Pelvic Floor Reconstruction

What is a pelvic floor reconstruction?

Well, before we can talk about a pelvic floor reconstruction, we must say a few words about the medical condition which leads to this procedure. Fortunately, it's not too difficult to summarize the conditions which lead to a complete loss of pelvic support.

The easiest way to think about this is to imagine that your body is a hollow tube which contains all of your organs. The lower end of the hollow tube is a flexible, fibrous layer of overlapping and criss-crossing muscles, fibrous tissues, and ligaments. This layer is called your pelvic floor. Your pelvic floor is attached to the inside of your pelvic bones and ligaments and stretches across the lowest portion of your pelvis. Much like a trampoline, your uterus, bladder, rectum and intestines bounce up and down on your pelvic floor every day as you proceed through life. Unlike a trampoline, which is one solid sheet of supporting material, your pelvic floor has some holes in it, through which your vagina, rectum, and urethra connect to the outside world. These holes weaken your pelvic floor, but they perform vital functions, allowing you to empty your bladder, go through childbirth, and have bowel movements.

Your pelvic floor is a very complex layer and usually functions very well, but it can be damaged if too much stress is placed upon it. In particular, childbirth and the tremendous forces of labor; the dilation of your pelvic floor to allow for passage of a baby; and the huge pressures exerted during the pushing phase of labor all act to weaken, damage, or break your supporting tissues.

But other things can also damage your pelvic floor. If you have a chronic cough you can seriously damage your support. Each cough, over a period of months or years creates a high pressure "hit" to your pelvic floor. The same is true of constipation. Constipation leads to straining with bowel movements. Over time, the pressures exerted with straining result in damage to your pelvic floor supporting tissues. And, some folks are just unlucky enough to have inherited a set of genes from their ancestors which code for weak supporting tissues.

Result when bladder support fails

Now with these visuals in mind, imagine what would happen if your pelvic floor loses it's support and begins to droop. Essentially everything attached to this layer would fall downward toward the floor. Gravity once again comes into play, and each of your pelvic organs which attach to your pelvic floor would lose their support and prolapse downward. Therefore, with a complete failure of your pelvic floor, you develop loss of bladder support (a cystocele and urethrocele), loss of rectum support (a rectocele), loss of uterine support (uterine prolapse), loss of upper vagina support (an enterocele), and loss of vaginal side wall support (loss of paravaginal support). A pelvic floor reconstruction is a major surgical procedure that is designed to restore strength and integrity to the pelvic floor by addressing each of these prolapsing organs, one by one, and either rebuilding the supporting layer, or removing the fallen organ.

Pelvic floor reconstruction techniques the best method to repair this myriad of support problems has been a very controversial issue in gynecology and urology for decades. Many surgical approaches have been proposed, and tried over the years, and so there is good data to help guide us in determining which method is best. Some of the procedures lead to other problems a few years later, while others have high failure rates. Some fail early while others last for a decade. Here is a list of procedures that have been used, or are still being used to correct these problems, which, if you look closely, almost all were designed primarily as a correction for urinary incontinence.

• MMK Procedure
• Burch Procedure
• Stamey Procedure
• Raz Procedure
• Anterior colporrhaphy
• Kelly Plication
• Urethral Sling
• Transvaginal Tape Procedure
• Transobturator Tape Procedure

With modern thinking, many now believe that you must look at the pelvis as a whole. With this holistic philosophy, it does the patient a disservice to treat only one aspect of pelvic support failure and disregard the others. Therefore the term "Pelvic Floor Reconstruction" has gained wide popularity since this focuses treatment on every aspect of the pelvis to correct all support issues.

So, how is a Pelvic Floor Reconstruction done?

If your uterus is still present, and you have completed your childbearing, then you should consider having your uterus removed during the pelvic floor reconstruction procedure. The uterus acts as a weight, sitting atop the vagina, and can be detrimental in pushing down on your vaginal support tissues. Chances are, if you are having problems with pelvic support, then you probably already have some degree of uterine prolapse. A laparoscopic hysterectomy will add little recovery time and may greatly improve the quality of your life.

Pictorially, an Anterior Pelvic Reconstruction procedure is performed as follows:

An incision is being made along the vaginal skin (mucosa) overlying the fallen bladder. A catheter has been inserted into the urethra. The vaginal mucosa is opened up, revealing the bladder wall.

Once the bladder wall is visible through the vaginal incision, The Doctor will dissect your bladder off of the underlying vaginal wall, using a combination of scalpel, scissors, and blunt dissections with his finger. They will carry the dissection far laterally on each side until he can feel the inside surface of your pelvic bones. At this point, he will have dissected the space between your vagina and bladder, all the way out to your pelvic bone.

Once the dissection is complete, the Doctor will locate your ischial spines, located on each side of your pelvis. Running from your ischial spines to your sacrum is a firm ligament, called the sacrospinous ligament. This will be a key structure to attach the Repliform Graft Matrix as well as your vaginal apex.

In this picture, all of the skin and muscles have been removed for clarity, so that the ischial spine and sacrospinous ligaments are visible. The Doctor will use a special suturing instrument to attach permanent suture to your sacrospinous ligaments on each side. These sutures will be used to attach the Repliform Graft Matrix to your sacrospinous ligament, and additionally, to attach to your vaginal apex for upper vagina support.

The end result is placement of the Repliform Graft Matrix, in a hammock-like fashion across your pelvis. Above the Repliform Graft Matrix sits your bladder. Your vagina sits just below. This layer will create a strong bladder floor as your tissues grow into the Repliform Graft Matrix over the next 3-6 months.

With your anterior vaginal support corrected, The doctor can next assess your posterior vaginal wall for a rectocele. If a rectocele is present, indicating loss of pelvic support along your posterior vaginal wall, then he will repair this next.

A Posterior Pelvic Reconstruction is performed similarly with a closure of the fascial defect between the vaginal and rectum. Again graft material may be used on the repair to provide additional support and prolong the success of the repair. For additonal questions, please ask your physician.

You will be kept in the hospital overnight to monitor your progress. You can anticipate being discharged the day after your surgery.