Pelvic organ prolapse (POP) also known, as vaginal prolapse is a common problem among women of all ages. Prolapse simply means a lack of support or relaxation. Any of the following pelvic organs, the uterus, bladder, urethra, rectum and intestines can prolapse (or fall) out of its normal anatomic position. 50% of women who have had children will have some form of pelvic organ prolapse in their lifetime.

With prolapse, you may feel a bulge coming out of the vagina. It is vital that a proper diagnosis is completed prior to any procedure to ensure that the prolapse is addressed during any repair to reduce the risk of recurrence in the future. Drs. Miklos and Moore complete a comprehensive exam prior to surgery to ensure that all areas of vaginal support are addressed in one surgery.

Common causes of vaginal prolapse include

  • Childbirth
  • Menopause
  • Genetic pre-disposition
  • Hysterectomy
  • Previous pelvic surgery
  • Pelvic or spinal trauma

Figure 1a

Pelvic Organ Prolapse 1a-01

Figure 1a

“Normal” Vaginal and Uterine Support (side view)

Figure 1b

Example of a type of prolapse – Uterine Prolapse

Figure 1b

Pelvic Organ Prolapse 1b-01

Common causes of vaginal prolapse include

Types of Prolapse

  • Uterine Prolapse
  • Vaginal Vault Prolapse (upper 25% of vagina)
  • Cystocele (bladder)
  • Urethrocele (urethra + cough leakage)
  • Rectocele (rectum)
  • Enterocele (intestines)

Surgical Treatment Options

  • Hysteropexy (uterine suspension) or Mesh or Own ligaments
  • Uterosacral Ligament Suspension or Laparoscopic Mesh Sacrocolpopexy
  • Paravaginal Repair (abdominal approach) or Anterior Repair (vaginal approach)
  • Urethrocele (urethra + cough leakage)
  • Paravaginal Repair w/ Burch (abdominal/laparoscopic)
  • Enterocele repair

“After having a previous surgery that did not correct my problems (uterine prolapse), I wanted to find a specialist that could fix me. After doing some research and reading all the information that is on your website, I met with Dr. Miklos and discussed what went wrong with my recent surgery and what we needed to do to correct it. Dr. Miklos gave me a packet of information and I felt that I knew everything upfront. After my surgery, I felt great from day 1, I knew I made the right decision; unlike my previous surgery, where I had a problem once I left the hospital. To other women out there – you don’t have to live in silence anymore. Knowledge is power!
J.S.
Alpharetta, Georgia

Laparoscopic Hysteropexy Surgery

Uterine Preservation

• 90-95% Cure Rate

• Woman’s choice to keep her uterus

• Minimally Invasive procedure

• Outpatient surgery

• Can be completed with patients own ligaments or mesh

Traditional medicine recommends removal of the uterus (hysterectomy) when there is uterine prolapse. Drs. Miklos & Moore realize it is a woman’s right to make decisions about her uterus and ovaries and will do everything possible to respect the rights and wishes of the woman with respect to her uterus and ovaries. Uterine suspension (Hysteropexy) is now an option for women wishing to maintain or keep their uterus and avoid hysterectomy. The procedure has been shown to be an effective option for the treatment of uterine prolapse.

The laparoscopic hysteropexy may be completed with the patient’s own ligaments (round and uterosacral ligaments) and in certain cases mesh is recommended to increase the cure rate. The laparoscopic mesh hysteropexy procedure involves placing a piece of mesh on the uterus to suspend it to the tailbone, thus giving women the ability to keep their uterus while attempting to restore uterine and vaginal support. The mesh is a stronger substitute for the original uterosacral ligaments, and has a higher cure rate than the patients’ original supportive ligaments.

Figure 2a

Pelvic Organ Prolapse 2a-01

Figure 2a

Prolapsed Uterus

Figure 2b

Mesh attached to the sacrum and uterus to reestablishes uterine support

Figure 2b

Pelvic Organ Prolapse 2b-01

Laparoscopic Sacrocolpopexy

Vaginal Vault Prolapse

• 98% Cure Rate

• Authored largest published series in the World literature on Laparoscopic Sacrocolpopexies

• Over 1600 sacrocolpopexies performed

• Shorter recovery time vs. abdominal or robotic approach

• Decreased operating time vs. abdominal or robotic approach (Video “The 26 minute Sacrocolpopexy” click here to watch)

• Winners of the AAGL Golden Laparoscope Award for their surgical technique

• Gold Standard Procedure

The laparoscopic sacrocolpopexy is the most successful operation ever developed for vaginal vault prolapse and is considered the Gold Standard by all organizations including the American Urogynecologic Society and the FDA for severe vault prolapse. By performing the laparoscopic sacrocolpopexy, Dr. Miklos and Dr. Moore are able to reposition the vagina to its anatomic position using abdominal mesh attached to the vagina and then to the sacrum (tailbone) for anchoring support. This procedure is complex in its nature and requires great expertise for a favorable outcome.

Most surgeons perform this procedure through a large incision thus contributing to a longer recovery time. Drs. Miklos and Moore take 2-4 less hours to perform this procedure laparoscopically than surgeons utilizing the robot. The robotic approach has also been shown to have higher rates of post-operative pain and does not offer the patient any increased benefits compared to the laparoscopic approach.

Drs. Miklos and Moore have performed the laparoscopic sacrocolpopexy procedure over the past 15 years and wrote the largest published surgical experience in the world of over 400 patients in just 3 years. They have performed more than 1600 laparoscopic sacrocolpopexies.

Though some people have reservations about using mesh for vaginal vault suspension, Drs. Miklos’ & Moore’s paper on sacrocolpopexy illuminates how rare these complications occur. The sacrocolpopexy is without a doubt the BEST OPERATION ever developed for uterine and vaginal vault suspension.

Read Published Paper

Figure 3

Pelvic Organ Prolapse 3-01

Figure 3

Sacrocolpopexy “Y-mesh” placement. Lateral view of mesh attached to the both anterior wall and posterior wall of vagina and then to the sacrum (tailbone).

“Thank you so much for all you have done for me in the past 5 years. You have made my life so much better. I truly appreciate you and all your staff. I’m excited that I feel human again.”
R.C.
Boynton Beach, Florida

Cystocele

Prolapsed Bladder

Prolapsed Bladder (Cystocele) Symptoms:

• Vaginal pressure
• Vaginal bulge
• Lower back pain
• Urinary leakage
• Difficulty emptying bladder
• Straining with urination
• Urinary urgency/frequency

When a person has a fallen bladder ( bladder prolapses or bulges into or out of the vagina) this simply means the ceiling of the vagina that holds the bladder in its normal position is broken. This condition is called a cystocele.

When there is a break in the support of the anterior vaginal wall, the bladder and urethra fall or bulge into or out of the vagina, resulting in a cystourethrocele.

Two main types of cystocele repair or surgery for fallen bladder are:
1) Paravaginal repair
2) Anterior repair

Figure 4

Pelvic Organ Prolapse 4-01

Figure 4

Cystocele – bladder prolapse

Laparoscopic Paravaginal Repair

• 20-30 minute procedure

• Laparoscopic approach ~ minimally invasive

• 2015 ~ Drs. Miklos & Moore published the largest comprehensive review in worldwide literature on Laparoscopic Paravaginal Repair

Read Literature

Greater than 90% of cystoceles are due to paravaginal defects. This simply means the ceiling of the vagina, which supports the bladder, has torn away from its lateral attachment to the pelvic floor muscles. The anatomically correct surgical procedure for a fallen bladder (cystocele) is a paravaginal repair. The paravaginal repair is accomplished by using sutures to re-approximate the ceiling of the vagina back to its point of original attachment at the obturator internus muscle. The paravaginal repair will restore the bladder and the urethra to its normal anatomical position.

Figure 5a

Supported bladder – no defect

Pelvic Organ Prolapse 5a-01

Figure 5b

Paravaginal Defect / Fallen Bladder

Pelvic Organ Prolapse 5b-01

Figure 5c

Paravaginal repair

Pelvic Organ Prolapse 5c-01

“I had several procedures including the hysteropexy, paravaginal and posterior repairs. In all it was a more difficult surgery than I hoped but the recovery was also faster and more complete than I expected.
I want to thank you and your entire team. I had no idea how much I needed this surgery until it was over and I began to heal. At twelve weeks I feel wonderful, better than ever!!!!!!!”
Prolapse Patient
Green Bay, Wisconsin

Anterior Repair

The anterior repair is the most commonly utilized operation for correction of a cystocele. Anterior repairs should be used when the ceiling of the vagina is broken, which is known as midline or central defects.

The problem with doing an anterior repair on young, healthy, sexually-active woman with a paravaginal defect (lateral break cystocele) is that the surgeon does not really surgically support the bladder, but instead reduces the bulge by “scrunching ” the fascia under the bladder together. This is neither the best nor the anatomically correct surgical procedure to restore normal anatomy. This is why with most patients Drs. Miklos & Moore recommend the Laparoscopic Paravaginal repair to correct a significant cystocele as this approach actually repairs the tears where they occur.

The anterior repair for a cystocele should or can be utilized in patients with:
• Midline defects
• Mild anterior wall relaxation
• Defects which are not paravaginal
• Cystocele of any type in patients whose vaginal function and length is not important

Figure 6a

Pelvic Organ Prolapse 6a-01

Figure 6a

Identifying Midline Defect – The break in the pubocervical fascia (support layer) is present as the bladder can be seen through the defect.

Figure 6b

After the break in the pubocervical fascia is repaired, the covering layer known as the vaginal epithelium (skin) is closed using sutures.

Figure 6b

Pelvic Organ Prolapse 6b-01

Posterior Repair for Rectocele

Rectocele symptoms:

• Vaginal pressure / discomfort

• Protrusion/Bulge coming from the posterior vaginal wall

• Difficulty evacuating rectum

• Dyspareunia (painful intercourse)

• Repositioning of body during bowel movements

A rectocele (posterior vaginal prolapse) occurs when there is a break in the rectovaginal septum. The rectovaginal septum or rectovaginal fascia is the supportive layer of the posterior vaginal wall aka vaginal floor. When there is a loss of support present in the rectovaginal septum, the rectal wall will come into contact with the vaginal skin and create a bulge on the floor of the vagina.

Dr. Miklos and Dr. Moore utilize the site-specific posterior repair and add a biologic graft (when necessary). This rectocele repair restores normal anatomy and minimizes the risk of vaginal narrowing or shortening that is common with other traditional posterior repairs.

The vaginal skin is incised and the overlying skin is meticulously dissected from the underlying supportive rectovaginal fascia. The defects in the fascia are identified and repaired (site-specific fascia repair) using suture. Patients rarely complain postoperatively of painful intercourse or of a narrow vagina following this procedure. The majority of women with difficulty evacuating the rectum prior to surgery will typically find that there is an improvement in these symptoms following repair.

Figure 7a

Rectocele is a result of broken rectovaginal fascia (the support layer) of the posterior vaginal wall or floor of the vagina. Side view
Pelvic Organ Prolapse 7a-01

Figure 7b

The rectovaginal fascia defects are the most common type of tear. Here the supportive floor of the vagina, known as the rectovaginal fascia, has completely detached from the walls on each side or bilaterally.
Pelvic Organ Prolapse 7b-01

Figure 7c

The site-specific repair is complete. The rectovaginal fascia is re-attached to the perineal body where the distal defect was located.
Pelvic Organ Prolapse Figure 7c

“Dr. Miklos did my sacrocolpopexy, as well as anterior and posterior vaginal repair, tot sling and hysterectomy in late June 2008. My surgery was success and I am happy with the results.”
N.F.
Spain