our best efforts to stitch the vagina in place during hysterectomy.

5 5 We think this is because the ligaments that we attach the end of the vagina to are already damaged. As well as the end of the vagina prolapsing again, other parts of the vagina might also be affected. Laparoscopic mesh sacrohysteropexy is an operation that lifts the womb back into position using mesh. It seems that only 2 out of 100 women who have this operation will experience womb prolapse again. The mesh we use is strong and this is probably why the womb stays in place. There still remains a risk that the vaginal walls might prolapse after surgery, even if the womb stays in place. Thankfully, the risk of this happening appears to be low. Overall, the risk of prolapse coming back seems to be lower after laparoscopic mesh hysteropexy than hysterectomy. At the time of writing this information, there were no long-term research studies comparing the two operations head-to-head. For this reason we still cannot be certain that lifting the womb is better than removing it. We offer both procedures and we would be happy for you to choose whichever operation you prefer. 6 When might hysterectomy be a better choice? If you have prolapse of the womb, hysterectomy might be the best treatment in some circumstances. If you are affected by the following conditions, we might recommend a hysterectomy: Heavy or painful periods that are been difficult to treat Significant enlargement of the womb Abnormal cervical smears that require treatment Your ovaries and tubes will not removed during a hysterectomy unless you have asked us to do so. It is often best to leave the ovaries and tubes behind for health reasons. In some circumstances, we might recommend their removal. If you have a strong family history of ovarian cancer, you should talk to us about the benefits of removing them. 7 Is using mesh to lift the womb up safe? Recent media coverage has highlighted the risks of mesh implanted through the vagina for prolapse and urinary leakage. When we use mesh to lift up the womb, it is not implanted through the vagina and it does not come into contact with the vagina. This procedure is completely different to vaginal mesh surgery that has attracted recent criticism. When mesh is inserted through a cut in the vaginal skin to treat vaginal prolapse, some serious problems can occur. The mesh can push through the vaginal skin and become visible. Rarely, it can cut through the walls of the lower bowel, or cut into the bladder. These complications can cause long-term pain, painful sexual intercourse, vaginal discharge, infections, and other bowel and bladder problems. We do not use mesh in this way in our unit at UCLH.

6 6 When we use mesh to treat prolapse of the womb, the mesh is inserted through the abdomen. It is attached to the womb and a bone at the bottom of the spine. The mesh is not in contact with the vagina, although it is close to the bladder and bowel. The results of surgery in six hundred women have been published in international medical journals. There have been no reports of mesh pushing through the vaginal skin, or cutting into the bowel or bladder, after our specific mesh hysteropexy operation. Despite these reassuring findings, it does not guarantee that mesh complications will never happen. It is still possible that a problem could arise at some point, even though there have been no problems so far. 8 How is prolapse of the vaginal walls treated? Physiotherapy or vaginal pessaries are effective treatments for vaginal wall prolapse. If you would like to consider surgery for your vaginal prolapse, the surgery we offer you will depend on your circumstances. If you also have prolapse of the womb, surgery to remove the womb or lift it up can help to correct vaginal wall prolapse. Unfortunately, surgery to correct prolapse of the womb does not always help with vaginal wall prolapse. Sometimes, additional vaginal surgery is needed to repair vaginal wall prolapse fully. If you do not have any prolapse affecting the womb, then we will offer you a vaginal repair operation using stitches. 9 How is vaginal wall prolapse after hysterectomy treated? If you have vaginal prolapse after hysterectomy you could consider an operation. You should consider non-surgical treatments first. The type of surgery that we offer depends on what type of vaginal prolapse you have. After hysterectomy the very end of the vagina can sometimes prolapse. If this happens, the end of the vagina will need to be lifted up again and fixed in place. This can be done in two ways. The end of the vagina can be attached to a very strong ligament in the pelvis using stitches. This procedure is called a sacrospinous colpopexy. It is an operation performed through the vagina. The end of the vagina can be attached to a bone at the bottom of the spine using mesh. This procedure is called a laparoscopic mesh sacrocolpopexy. We normally carry out this operation using keyhole surgery through the abdomen. Using mesh seems to have some advantages. There is a better chance that the prolapse will not come back. The risk of other problems after surgery, such as urinary leakage and painful intercourse also seem to be lower. Despite these differences, satisfaction after both procedures appears to be good.

7 7 Earlier, we explained that using mesh inserted through a cut in the vaginal skin could cause significant complications. The risk of problems appears to be linked to how the mesh is put in. Although we offer a mesh repair of vaginal prolapse after hysterectomy, the mesh is inserted through the abdomen. The risk of complications is much lower than when the mesh is inserted through the vagina. The procedure is recommended by national and international organisations that advise on prolapse surgery. If the end of the vagina is still in place and only the walls of the vagina lower down are affected by prolapse, things are simpler. We will offer you a vaginal operation to repair the prolapse using stitches. 10 Will I need more than one operation? Sometimes prolapse might only affect one area. An example might be prolapse that only affects the womb. Some women might only be troubled by prolapse of the vaginal walls. More commonly, prolapse affects more than one area at a time. For this reason, we might need to perform more than one surgical procedure to help you. If you are affected by prolapse in more than one area, we will explain which types of surgery we think are needed. If we need to combine two or more procedures, we usually perform them on the same day. Sometimes, combining different operations on the same day might increase the risk of complications. If this is the case, we might recommend having separate operations instead. If you need more than one procedure, we will provide you with separate information for each operation. 11 Can I have surgery if I want more children? We generally recommend that you avoid surgery if you are planning to have more children. Our concern is that further pregnancy or vaginal delivery might reduce the long-term success of your operation. However, if your symptoms are difficult to control with non-surgical treatments we can discuss other options. If you have prolapse of the womb, we can lift up the womb using stitches inserted using keyhole surgery. This operation is called a laparoscopic suture sacrohysteropexy. Pregnancy and vaginal delivery are possible after this procedure, although the success of the operation might be affected. Other procedures to lift the womb are available but we do not usually recommend them if pregnancy is planned. If you have vaginal wall prolapse, a vaginal operation to repair the prolapse using stitches is an option. We would only consider this if your were willing to have a caesarean section in a future pregnancy. This is because another vaginal birth would damage the repair and your prolapse might come back. Sometimes, just getting pregnant again can affect your repair, even if you do not have a vaginal birth. For this reason, it is best to avoid surgery and try other treatments until your family is complete.

8 8 12 Where can I get more information? The British Society of Urogynaecology Website: bsug@rcog.org.uk Telephone: Fax: The International Urogynecological Association Website: at: UCLH cannot accept responsibility for information provided by other organisations. 13 References Bugge, C., et al. (2013). "Pessaries (mechanical devices) for pelvic organ prolapse in women." Cochrane Database Syst Rev(2): CD Hagen, S., D. Stark, C. Glazener, S. Dickson, S. Barry, A. Elders, H. Frawley, M. P. Galea, J. Logan, A. McDonald, G. McPherson, K. H. Moore, J. Norrie, A. Walker, D. Wilson and P. T. Collaborators (2014). "Individualised pelvic floor muscle training in women with pelvic organ prolapse (POPPY): a multicentre randomised controlled trial." Lancet 383(9919): Jefferis, H., N. Price and S. Jackson (2017). "Laparoscopic hysteropexy: 10 years' experience." Int Urogynecol J. Epub: DOI /s Krause, H. G., J. T. Goh, K. Sloane, P. Higgs and M. P. Carey (2006). "Laparoscopic sacral suture hysteropexy for uterine prolapse." Int Urogynecol J Pelvic Floor Dysfunct 17(4): Kupelian, A. S., A. Vashisht, N. Sambandan and A. Cutner (2016). "Laparoscopic wrap round mesh sacrohysteropexy for the management of apical prolapse." Int Urogynecol J. Maher, C. F., B.; Baessler, K.; Schmid, C. (2013). Surgical management of pelvic organ prolapse in women. The Cochrane Library, The Cochrane Collaboration. Maher, C. F., M. P. Carey and C. J. Murray (2001). "Laparoscopic suture hysteropexy for uterine prolapse." Obstet Gynecol 97(6): Maher, C. F., A. M. Qatawneh, P. L. Dwyer, M. P. Carey, A. Cornish and P. J. Schluter (2004). "Abdominal sacral colpopexy or vaginal sacrospinous colpopexy for vaginal vault prolapse: a prospective randomized study." Am J Obstet Gynecol 190(1): Marchionni, M., G. L. Bracco, V. Checcucci, A. Carabaneanu, E. M. Coccia, F. Mecacci and G. Scarselli (1999). "True incidence of vaginal vault prolapse. Thirteen years of experience." J Reprod Med 44(8):

9 Prodigalidad, L. T., Y. Peled, S. L. Stanton and H. Krissi (2013). "Long-term results of prolapse recurrence and functional outcome after vaginal hysterectomy." Int J Gynaecol Obstet 120(1): Rahmanou, P., B. White, N. Price and S. Jackson (2014). "Laparoscopic hysteropexy: 1- to 4-year follow-up of women postoperatively." Int Urogynecol J 25(1): Symmonds, R. E. and J. H. Pratt (1960). "Vaginal prolapse following hysterectomy." Am J Obstet Gynecol 79: Contact details Urogynaecology nursing team Direct line: Mobile: Fax: urogynaecology@uclh.nhs.uk Women s Health Physiotherapy Direct line: Fax: uclh.whphysio@nhs.net Urogynaecology secretary Direct line: Fax: University College Hospital Switchboard: Website: How to find us The Urogynaecology and Pelvic Floor Unit Clinic 2, Lower Ground Floor Elizabeth Garrett Anderson (EGA) Wing University College Hospital 25 Grafton Way London WC1E 6DB

10 10 Space for additional notes If you need a large print, audio, braille, easy read, age-friendly or translated copy of this document, please contact us on We will try our best to meet your needs. First published: October 2017 Date last reviewed: October 2017 Date next review due: October 2019 Leaflet code: UCLH/SH/WH/UROGYNAE/PROLAPSESURG/1 University College London Hospitals NHS Foundation Trust 2017