Definition and Overview
Pelvic surgery is a broad term that refers to surgical procedures performed in the pelvic area, the majority of which are gynecologic operations. Although any operation on the pelvic floor, pelvic bones or pelvic organs may be classified as pelvic surgery, pelvic surgery in this article will be used to refer to urogynecologic procedures performed for female pelvic floor disorders. These disorders include pelvic organ prolapse and urinary incontinence.
Pelvic organ prolapse is a condition wherein a pelvic organ, such as the uterus, bladder or the rectum, falls from its normal location. On the other hand, urinary incontinence is the inability to hold in one’s urine, resulting in involuntary urination. Both conditions occur due to the weakness of the pelvic muscles, usually attributed to stretching during childbirth. It can also be associated with gynecologic surgery, such as a hysterectomy. Aside from these, other conditions and diseases may predispose to the development of pelvic floor disorders. These include conditions that cause increased pressure inside the abdomen, such as chronic pulmonary disorders and obesity.
More than 10% of females undergo pelvic surgical operations. This amounts to approximately 200,000 pelvic operations every year in the United States alone.
Who Should Undergo the Procedure and Expected Results
Patients with pelvic floor disorders present with various symptoms while mild cases of pelvic organ prolapse may remain asymptomatic. In more severe forms, the pelvic organs can be visualized protruding through the genital area. Patients with pelvic organ prolapse typically experience discomfort or pain in the pelvic area, usually described as a feeling of fullness in the vagina. The discomfort may improve when the patient is lying down. Spotting and pain during coitus can also occur. Urinary incontinence may be experienced as a separate condition, or may be an associated symptom of pelvic organ prolapse. There are several kinds of urinary incontinence, such as stress incontinence, urge incontinence and overflow incontinence. Of these kinds, stress incontinence is the type that can benefit with pelvic surgery. With stress incontinence, sneezing, coughing, lifting weights or similar activities can result in involuntary leakage of urine. Incontinence can lead to urinary tract infections, or irritation and inflammation of the skin on the genital area.
Patients with pelvic floor disorders are initially treated conservatively with lifestyle modification techniques such as weight loss. Exercises of the pelvic muscles and bladder training strategies may be of some benefit. Devices, such as adult diapers and pessaries, may likewise be used. However, if medical management fails to improve the symptoms, then surgery should be performed. Surgery for pelvic floor disorders has high reported success rates, ranging from 76% to 100%.
How Does the Procedure Work?
Various approaches and techniques are involved in pelvic surgery, depending on the specific condition and the cause. It is important to determine the specific defect to determine the best approach for the repair.
The treatment of pelvic organ prolapse may be approached via the vaginal or the abdominal route. Surgeries performed through the vaginal route include colporrhaphy and fixation of the vagina to the sacral ligaments. Colporrhaphy involves plication of the muscular layer, making the vaginal canal smaller. Meanwhile, the abdominal approach allows pelvic reconstruction, such as sacrocolpopexy, wherein a graft is used to provide support for the vagina. Nowadays, the abdominal approach can be performed laparoscopically, allowing a minimally invasive approach to the procedure. In some patients, especially those who are poor surgical candidates, colpocleisis, or the removal of the epithelium and closure of the vagina, may be indicated. Urinary incontinence can also be managed surgically with the goal to create a partial obstruction in the urethra to facilitate closure and prevent urine leakage. Several procedures can be performed to achieve this goal, including retropubic suspension, the Burch procedure and the Marchall-Marchetti-Krantz procedure. Pelvic procedures for incontinence may also involve the creation of slings or insertion of artificial sphincters.
After the procedure, patients are advised to avoid stressful exercises and lifting of heavy weights. Sexual activity is avoided as well. Estrogen therapy may be necessary, especially in postmenopausal women.
Possible Complications and Risk
Pelvic injury can result in injuries to various pelvic structures, such as the bladder. Injuries to the ureter occur in approximately 2% of patients undergoing the procedure, while injuries to the urethra are quite rare. Approximately half of patients who undergo pelvic surgery for pelvic organ prolapse may experience dyspareunia or pain during sexual intercourse. Several procedures for pelvic organ prolapse may also result in worsened urinary incontinence.
The use of grafts or mesh for pelvic surgery may also be associated with certain complications. Erosion of the mesh can occur in a small percentage of patients, wherein the mesh cuts through tissue or extrudes through the skin. This can result in pain and infection. When erosion occurs, the removal of the foreign body is necessary.
Late complications include the development of hernias, especially with abdominal procedures.
DeSimone CP, Ueland FR. Gynecologic laparoscopy. Surg Clin North Am. 2008;88:319-341.
Gaitán HG, Reveiz L, Farquhar C. Laparoscopy for the management of acute lower abdominal pain in women of childbearing age. Cochrane Database of Systematic Reviews. 2011, Issue 1. Art. No.: CD007683.