Prolapse

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INFORMATION AND CONSENT FOR PELVIC ORGAN PROLAPSE SURGERY

We recommend that you read this handout carefully in order to prepare yourself or family members for the proposed procedure. In doing so, you will benefit both the outcome and safety of the procedure. By signing this form you are stating that you have been fully informed and understand the indications, risks, benefits and expected outcomes of this procedure, and have had time to ask questions. If you still have any questions or concerns, we strongly encourage you to contact our office prior to your procedure so that we may clarify any pertinent issues.

Prolapse of Pelvic Organ

Prolapse of the uterus or vagina simply means the “dropping” of these structures to an abnormally low position. This bulge from the vagina may include your uterus, intestines, bladder, rectum, or any combination of the above. Because of the complex nature of this problem, it is common for multiple procedures to be performed at the time of surgery.

Hysterectomy

Hysterectomy is the surgical removal of the cervix and uterus. This procedure may be accomplished abdominally, vaginally, or a combination of both.

Enterocele

Enterocele is a hernia of the small intestine into the vagina. The goals of enterocele repairs are to replace the intestines to its normal position and restore the tissue so it will not recur.

Rectocele

Rectocele, in its literal sense, means rectum appearing like a balloon. This balloon-like structure protrudes through the vagina. Rectocele repair attempts to restore the normal anatomy either with your own tissues or a graft material.

Cystocele

Cystocele means bladder appearing like a balloon prolapsing (“dropping”) into and out of the vagina. To repair this problem, we use either your own tissues or synthetic mesh material.

Urinary Incontinence

Urinary incontinence is a very common problem that occurs in conjunction with pelvic organ prolapse. If this is present, it is generally repaired at the same time as your prolapse surgery. Repair of this problem usually involves placing a piece of mesh material underneath the mid-portion of your urethra by passing it through small incisions either above the pubic bone or next to the labia. After the procedure, a telescope called a “cystoscope” may be placed in the bladder to inspect the inside of the bladder.

Vaginal Augmented Repair

These mesh graft procedures are new minimally invasive techniques to help repair different types of prolapse. These procedures use small, specially designed instruments to pass a minimally reactive sterile medical mesh material to reinforce the areas of poor support in the pelvis. This material acts as a scaffold for your tissue to regain and provide stronger support.

Abdominal Sacral Colpopexy

This surgery uses an abdominal approach to attach a permanent mesh graft from the top of the vagina to the back of the pelvic bone in order to permanently hold the vagina in place.

Possible Complications of the Procedure

All surgical procedures, regardless of complexity or time, can be associated with unforeseen problems. They may be immediate or even quite delayed in presentation. While we have discussed these and possibly others in your consultation, we would like you to have a list so that you may ask questions if you are still concerned. Aside from anesthesia complications, it is important that every patient be made aware of all possible outcomes, which may include, but are not limited to:

  • Urinary Tract Infection or Sepsis: Although we may give you antibiotics prior to and after the operation, it is possible for you to get an infection. The most common type is a simple bladder infection (after the catheter is removed) that presents with symptoms of burning urination, urinary frequency, and a strong urge to urinate. This will usually resolve with a few days of antibiotics. If the infection enters the bloodstream, you might feel very ill. This type of infection can present with both urinary symptoms and any combination of the following: fevers, shaking chills, weakness or dizziness, nausea, and vomiting. You may require a short hospitalization for intravenous antibiotics, fluids, and observation. This problem is more common in diabetics, patients on long-term steroids, or in patients with disordera of the immune system.

  • Wound Infection: The incision sites can become infected. While it typically resolves with antibiotics and local wound care, occasionally part or all of the incision may open and require revision and/or catheter replacement.

  • Treatment Failure: Although usually associated with a high success rate, the procedure can fail in the immediate postoperative period, or months to years later.

  • Urinary retention: Retention is the inability to urinate, and it occurs in fewer than 5% of cases. Usually, a patient is able to urinate normally within one to two weeks following the procedure. However, if retention is prolonged, a catheter may be necessary. You could learn to self-catheterize or simply have a urethral catheter placed back in for a few days at a time. It would periodically be removed to test whether you are able to urinate. We always encourage patients to be patient, because urinary retention usually resolves with time and observation. In rare instances of prolonged retention, a corrective procedure may be required. Factors which may delay the rapid return of voiding include: excessive sling tension, poor bladder function before the surgery, and multiple repaired organs (i.e. a dropped bladder, a dropped uterus, or a prolapsed rectum) during the same surgery. Urodynamic testing may need to be performed for further assessment.

  • Blood Loss/Transfusion: The vaginal region is quite vascular. Usually blood loss in this procedure is minimal to moderate. In 1-2% of cases, blood loss can be significant enough to necessitate transfusion.

  • Ureteral Injury/Ureteral Kinking: Enterocele repair procedures often utilize structures within the pelvis that are near or adjacent to the ureters (tubular structures that carry urine from the kidneys to the urinary bladder). When tension is placed on these structures, the ureters can be drawn away from their normal position and partially or completely blocked by kinking. It is also possible to inadvertently injure the ureter by placing an instrument across it, a suture around it, or cutting it with surgical instruments. Ureteral injury can be quite serious and requires prompt attention.

  • Organ Injury: During any part of the surgical procedure, any organ in the abdomen or pelvis (liver, spleen, colon, intestine, bladder, stomach, ureter, etc.) can be inadvertently injured. Often this injury is minor and can be treated with relative ease. In other instances, when the injury is major or the repair is complicated, more extensive surgery may be necessary. Treatment depends on the particular organ injured and the severity of the injury.

  • Bowel/Rectal Injury: It is possible to make a hole in the deeper tissue of the rectum or bowel. In almost all cases, the hole can be repaired, and there are no long-term problems. In severe injuries, we may ask for a consultation from a general surgeon to ensure that no other protective surgical measures should be undertaken.

  • Painful Intercourse and Vaginal Shortening: After prolapse surgery, the shape of the vaginal vault can change. In certain cases, the depth of the vagina may be lessened and the angle changed. While usually not a problem, some women may complain of pain or difficulty with intercourse. Sometimes it is temporary, but it can also be permanent.

  • Deep Vein Thrombosis (DVT)/Pulmonary Embolus (PE): In any operation (especially longer operations), you can develop a clot in a vein of your leg (DVT). Typically, this presents two to seven days (or longer) after the procedure as pain, swelling, and tenderness to touch in the low leg (calf). Your ankle and foot can become swollen. If you notice these signs, you should go directly to an emergency room and also call our office. Although less likely, this blood clot can move through the veins and block off part of the lung (PE). This would present as shortness of breath and possibly chest pain. We may sometimes ask the medical doctors to be involved with the management of either of these problems.

  • Sling Erosion: It is possible for the sling material to erode through the tissue that surrounds it. If the vaginal tissue breaks down, the sling can often be removed with a minimal procedure. Often, the patient is still continent because scar tissue from the surgery will continue to support the urethra. On the contrary, if the back of the sling erodes into the urethra, the surgical removal is more involved, and the rates of incontinence afterward are higher.

  • Graft/Mesh Erosion: It is possible for the permanent graft material to erode through the tissue that surrounds it. If the vaginal tissue breaks down, the graft may need to be removed with another operation. Removal of the graft may lead to repeat prolapse formation and, in rare cases, chronic pain.

  • Bleeding/Hematoma: When a small blood vessel continues to ooze or bleed after the procedure is over, the area of collected blood is referred to as a hematoma. The body normally reabsorbs this collection over a short period of time, and surgical drainage is rarely necessary.

  • Lower Extremity Weakness/Numbness: This, too, is a rare event that may arise due to your position on the operating table. It is possible in procedures in which you are in the lithotomy position (lets up in the air) for a long period. The problem is usually self-limited, with a return to baseline expected; rarely is it permanent.

  • Chronic Pain: As with any procedure, a patient can develop chronic pain in an area that has undergone surgery. Typically, the pain disappears over time, although some feeling of numbness may persist. If persistent, further evaluation may be necessary.

    If you would like a copy of the patient labeling from the manufacturer of the product used in your repair, please inform us and we will obtain a copy for you.

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    Physician/Date Patient/Date Witness/Date