Published: November 19, 2008 10:45 am      

Ask the Doctor tackles long-term surgical success

QUESTION: My womb and bladder have been hanging out a good three inches for the past year and I've been getting a lot of bladder infections. A much older lady friend of mine had the same problems and it scares me to think about what has happened to her the past two years. She has had two major surgeries that have failed. The first one, her uterus was removed and her bladder was tied up. Later last year, after that first surgery failed, the same doctor did another bladder repair but placed a piece of mesh under the bladder for additional support

Six months later, not only is her bladder failing out again but now she suffers from almost constant leakage and has more bladder infections than ever before. How can I prevent this from happening to me?

ANSWER: Unfortunately, your friend’s story is not uncommon and your concerns are well founded. After reminding you that any surgery for a dropped bladder and/or a dropped uterus can fail, there are a few very important and basic principles that many of us gynecological/pelvic reconstruction surgeons follow that can reduce surgical complications and increase the chances for long term surgical success. They are:

• Do not remove a uterus that does not have significant disease simply because “it has dropped.” The uterus, especially the cervix, is the strongest “anchoring organ” that can be reattached to the torn support ligaments arising from the the sacrum. The sacrum is the large triangular shaped flat bone at the base of the spine and is also the bone that the tailbone hangs off of.

Unlike what previous and now outdated conventional wisdom suggested, removing a dropped uterus actually increases surgery complications while increasing a women's future risk of her vagina and/or her bladder dropping out. In addition, performing a hysterectomy can cause an increase in post-op infections requiring a hospitalization, painful sexual relations, and bladder control problems.

• Whenever surgery is done to repair a dropped bladder in the presence of even a slightly dropped uterus or dropped vagina, if the uterus was previously removed, it is important to reattach the cervix or the upper vagina back to the ligaments arising from the sacrum using permanent sutures.

There are actually two supporting ligament systems arising from the sacrum that can be used to suspend the upper vagina vault or the cervix, to repair the dropped organs and to help prevent the vagina and/or uterus from falling out again.

• When confronted with a dropped bladder and/or a dropped uterus, the nonsurgical option of using a removable pessary should be discussed with all patients, especially those who wish to avoid surgery and those who are not a good surgical candidates due to significant medical problems. A pessary is a device that is placed into the vagina which can support a dropped bladder and/or uterus as long as the vaginal opening is not too large.

• If a woman is not sexually active and never plans to become sexually active again, a simple and highly effective 40 minute outpatient procedure should be offered. This low risk surgery involves manually placing the dropped organs back into their proper locations and then suturing the top and the bottom vaginal walls together. This partially closes off the vagina and reduces the size of the vaginal opening.

This does not cause any noticeable or visible change externally and does not affect a woman's ability to urinate. This procedure can also be performed together with a urine leakage sling procedure if a woman also suffers from urine leakage.

• The more the bladder and/or the uterus has dropped and the younger the woman is when she develops these dropped organs, the more likely she may have genetically or inherited weak supporting ligaments. These women, even during their first surgery, may benefit from having man-made mesh implants used in their repairs. These sheets of mesh used in today's pelvic reconstructive surgeries are similar to the sheets of mesh general surgeons commonly use now-a-days to repair hernias. The use of mesh or sheets of animal or human derived support tissues also can be very helpful for enhancing the long term success for women who have failed the older types of surgeries.

When mesh implants are used, it is safest not to remove the uterus since removing the uterus increasing the surgical risks and increases the post operative complications. One of those complications involves a portion of the mesh eroding through the vaginal wall which delays the healing process by up to three months.

I suspect that the first surgery your lady friend had was an “Anterior Repair.” This surgery is where the bladder is “bunched up” in the midline with sutures and actually pulls the edges of the bladder even further away from their natural supporting ligaments deep inside the pelvis. It’s an ancient surgical procedure with a very high failure rate. But for 70 years it was one of only few safe surgeries available to try to repair a dropped bladder. The only time that the “Anterior Repair” has a high success rate is when the bladder drops due to a support tissue defect or tear under the "middle" of the bladder. This type of defect only accounts for five percent of all dropped bladders.

• When a surgical repair for prolapse is performed, it is important to repair not only the support system of the bladder but also the support system of all of the other compartments within the pelvis. If the surgeon does not repair the lower compartment where the uterus, vagina, and/or rectum have torn away from their supporting ligaments arising from the sacrum, then the downward forces of these unrepaired areas will frequently cause the repaired bladder to break down.

This failure to surgically address or correct the support system of the uterus, cervix, vagina, and/or rectum is one of the main reasons for all the failed first, second, and third surgeries.

This, along with the removal of the uterus, may be one of primary reasons why your friend's surgery has failed twice now.

• It is vital to correct a woman's constipation before surgery and to keep it corrected indefinitely after surgery with soft, easy to pass, bowel movements. This is especially important within the first three months post-op as the scarring process adds further strength to the sutured areas and the mesh repairs. The bearing down forces necessary to pass hard or stiff stools can play havoc on these dropped organ repairs, including causing the permanent sutures to tear out of a woman's genetically weak supporting ligaments.

• Prior to even the first surgical repair for a dropped bladder and/or uterus, it is very important to evaluate the bladder function with a specialized bladder test called urodynamics. This is especially important before any “second attempt” at a surgical correction.

This urodynamics test checks for the potential for post-op bladder leakage problems which can occur once the dropped bladder has been surgically repositioned back into the vagina and after the urethra has been “unkinked” as a result of surgery. If this test had been done prior to your friend’s second surgery, she could have had a urine leakage sling placed at the time of her second surgery. At least she probably would not be suffering from constant urine leakage at this point.



Dr. Nolan Hetz is a Board Certified Gynecologist. He is a Pelvic Reconstructive Surgeon and a Female Bladder Control Specialist at the Quality Care Clinic in Clinton. Questions that could be used in a future “Ask The Doctor” column can be e-mailed to nolanhetz@yahoo.com or by calling his office at 242-3208.