Last month another clinical study related to pelvic organ prolapse was described in the American Journal of Obstetrics & Gynecology. This study involved 108 women and compared two pelvic organ prolapse treatment approaches: laparoscopic sacrocolpopexy and total vaginal mesh.

Laparoscopic sacrocolpopexy is a procedure that uses soft synthetic mesh to support pelvic organs that have slipped out of their normal positions. The mesh is initially held in place by friction from strap-like arms of mesh material woven through the pelvis. Body tissues then grow through the mesh, creating the final support. This minimally invasive surgery takes only one to two hours. With the da Vinci Sacrocolpopexy procedure that I offer, the surgery is performed using general anesthesia.

While laparoscopic sacrocolpopexy is performed by laparoscopic access, total vaginal mesh is performed by vaginal access. Another difference is that laparoscopic sacrocolpopexy suspends the mesh from the sacrum — a large, triangular bone at the base of the spine — whereas in a total vaginal mesh procedure the mesh is suspended from pelvic ligaments.

Both procedures have been approved for several years; however, until this study was conducted in Australia, there had never been a controlled trial of this scope.

According to the article in the American Journal of Obstetrics & Gynecology, the study found that despite longer average operating time for laparoscopic sacrocolpopexy (97 minutes vs. 50 minutes for total vaginal mesh), the laparoscopic sacrocolpopexy held several significant advantages over total vaginal mesh: The laparoscopic sacrocolpopexy patients generally experienced fewer days as an inpatient, less blood loss, a shorter catheterization period and a quicker return to regular activities. More importantly, two years after surgery the laparoscopic sacrocolpopexy procedures had a success rate of 77% compared to 43% for the total vaginal mesh procedures. Finally, the reoperation rate (to treat symptoms such as further prolapse, incontinence, and mesh contraction or erosion) was 5% for laparoscopic sacrocolpopexy compared to 22% for total vaginal mesh.

I found these results particularly interesting as well as reassuring, since laparoscopic sacrocolpopexy is the primary pelvic organ prolapse treatment I offer in my practice.

More information on laparoscopic sacrocolpopexy and the da Vinci Sacrocolpopexy procedure can be found here. If you have any questions about these procedures or the symptoms they can be used to treat, please give my office a call.

Dr. John Garofalo, M.D., is gynecologist located in Fairfield County, Connecticut. For more information on Dr. Garofalo and his medical practice, go to www.garofaloobgyn.com. Dr. Garofalo can be reached for a personal consultation at 203.803.1098.

I’m writing about pelvic organ prolapse again because of a recent clinical study that was set up to see if synthetic mesh inserted through a vaginal incision is beneficial in the repair of pelvic organ prolapse. This surgical procedure, called vaginal colpopexy, has been performed using sutures for many years with success rates in the neighborhood of 65-75%. These failure rates are much higher than the failure rate with da Vinci sacrocolpopexy, which I wrote about in my April blog.

Because the failure rate of vaginal colpopexy without mesh was so high, many surgeons have been adding mesh augmentation of vaginal colpopexy in an effort to improve outcomes. Unfortunately, the use of mesh for this indication had never been tested with the most rigorous of scientific studies — the randomized clinical trial — until the study referenced in this blog.

The bottom line from this study is that there were so many complications with the vaginally implanted mesh that the trial was cut short. More than 15% of the patients who received the mesh experienced a potentially serious complication called “erosion”, in which the vaginal tissue split and the mesh protruded, often causing pain and infections. These results were much more negative than the FDA’s warning in 2008 that vaginally implanted mesh complications were “rare”.

Not only were more complications found among the patients in the mesh group, there was also no improvement in success rates for the remainder of patients who had mesh placed. The success rate of surgery was the same whether or not the patient had a mesh implant. In the words of the report’s lead author, “The bottom line is not only were there more complications, but the mesh didn’t prove any better than traditional surgery.”

The alternative to surgical procedure that I recommend for pelvic organ prolapse is da Vinci sacrocolpopexy. In a sacrocolpopexy, the vaginal vault is supported by affixing it to a bone called the sacrum, located at the base of the spine. Sacrocolpopexy is also done with mesh, but it does not result in a high risk of mesh complications because the mesh is not placed through the vagina.

A recent medical report entitled Surgical Management of Pelvic Organ Prolapse in Women supported sacrocolpopexy as the gold standard for pelvic organ prolapse treatment. According to the report, sacrocolpopexy advantages include a high success rate, durability of the repair, and the essential absence of mesh complications. Since sacrocolpopexy using the da Vinci surgical technique can be done without the large abdominal incision previously used for abdominal sacrocolpopexy (discussed on this page of my website), it can be done without the need for a prolonged or painful recuperation.

I have been performing sacrocolpopexy surgery with the da Vinci surgical system with outstanding results, and I am happy that I have avoided the use of vaginally placed mesh for repair of pelvic organ prolapse. We have not seen any cases of mesh erosion in the patients who have had da Vinci sacrocolpopexy. In my  opinion da Vinci sacrocolpopexy is the best procedure for pelvic organ prolapse.

Dr. John Garofalo, M.D., is gynecologist located in Fairfield County, Connecticut. For more information on Dr. Garofalo and his medical practice, go to www.garofaloobyn.com. Dr. Garofalo can be reached for a personal consultation at 203.803.1098.

Prolapse literally means “to fall out of place”. When pelvic organ prolapse occurs, organs such as the uterus or bladder fall down or slip out of place, often pushing into or through the vagina. Pelvic organ prolapse can be uncomfortable and it can interfere with urination, bowel movements and sexual activity.

Going back just a decade or so, the most common treatment options for serious pelvic organ prolapse cases were relatively limited. Reconstructive surgery was one option, and hysterectomy was another. Today, an increasingly common option is called sacrocolpopexy. This is an open surgery in which soft synthetic mesh is used to permanently hold the vagina in the correct anatomical position. After the surgery, your body creates tissue that grows through and around the mesh, helping to restore your anatomy to its natural position and reinforcing the structures around your vagina to maintain support.

This is where da Vinci technology comes in. Instead of the 15-30 cm incision needed for a “regular”, open-surgery sacrocolpopexy, the da Vinci system uses five very small abdominal incisions and state-of-the-art computer technology to convert my hand movements into precise movement of the da Vinci surgical instruments. The procedure usually takes only one or two hours.

As with other da Vinci procedures, da Vinci sacrocolpopexy can provide several advantages. Compared to open abdominal surgery, there’s typically less bleeding, less pain, minimal scarring, quicker recovery, a shorter hospital stay, and a lower likelihood of complications. After a da Vinci sacrocolpopexy, most women usually return home the next day. Many women resume most normal daily activities within four days and recover in two to three weeks, although heavy lifting, strenuous exercise and sexual intercourse should be avoided for up to six weeks.

Sacrocolpopexy also can be performed as a preventative measure. If you or someone you know has decided to have a hysterectomy, sacrocolpopexy can be done after the hysterectomy to provide long-term support of the vagina.

Here are a few quotes from women who have had da Vinci sacrocolpopexy. These quotes and the stories behind them can be found on www.davincistories.com.

“I had a problem with uterine prolapse and urination. I am 100% better after having da Vinci Surgery. Recovery was very fast. There was no pain or discomfort. I was back to work in three weeks, but I could have gone back sooner. I would definitely recommend this surgery to anyone who needs it. It was a breeze.” – Velma, Norwalk CT

“I would not think twice about having another surgery with the da Vinci surgical method. I cannot tell you how pleased I am with my outcome, and I am only five days post-op.” – Diane, North Haven CT

If you live in Connecticut, Dr. Garofalo is a gynecologist serving the Stamford and Bridgeport metro areas.

In the next few weeks, I’ll be posting a series of blogs about da Vinci surgery and how I use it in my own medical practice. If you have any experiences you’d like to share, please feel free to comment.

First, here’s a bit of history about the da Vinci Surgical System:

Back in the late 1980s, a company working with the U.S. Army developed a system that would allow surgeons to perform battlefield surgery by using remote-controlled medical instruments and cameras. This allowed the surgeons to stay away from the fighting, but it had a few other advantages. The surgery was highly precise and “minimally invasive” (it used very small incisions, usually allowing for quicker recovery and less bleeding than “open” surgery). It’s not exaggerating to say that this company developed a breakthrough in surgical technology.

Some of the people associated with the project realized that the technology could be used with a wide variety of surgeries, and not just on the battlefield. In 1995, a company called Intuitive Surgical was founded to develop the technology for commercial use. Intuitive Surgical launched the da Vinci Surgical System in 1999, and in 2000, da Vinci became the first surgical system of its kind approved by the FDA for general laparoscopic surgery. Since then the da Vinci Surgical System has been used successfully in tens of thousands of procedures.

Next week I’ll write about how da Vinci surgery works. If you need information more quickly, you can click on any of the links below, or you can contact my office directly.

Links to da Vinci surgery resources

daVinciSurgery.com
da Vinci Surgery Patient Stories
Dr. Garofalo’s da Vinci information page

Dr. John Garofalo, M.D., is a certified da Vinci surgeon in Fairfield County, Connecticut. For more information on Dr. Garofalo and his medical practice, go to www.garofaloobyn.com. Dr. Garofalo can be reached for a personal consultation at 203.803.1098.