The pelvic floor is a set of muscles that form a hammock or sling around the opening of the pelvis. The pelvic organs, including the womb (uterus), rectum and bladder, are held in position by the pelvic floor muscles and the surrounding tissues. The incidence of pelvic floor disorders increases when the muscles of the pelvic floor and connective tissue are injured or weakened. Some of the common pelvic floor disorders include pelvic organ prolapse, urinary incontinence, and anal incontinence.
When the pelvic floor muscles and connective tissue that support the pelvic organs are weakened, the pelvic support is lost resulting in protrusion of the bladder, urethra, cervix and rectum. This is called pelvic organ prolapse. Women with pelvic organ prolapse will experience excessive pressure in the lower abdomen associated with a bulging or aching sensation, difficulty in urination, and urinary tract infections. If the symptoms are mild, non-surgical treatment options such as medications, pelvic floor exercises, vaginal pessaries (a device that is inserted in the vagina to support the pelvic floor), and lifestyle changes may be helpful.
Surgery can be considered in patients with severe symptoms of pelvic organ prolapse. There are different types of procedures to address a specific prolapse. The aim of pelvic floor reconstruction is to restore normal anatomy and function of the pelvic organs. Surgery can be done through an open incision in the abdomen or the vagina or through tiny incision over the abdomen with the use of laparoscopic instruments. Robotic assisted surgery may also be an option. The most essential part of the surgery is to restore support to the vaginal apex.
The most common procedures to restore vaginal apex support are:
Abdominal Sacral Colpopexy (ASC): During this procedure, straps of graft material are placed over the front and back walls of the vagina and secured to the ligament over the sacrum. As a result, the vagina is suspended over the pelvic muscles, to the sacrum. This graft material replaces the uterosacral ligaments, which is a natural support of the uterus.
Uterosacral or Sacro-spinous Ligament Fixation – This is performed through a vaginal approach. The vaginal apex is suspended to a patient’s uterosacral or the sacro-spinous ligaments. Traditionally, graft material was not used. However, recently, graft materials are being employed to enhance the durability of the prolapse repair in patients with weak vaginal wall.