Dr. Raymond Todd Foster SR., MD

More and more, gynecologic surgery is moving towards the use of minimally invasive surgery. Minimally invasive surgery uses several small incisions and tiny tools and scopes to perform the operation, rather than one large opening. While it is not appropriate in every case, minimally invasive surgery can lead to less scarring, less blood loss, faster recovery, and a lower chance for infection. Minimally invasive gynecologic surgery may be performed with a laparoscope, a thin tube with a camera on the end that allows the surgeon to see inside the body. It may also be performed robotically, using even smaller tools and cameras that a surgeon controls from a computer. Robotic surgery allows even better vision, precision, and control than laparoscopic surgery.

Over the course of a lifetime, many women need pelvic surgery to stay healthy. Qualified gynecologic surgeons will have the right tools at their disposal to provide care with a minimum of discomfort.

The choice of treatment for pelvic organ prolapse depends on the severity of the condition. Mild to moderate prolapse may be managed by doing pelvic floor strengthening exercises, taking hormone replacement therapy, or using pessaries. Pessaries are small devices inserted into the vagina to help support the pelvic organs. Pessary fitting is a quick procedure done in a doctor's office. For severe prolapse, surgical treatment may be necessary. Pelvic organ prolapse surgery repairs the following:

• Cystocele or bladder prolapse, where the bladder sags into the vagina. The surgeon repairs a cystocele by strengthening the front wall of the vagina using stitches so that the bladder will no longer sag.
• Enterocele or small bowel prolapse, which occurs when the small bowel descends towards the vagina. To correct an enterocele, the tissues between the small bowel and the vagina are sewn together, allowing them to provide more support.
• Rectocele or posterior prolapse, which is the bulging of the front wall of the rectum into the back wall of the vagina. Surgery to repair a rectocele removes the excess stretched tissue between the rectum and vagina.
• Uterine prolapse, which occurs when the uterus slips down to the vagina. To treat a uterine prolapse, the surgeon may secure the neck of the uterus (called cervix) to a ligament in the pelvis using stitches. Another option for this type of prolapse is a vaginal hysterectomy, which is the removal of the uterus.

Each of these procedures is performed through a vaginal incision, but an enterocele repair may use the abdominal approach as an alternative. If two or more pelvic organs have prolapsed, a combination of any of these procedures may be performed during the same surgical session.

For women who no longer wish to have intercourse, an operation called colpocleisis

may be a surgical option as well. By closing the vaginal canal, colpocleisis treats pelvic organ prolapse and eliminates any risk of its recurrence.

In most instances, pelvic organ prolapse surgery only requires a hospital stay of one day. Patients may experience vaginal bleeding for the first few weeks following surgery. If this happens, patients should use sanitary pads rather than tampons, as a higher risk of infection is associated with the use of tampons. To further help with recovery, patients should begin doing gentle pelvic floor strengthening exercises a few days after surgery. Doing these exercises at least three times a day as a routine tightens the pelvic floor muscles and prevents the recurrence of prolapse.

SNS surgery has two parts. The first part is an evaluation phase, during which it is determined if neurostimulation is effective treatment option for patients. Patients lie on their stomachs while a temporary electrode lead, through which electrical signals will travel, is inserted into their lower back. A permanent lead may also be used, and it would remain in place should the trial period prove successful. The lead is connected to an external neurostimulator. The procedure takes approximately one hour and may be performed in a doctor's office, hospital, or surgical center. After the procedure, patients are required to keep a log of their toilet habits over approximately two weeks, and they may need to limit their activities during this time. If patients' symptoms do not improve after the trial, they may repeat the test phase or discuss other treatment options with their doctors.

If the trial stimulator is effective, patients will undergo the second phase of SNS surgery, which is permanent implantation. In the second stage of surgery, the temporary lead (if used) will be replaced with a permanent lead. Then the sacral nerve stimulator will be implanted subcutaneously (under the skin) in the upper buttock. Patients should be able to return home the day of their procedure.

If patients are sore after surgery, their doctors may give them medication. The sacral nerve stimulator will be programmed after the procedure, and when it is turned on, patients should feel a sensation similar to pulling, tapping, tingling, or pulsing. Patients will need to work with their doctors during follow-up appointments to determine the most effective settings for the stimulator. Patients will be given instructions on how to adjust it themselves at home. The stimulator is powered by a battery that will last approximately five years, after which it can be replaced.