Surgical Treatments

Pelvic Organ Prolapse Surgery

Dr. Zipper is a world leader in Urogynecology innovation and has trained over 1000 physicians in his surgical methods.  Over the past two decades, Dr. Zipper has been responsible for major improvements in the treatment of incontinence and pelvic organ prolapse.  Many of these improvements have allowed women to live more comfortable, healthy lives.

At his office in Melbourne, Florida, Dr. Zipper treats women suffering from various types of prolapse everyday.  Often these conditions are severe and patients experience great pain, discomfort, and embarrassment.  Pelvic organ prolapse is a common disorder from which many women suffer. This disorders is characterized by a loss of support to the pelvic organs. In layman’s terms, the bladder, rectum, and/or uterus may bulge down or even out of the vagina.  Women who have had a hysterectomy may even experience vaginal vault eversion, a debilitating condition where the vagina turns inside out and hangs down between the legs. These disorders are embarrassing, disabling and cause my patients great physical and mental anguish.

Conventional surgery for such disorders involves pinching together the weakened pelvic tissues in order to reduce the bulge. These surgeries are referred to as anterior and posterior repairs. Unfortunately, pinching together weakened tissue creates a weak repair that often fails.  In search of a better way, surgeons over the last several decades have looked to medical device companies for surgical ‘patches’ that may be used to support the pelvic organs. These patches are known as ‘mesh.’  Like most new technology, this material remains a work in progress and the ideal mesh has not yet been identified.  Although the FDA has approved transvaginal placement of polypropylene mesh for many years and has not taken such off the market, it is not a good material. It is, however, the best available material.

While device companies are still trying to develop better mesh technology, they have shown no reluctance in the marketing of suboptimal mesh to non-expert surgeons across the county. They are in the business of selling product.  As a result, thousands of women have suffered complications of transvaginal mesh surgery.  Medical research suggests that more than fifty percent of women could be experiencing adverse post-surgery complications from this material.

The FDA recently released a second update on the transvaginal placement of mesh. Here are some highlights of the FDA update:

  • The most frequent complications of transvaginal mesh placement
    • Erosion of the mesh (mesh exposed causing bleeding and discharge)
    • Pelvic Pain
    • Pain with intercourse
    • Inability to have intercourse
  • Additional surgeries may be required to deal with complications
  • There is limited evidence to suggest that mesh surgery provides superior results to traditional non-mesh vaginal surgeries
  • Mesh placed abdominally is associated with lower complication rates
  • Surgeons should receive special training in using mesh
  • Surgeons should recognize that most cases of prolapse can be treated successfully without mesh

After reviewing credible literature, interacting with other surgeons and drawing from my fifteen years of experience as a pelvic surgeon, I agree with the many of the FDA's conclusions. In most cases, prolapse can be treated without the use of mesh. Although I continue to use mesh for the most severe forms of prolapse, I feel that women should avoid mesh surgery whenever possible. In cases where I determine mesh is necessary, I typically use the da Vinci robot to safely insert the material. There is growing data to suggest that the Robotic placement of mesh can substantially lower the chances of experiencing complications. Indeed, we have not had a single complication from mesh placed with the robot. For severe cases of prolapse where mesh is required, it is important to always ask about robotic placement of the material. If something doesn't sound right, don't hesitate to get a second or third opinion.

Finally, remember that you have a choice. Read up before your appointment, ask tons of questions, and don't agree to anything that makes you uncomfortable. I understand the pain and embarrassment associated with prolapse, I see it everyday. Do not let that embarrassment and discomfort cloud your good judgment. You don't have to say yes to mesh. Below is a description of common surgeries performed for pelvic organ prolapse. Our preferred procedures are marked with a big smile.

Thermal Colporrhaphy:
Zipper Urogynecology Success Rates (70-80%)

plasma bladeThis is a newer method of prolapse surgery developed by Dr. Zipper.  It is a more comprehensive version of the Incisionless Vaginal Rejuvenation® surgery developed by Dr. Zipper in 2008. Although Thermal Colporrhapy not incisionless, it utilizes many of the principles of Incisionless Vaginal Rejuvention®. Rather than use mesh to cover weak areas, energy is used to stimulate new collagen formation.  Not only does Thermal Colporrhaphy allow us to avoid the use of mesh in cases of moderate prolapse, it significantly reduces the amount of suture material required. Also, unlike traditional anterior and posterior repairs that tend to destort vaginal anatomy, this method tends to restore normal anatomy.

daVinci Robotic Sacrocolpopexy:zipper happy face
National Average Success Rates (60-80%)
Zipper Urogynecology Success Rates (70-80%)

davinci robotic systemThis is a surgery that utilizes the daVinci Robot to suspend the vagina to a bone in the pelvis called the sacral promontory.  Sacrocolpopexy was originally performed as an open surgery (a large incision was made in the abdomen). This surgery, known as abdominal sacrocolpopexy is still performed by many surgeons. Although results are excellent, abdominal incisions are associated with significant discomfort, slower healing, and higher risks than laparoscopic surgery. Hence, some surgeons perform sacrocolpopexy using as series of small abdominal incisions and a camera. This is called Laparoscopic Sacrocolpopexy.  Dr. Zipper is one of a growing number of urogynecologists using the da Vinci Robot to perform this laparoscopic procedure. Data suggests that Robotic Sacrocolpopexy has a lower complication rate and more rapid recovery than other methods. Although all forms of sacrocolpoexy utilize a small piece of mesh, complications of mesh used in this surgery are rare compared to vaginal mesh surgery.

Although everyone wants to be treated quickly, rushing is usually a mistake. Many patients suffer from combined prolapse (such as vaginal and bladder).  Rather than undergo a both Robotic Sacrocolpopexy (for the vaginal prolapse) and Thermal Colporrhapy (for the bladder prolapse),  Dr. Zipper often recommends waiting on the latter. “When performing the Robotic Sacrocolpopexy with or without Robotic Supracervical Hysterectomy, we are able to reduce a significant amount of bladder bulge and rectal bulge. Hence, it makes the most sense to allow several months to elapse following the robotic surgery before considering other surgery. Many patients will require no further surgery. Those few that do require additional surgery usually can be treated with a much smaller outpatient procedure.

Anterior and Posterior Repairs:
National Average Success Rates (60-80%)
Zipper Urogynecology Success Rates (70-80%)

These are also commonly referred to as anterior and posterior colporrhaphies. They are midline plication surgeries. This means the surgeon treats a hernia in the center of a cystocele or rectoceles by pinching it closed with the surrounding tissue. This is done through vaginal incisions. Failure rates are high secondary to the fact that the surrounding tissue is often as weak as the herniated tissue. Success rates are highest among younger patients treated by experienced surgeons. We rarely offer Anterior and Posterior Colporrhaphy as the primary treatment for prolapse. The most common complication is deformity of the vagina leading to sexual dysfunction. Many surgeons cut out some of the vaginal mucosa. This is the "skin" of the vagina. Removing skin can deform the vagina. We remind our student surgeons that our patients do not have more skin then they were born with. Removing the skin is usually a mistake.

Paravaginal Repair:
National Average Success Rates (60-80%)
Zipper Urogynecology Success Rates (70-80%)

This is a lateral plication surgery used for anterior compartment failure. If the surgeon identifies a tearing of the anterior compartment support (bladder support) from its attachment to the pelvic side wall, he can pinch this closed with suture. This can be done through a vaginal incision. Failure rates are high secondary to the fact that the surrounding tissue is often almost as weak as the herniated tissue. Success rates are highest among younger patients treated by experienced surgeons. We rarely offer Paravaginal Repair as the primary treatment for anterior compartment failure. The most common significant complication is injury to the ureters (the tubes that drain urine from the kidneys to the bladder). This is uncommon when surgery is performed by a surgeon well experienced in this technique.

Sacrospinous Colpopexy:
National Average Success Rates (60-80%)
Zipper Urogynecology Success Rates (N/A)

Colpopexies are a group of surgeries used to treat prolapse of the vaginal apex. Sacrospinous colpopexy is a vaginal approach to apical suspension. The surgeon attaches the vagina directly to the sacrospinous ligament. This is a strong band of collagen overlying the coccygeous muscle. This ligament is typically quite strong even in older patients with severe prolapse. Unfortunately, the tissues of and surrounding the vagina are weak. Hence, the surgeon is attaching weak vaginal tissue to a strong ligament. Failure rates are high secondary to the weak vaginal tissue. The most common complications are surgical hemorrhage leading to blood transfusion and injury to nerves of the pelvis. Many patients experience prolonged sciatic nerve discomfort following this surgery. This surgery also tends to deviate the vagina to one side. We do not perform this surgery.

Graft Surgeries

Warning: The transvaginal placement of material may be associated with significant complication and Zipper Urogynecology reserves such treatment for only the most severe forms of prolapse. Most severe prolapse can be treated with a combination of our preferred methods avoiding transvaginal graft (mesh) placement.

Natural Graft MaterialNatural Graft Material:
National Average Success Rates (70-80%)
Zipper Urogynecology Success Rates (85%)

Warning: The transvaginal placement of material may be associated with significant complication.

The most commonly used natural material is porcine dermis. This is the thick tissue directly beneath the outer layer of pig skin. Cadaveric human fascia (the thick covering of human muscle) is also used. However, the best results have been achieved with porcine dermis. This is at least in part secondary to the fact that cadaveric fascia typically comes from old and sick people (remember, they are dead). One of the most common complications of graft surgery is incisional separation. This means that the incision in the vagina opens after surgery. When this occurs with a natural graft material, it often closes. No surgery is required. This is not true of synthetic grafts. The down side to natural material is that it may not last. The success of the natural graft is predicated on the ingrowth of your own cells. This means your body needs to react to the material and send new cells through it. When the process is successful, you create healthy natural scar tissue that provides support. However, in many patients, the natural graft will not last long enough for this process to occur. The surgery fails. Still success rates are substantially higher than the old fashioned plication ("pinching") surgeries and the risk of vaginal distortion is lower.

Synthetic Graft Material

Synthetic Graft Material:
National Average Success Rates (70-90%)
Zipper Urogynecology Success Rates (95%)

Warning: The transvaginal placement of material may be associated with significant complication.

The only synthetic material routinely used in vaginal surgery is polypropylene mesh. This is a light weight weaved plastic material which is soft and durable. Polypropylene mesh is used in the majority prolapse surgery performed by Urogynecologists. As no other synthetic materials are routinely used, the word mesh is often assumed to mean polypropylene. Not surprisingly, mesh fails less often than natural animal grafts (also called xenografts). This is because mesh is permanent. Although its porous nature allows the bodies cells to migrate through, the success of the surgery is not predicated on this. The mesh is permanent. Unless the mesh tears off the attachment points used by the surgeon, failures are rare. As is true also for natural graft material, one of the most common complications is incisional separation. However, when incisional separation occurs over a piece of mesh, spontaneous healing is less likely. Although there are often no symptoms associated with incisional separation, bleeding, discharge, and odor can occur. In addition, a small piece of exposed mesh can cause male discomfort with intercourse. Therefore when incisional separation occurs in a sexually active patient or when there is spotting or discharge, we recommend surgical correction. This is a 5-minute procedure that involves excision of the small exposed area of mesh and one or two stiches. Incisional separations are extremely rare for posterior compartment surgery but quite common in anterior compartment surgery. The reason for such remains unclear.

Synthetic Graft MaterialSynthetic Graft MaterialSynthetic Graft Material

Anterior and Posterior Graft Vaginoplasties:
This involves the use of graft material to treat anterior and/or posterior compartment failure. A Urogynecologist may shape their own graft material or use preshaped pieces that come in surgical kits manufactured for pelvic organ prolapse. Shown below are some of the more commonly used kits. Visit Diagram Gallery

Graft Colpopexies:
This involves the use of graft material to support the vaginal apex. The graft material is most commonly secured to strong structures in the pelvis such as the sacrospinous ligament or arcus tendineus. Alternatively, the graft may be attached directly to the sacrum. Unlike old fashioned colpopexies the weakened vaginal tissues are never attached directly to these supporting tissues. . Visit Diagram Gallery

Approaches to Prolapse Surgery:
Prolapse surgery may be performed through a vaginal incision, an abdominal incision, or through laparoscopy (a series of small abdominal incisions through which scopes are placed) . A skilled vaginal surgeon can treat most types of prolapse through a vaginal incision. However, more severe forms of prolapse may require an Abdominal and Laparoscopic approach. This is called sacrocolpopexy. The da Vinci Robot has allowed urogynecologists to perform more comprehensive repairs laparoscopically. Hence, the da Vinci robot may be combined with our preferred non-mesh approaches to treat the majority of pelvic organ prolapse.

When considering an approach to prolapse surgery, it is important to make sure your surgeon is skilled in that approach.

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