Dr. Kevin Stepp, MD - Urogynecology and Robotic and Laparoscopic Surgery - Carolinas HealthCare System - Mercy Hospital
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Pelvic Organ Prolapse
Urinary Incontinence
Fecal Incontinence
Reconstructive Pelvic Surgery
Uterine Fibroids
Ovarian Cysts
Minimally Invasive Hysterectomy
Single Incisiion Laparoscopy
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How is prolapse treated?

There are several ways to surgically treat prolapse. In general, the options that will be offered to a woman will depend on the training and experience of the surgeon. There is no one right answer for all patients. We suggest a consultation with a fellowship-trained urogynecologist to determine which option is best for each patient. Below is a brief explanation of the different types of surgical repairs that may be considered.

Vaginal Repairs

Traditional vaginal repairs have been used for several decades. These repairs are used for bladder prolapse, cystocele, rectocele, enterocele, uterine prolapse, and vaginal prolapse. These repairs are very common and are performed by many gynecologists. They are called anterior or posterior repair, colporrhaphy, uterosacral or sacrospinous vault suspensions. They are the simplest to perform and have the advantage of being performed through an entirely vaginal approach. That means that they don't generally require a long hospital stay and are relatively well tolerated. Patients usually stay 1-3 days in the hospital after surgery. The surgeon treats the prolapse using the patient's own tissue to repair the connective tissue attachments. Although this may be a good option for some patients, it is the approach that has the highest risk for recurrent prolapse. According to the literature, 20-40% of patients may experience return of their prolapse in the future. It should be noted that although this is a seemingly high recurrence rate, many of those patients will NOT have symptoms or need repeat surgery.



Abdominal Repairs

Another option for prolapse repair is called abdominal sacral colpopexy. This procedure has been performed for more than 20 years. It is a very good operation for uterine or vaginal prolapse. In fact, many would consider it to be the "gold standard." The success rate is well above 90% for at least 20 years. This success rate is, at least in part, because the repairs are performed using a permanent surgical mesh implant.

For many urogynecologists, this is the procedure used when vaginal surgery fails or recurs. It is more difficult and is generally only performed by specialists. The vagina is re-suspended to strong ligaments in the pelvis by the mesh. Since the repair is not relying on the patient's own tissues, the repair has a much better chance of lasting 20-30 years or more. Other defects can be treated at the same time with procedures that repair specific defects: paravaginal defect repair and/or enterocele repair.

The disadvantage is that with most surgeons, it is usually performed through a large abdominal incision. This is much more invasive than vaginal repairs. Patients often spend 2-4 days in the hospital.

Laparoscopic and Robotic Assisted Repairs

Relatively recently, surgeons skilled in advanced laparoscopy have perfected laparoscopic sacral colpopexy. With this approach, patients can receive the "gold standard" procedure with the best success rates - but in a minimally invasive procedure. A small camera is inserted through the umbilicus (belly-button). Additional thin instruments are inserted through a few small incisions less than ½ inch long. The remainder of the surgery should be completed exactly like the well-studied abdominal approach. There can be no short cuts. Therefore laparoscopic sacral colpopexy is difficult and requires several specific skills to complete. With additional training, surgeons can perform the entire case by laparoscopy. In some cases, surgeons may use robotic assistance to overcome some of the more difficult aspects of this complex laparoscopic case. Many patients are able to go home the same day of surgery or after observation overnight. Some patients may be a candidate for the newest type of laparoscopy called Laparo-Endoscopic Single Site surgery (LESS) using only a single tiny incision in the umbilicus to complete the entire prolapse repair.

Vaginal Mesh Repairs

When comparing traditional vaginal repairs with sacral colpopexy, many surgeons feel that the better success rates of sacral colpopexy are due to the use of a permanent mesh material rather than relying on the patient's own weakened tissue. In an effort to improve the results of traditional vaginal repairs and avoid the more invasive open abdominal approach, surgeons began to explore placing mesh vaginally to repair prolapse. Surgeons in Europe were the first to develop some of these techniques and it has been performed in the United States since 2001. (Dr. Stepp trained with one of the original developers in France.) During the procedure, a mesh implant is placed through vaginal incisions using specifically designed instruments. The early results of published reports suggest vaginal mesh procedures have the potential to improve the anatomic success rates for prolapse repair. Other advantages for these procedures are that they result in minimal pain, overnight hospital stay only, and they can be performed quickly. Longer surgeries place patients at higher risk of complications - particularly patients over 70 years old. Potential disadvantages include lack of long-term research, possible pain with sexual activity, or problems related to mesh healing. We generally do not perform this procedure on patients who are or plan to be sexually active.

Pelvic Reconstructive Surgery

Dr. Stepp specializes in rebuilding and restoring the vagina and pelvic anatomy to its normal state. Whether patients have experienced trauma during childbirth and/or episiotomy, or as a result of complications from prior surgery, Dr. Stepp can help restore the normal supportive and functional structures of the pelvis and vagina. His approach is to address the entire pelvis from the deeper supportive ligaments to the outer structures also responsible for good support and function.