Abdominal Mesh Operation for Vaginal Vault Prolapse (Sacrocolpopexy or Sacrohysteropexy or Sacrocervicopexy)

Abdominal mesh operation for vaginal vault prolapse (Sacrocolpopexy or Sacrohysteropexy or Sacrocervicopexy)

Department of Gynaecology

It has been recommended that you have a Sacrocolpopexy or Sacrohysteropexy or
Sacrocervicopexy with or without Hysterectomy for prolapse.

This leaflet explains some of the benefits, risks and alternatives to the operation. We
want you to have all the information you need to make the right decision. Please ask
your Gynaecologist or Specialist Nurse about anything you do not fully understand or
want to be explained in more detail.

We recommend that you read this leaflet carefully. You and your doctor (or other
appropriate health professional) will also need to record that you agree to have the
procedure by signing a consent form, which they will give you.

What is a prolapse?
A prolapse is the collapse of the uterus (womb) and/or vaginal walls away from their
normal position inside the body. Vaginal vault prolapsed is descend of the top of the
vagina from its normal position. The vagina and womb is held in position by the body’s
natural supporting structures. Prolapse happens when these supporting structures
become weakened and the womb and the vagina slips down from its normal position.

The condition occurs more commonly with increasing age but may also be associated
with inherited muscle weakness, previous hysterectomy, obesity, changes in your
hormone levels and childbirth (particularly vaginal birth).

What is Sacrocolpopexy?
It is an operation to treat a vaginal vault prolapse (sacrocolpopexy) or a prolapse of the
womb (sacrohysteropexy) or a prolapse of the womb where of neck of womb is left
behind (Sacrocervicopexy). It lifts the vagina, uterus or cervix back into its normal
position by attaching a piece of synthetic mesh between the top and back of the vagina
to the ligament over the bone of the pelvis (the sacrum). The aim of this operation is to
reduce vaginal wall prolapse and to restore anatomy and function of the vagina.

Additional procedures like repair for co-existing prolapse or TVT for incontinence or
Hysterectomy may be carried out at the same time depending on your symptoms. This
will be discussed with you in the clinic.

It is either performed abdominally through a 8 – 10cm cut just above the pubic hairline
or via keyhole surgery (laparoscopy). Your doctor will advise which method is the most
suitable for you. Factors such as previous surgery will affect which type will be used.
Both types of operation are performed under a general anaesthetic. This means you will
be asleep for the procedure. These operations normally take about 1-1.5 hrs hours open
or about 1.5-2.5 hrs laparoscopically. If you are having keyhole surgery, please ask for
a copy of the laparoscopy information leaflet.

The wound is closed with clips or stitches that are usually removed on the fourth
day after the operation (could be absorbed itself). A catheter will be inserted into the
bladder to help the bladder to drain. You will have a drip in your arm, which will allow
you to have fluids until you are able to drink normally. A ribbon gauze (known as a pack)
may be put in your vagina to apply some pressure to the cut surfaces to reduce bleeding
and will be removed next day.

At the end of the operation you will be transferred to the recovery where your blood
pressure and pulse will be monitored. Once you are awake and the staff is happy with
your progress you will be taken back to the ward. Recovery from a traditional operation
takes 3 or 4 days in hospital and approximately 6 weeks off normal activities until you
feel well enough to return to your routine. Recovery from a keyhole operation
(laparoscopic) is similar although pot-operative discomfort may be a little less and
discharge perhaps a day earlier.

Diagram showing the pelvis after the mesh has been inserted

How successful is the operation?
Sacrocolpopexy has been used for almost 20 years with good results. The success rate
is 90%. This is the same for the open or the keyhole operation. Because laparoscopic
procedures are newer than abdominal procedures, there is less knowledge of how
successful laparoscopy is in the long term.

What are the benefits of this surgery?
The benefits of this surgery are to improve or resolve the symptoms of prolapse (eg to
remove the feeling of a lump in the vagina).

What are the risks involved in having a sacrocolpopexy?
Every attempt is made to reduce the risk of complications, but no surgery is without risk
and sometimes complications can occur even when a procedure is done by the very
best surgeon.

The following general complications can happen after any surgery:

• Anaesthetic problems – With modern anaesthetics and monitoring equipment, these
  are very rare.
• Bleeding – Occasionally it is difficult to control bleeding from the veins around the
  backbone, and rarely you may need a blood transfusion. Rarely, a second operation
  may be necessary to stop the bleeding.
• Wound infection – Although we give you antibiotics and we keep everything sterile
  it is not possible to completely prevent you from getting an infection. This will usually
  clear with a course of antibiotics, but you may need to be in hospital for longer than
  expected and you may notice some discharge from the wound.
• Cystitis – Sometimes you can get some burning on passing urine from a bladder
  infection. This may occur while you are in hospital or after you have gone home. If
  the doctor thinks you have a bladder infection you will be advised to take a course
  of antibiotics to clear it.
• Immediately after the catheter is removed you may have difficulty passing urine, this
  usually settles over a few days but may require a further catheter in the bladder.
• Damage to nearby organs e.g. damage to the bladder, ureter (tube from the kidney
  to the bladder) or bowel. This is more likely to occur if you have had previous surgery
  in your tummy. This would usually be repaired at the time of the operation but may
  require further surgery or conversion to a laparotomy (a large midline cut to open
  the abdomen) if serious.
• There is a small risk of thrombosis (blood clot in the leg) but injections are given
  following the operation to reduce this.
• Pain and Sexual dysfunction (rare). Persistent discomfort during intercourse can be
  a problem for 1 in 10 ladies.

The following complications are particular problems of sacrocolpopexy.

• Failure of the operation to achieve its aim. There is a possibility that following a
  prolapse operation it will not cure all your symptoms even if the prolapse is
  effectively repaired and also that over time a prolapse will return. This may not be
  a prolapse of the same part of the vagina. In about 5-10% cases a vault prolapse
  will recur after an abdominal sacrocolpopexy.
• Some women who have an operation for prolapse get problems with their bladder
  after. If the doctor thinks this is particularly likely they will have discussed the
  possibility of a TVT / colposuspension at the same time. Unfortunately, a small
  percentage of women (2-5%) develop stress incontinence (bladder leakage with
  coughing or exercise) after this operation even when it is not expected. You may
  find that you need further surgery for this at a later time.

• Very occasionally (approximately 1% of women) the mesh can wear through into
  the vagina, and this may cause a vaginal discharge. If this happens it can usually
  be fixed by trimming the mesh and sewing the vagina over – which can be done as
  a day case procedure. More rarely (1 in 200 cases) the mesh can work its way into
  either the bladder or bowel which is a more serious complication and require further
  surgery. Infection and rejection of the mesh by the body requiring its removal.

• Post operative bowel ileus (slowing of bowel movements) and post operative bowel
  obstruction requiring further surgery (laparotomy) can happen in 1% cases. The
  latter may not become apparent for up to 7-10 days post-operatively. If this happens
  the mesh may need to be removed and bowel surgery may be required. Some
  patient may suffer from temporary Constipation following surgery which improves
  itself.

• If you are planning to have children after the procedure, a pregnancy may
  damage the repair and cause the prolapse to recur. To help prevent this, you may
  be advised to have a scheduled caesarean section rather than a vaginal birth.

Alternatives to surgery
Not all women with prolapse symptoms opt for surgery, and because prolapse occurs
at different degrees not all women need to have surgery as first-line treatment. The
decision to proceed with surgery is taken on an individual basis. The alternatives offered
depend on the type of symptoms you present with. Treatments include:

• Physiotherapy.
• Pelvic floor exercises.
• Vaginal pessary (a plastic device inserted into the vagina to hold the prolapse up).

Your pre-surgery assessment visit
You may be asked to attend a pre-surgery assessment clinic before admission. This
allows you, the nurse and doctor to go through all the paperwork and discuss any
queries. The nurse will explain the ward routine and what to expect before and after the
operation. For example, when you will be allowed to eat and drink before and after the
operation, when you can expect to be out of bed and what observations the nurses need
to do. At this appointment, we will also record your current symptoms and past medical
history, including any medication you are taking. Your heart and lungs will be examined
to check that you are well enough for surgery. Blood tests and x-rays will usually be
taken or arranged during this clinic.

The members of the gynaecology team will check that you agree to have the planned
surgery. If you have been given a consent form please bring it with you, alternatively
you may be given a consent form in clinic. Make sure that you have read and understood
this information before your clinic visit. If you have not understood any part of the
information, you will be able to ask any questions you may have about your planned
surgery. You may also receive two drinks 2-4 hours apart to clean out your bowel day
before the operation.

Before you come into hospital
There are some things you can do to prepare yourself for your operation and reduce the
chance of difficulties with the anaesthetic.

• If you smoke, consider giving up for several weeks before the operation. Smoking
  reduces the amount of oxygen in your blood and increases the risks of breathing
  problems during and after an operation.
• If you are overweight, many of the risks of anaesthesia are increased. Reducing
  your weight will help.
• If you have loose or broken teeth or crowns that are not secure, you may want to
  visit your dentist for treatment. The anaesthetist will usually want to put a tube in
  your throat to help you breathe. If your teeth are not secure, they may be damaged.
• If you have long-standing medical problems, such as diabetes, hypertension (high
  blood pressure), asthma or epilepsy, you should consider asking your GP to give
  you a check-up.

There is a risk that your procedure will be cancelled if there is a chance of very early
pregnancy. In order to be sure you are not pregnant at the time of the procedure you
must not have sex or you must use reliable contraception between the first day of the
last NORMAL period to the date of procedure.

Being admitted to the ward
You will usually be admitted on the day of your surgery we can prepare you for the
surgery. We will welcome you to the ward and check your details. We will fasten an
armband containing your hospital information to your wrist.
If you are at high risk of blood clots in your legs after surgery, we may give you heparin
injections and ask you to wear support stockings before and after your surgery. We will
usually ask you to continue with your normal medication during your stay in hospital, so
please bring it with you.

Your pre-surgery visit by the anaesthetist
After you go into hospital, the anaesthetist will come to see you and ask you questions
about:

• your general health and fitness;
• any serious illnesses you have had;
• any problems with previous anaesthetics;
• medicines you are taking;
• allergies you have;
• chest pain;
• shortness of breath;
• heartburn;
• problems with moving your neck or opening your mouth; and
• any loose teeth, caps, crowns or bridges.
  Your anaesthetist will discuss with you the anaesthetic they will use.

On the day of your operation

Nothing to eat and drink (nil by mouth)

• It is important that you follow the instructions we give you about eating and drinking.
  We will ask you not to eat or drink anything (including chewing gum or sucking
  sweets) for six hours before your operation. This is because any food or liquid in
  your stomach could come up into the back of your throat and go into your lungs
  while you are being anaesthetised. You may take a few sips of plain water up to two
  hours before your operation so you can take any medication tablets.
• If your surgery is scheduled in the morning you must have nothing to eat or drink
  from midnight unless instructed by your doctor.
• If your surgery is scheduled for the afternoon you must not eat or drink from 7.30am.

Your normal medicines

• You may be asked to stop Aspirin and other non-steroidal anti-inflammatory
  medications 7 days prior to surgery.
• Hormonal medication such as HRT should normally be stopped 3 – 4 weeks before
  your surgery
• Medications for diabetes and heart conditions may also be continued.

It is important to let us know, before you are admitted, if you are taking anticoagulant
drugs (for example, warfarin, aspirin or clopidogrel).

Also provide us, and the anaesthetist, with a list of all the medications you are taking or
have recently taken, including medicines prescribed by your family doctor and those
bought “over the counter” without prescription, and also any herbal medications.
Keeping an up-to-date list of medications with you is highly recommended.

Please contact us if you are unsure which medications you must stop. If we do not want
you to take your normal medication, your surgeon or anaesthetist will explain what you
should do. We will need to know if you do not feel well and have a cough, a cold or any
other illness when you are due to come into hospital for your operation. Depending on
your illness and how urgent your surgery is, we may need to delay your operation as it
may be better for you to recover from this illness before your surgery.

Your anaesthetic
We will carry out your surgery under a general anaesthetic. This means that you will be
asleep during your operation and you will feel nothing.

When it is time for your operation, a member of staff will take you from the ward to the
operating theatre. They will take you into the anaesthetic room and the anaesthetist will
make you ready for your anaesthetic.
To monitor you during your operation, your anaesthetist will attach you to a machine to
watch your heart, your blood pressure and the oxygen level in your blood. General
anaesthesia usually starts with an injection of medicine into a vein. A fine tube (venflon)
will be placed in a vein in your arm or hand and the medicines will be injected through
the tube. Sometimes you will be asked to breathe a mixture of gases and oxygen through
a mask to give the same effect.

Once you are anaesthetised, the anaesthetist will place a tube down your airway and
use a machine to ‘breathe’ for you. You will be unconscious for the whole of the
operation and we will continuously monitor you. Your anaesthetist will give you
painkilling drugs and fluids during your operation. At the end of the operation, the
anaesthetist will stop giving you the anaesthetic drugs. Once you are waking up
normally, they will take you to the recovery room.

Pain relief after surgery
Pain relief is important as it stops suffering and helps you recover more quickly. We may
give you tablets or injections to make sure you have enough pain relief. Once you are
comfortable and have recovered safely from your anaesthetic, we will take you back to
the ward. The ward staff will continue to monitor you and assess your pain relief. It is
important that you report any pain you have as soon as you experience it.

After your surgery
After your surgery, while you are still under the effects of the anaesthetic, you will be
taken to the recovery room where you will be monitored by the recovery staff until you
are transferred back to the ward. Back on the ward, the nursing staff will monitor your
condition and take routine observations. Our medical team will explain how the surgery
went and what the findings were.
Following surgery, you may experience the following:

• Tiredness;
• Muscle pain;
• Mild nausea;
• Pain or discomfort at the site of the incisions;
• Cramps (similar to period pain);
• Vaginal discharge or bleeding for a few days;
• A sensation of bloating in the abdomen.

Leaving hospital

Medication when you leave hospital
Before you leave hospital, the pharmacy will give you any extra medication that you
need to take when you are at home.

Convalescence
How long it takes for you to fully recover from your surgery varies from person to person.
For most women this takes 6-8 weeks. For the first 2 weeks back home you should rest
and relax. You can make a cup of tea, help with washing up, dusting and easy household
tasks but should not attempt to vacuum, iron or carry loads of washing for at least 6
weeks. You should avoid standing for long periods of time and continue the exercises
that you were shown in hospital for the next 6 weeks.

Try to take a short walk every day, look after your posture and rest whenever you need
to. You should consider who is going to look after you during the early part of this time.
You may have family or close friends nearby who are able to support you or care for you
in your home during the early part of your recovery period. You might consider going to
stay with relatives or you may want to make your own arrangements to stay in a
convalescent home while you recover. After you return home, you will need to take it
easy and should expect to get tired to begin with. Constipation occurs frequently after
sacrocolpopexy and you may need some laxatives to help with your bowel movement.

Stitches
We usually use dissolvable stitches. If these have not disappeared after seven days,
they can be removed by the nurse at your GP practice.

Personal hygiene
You may bathe or shower normally after you leave hospital.
We recommend that you do not use tampons immediately after your procedure. Sanitary
pads may be used and should be changed regularly.

Diet
You do not usually need to follow a special diet. If you need to change what you eat, we
will give you advice before you go home. You should avoid constipation and straining
for bowel motions and ensure that you get plenty of rest while you are recovering.

Exercise
You should do light exercise, such as walking and light housework, as soon as you feel
well enough. Normal physical activity may be resumed when any discomfort has
disappeared, and when you are feeling well enough. This may take anywhere from three
days to a few weeks, depending on the nature of your procedure and your general
health.

Sex
Initially sexual intercourse may be a bit painful. Sex is best avoided for the
duration of your recovery period as it may impair the healing process inside.

Driving
You are allowed to drive after 4-6 weeks if you are able to perform an emergency stop,
but you will need to check details with your insurance company.

Work
How long you will need to be away from work varies depending on:

• how serious the surgery is;
• how quickly you recover;
• whether or not your work is physical; and
• whether you need any extra treatment after surgery.

For most cases you can return to work after six weeks. Please ask us if you need a
medical sick note for the time you are in hospital and for the first six weeks after you
leave.

Outpatient appointment
Before you leave hospital we may give you a follow-up appointment to come to the
outpatient department, or we will send it to you in the post. Your appointment will
normally be for between three to six months after surgery. At this stage, we will discuss
the surgery and findings in detail and recommend ongoing treatment options if required.

Once you leave hospital
If you experience fever-like symptoms, or excessive pain, redness and discharge at the
incision sites you should contact us.

You should report to your GP or us if you experience any of the following:

• Persistent bleeding from the vagina that is smelly or becomes heavier than a normal
  period and is bright red;
• Persistent redness, pain, pus or swelling around the wounds, of a fever or more
  than 38 c, or chills, which may indicate infection;
• Pain or burning on passing urine or the need to pass urine frequently, as this may
  indicate a urinary tract infection;
• Increasing nausea;
• Increasing abdominal pain with vomiting.

Contact details
If you have any specific concerns that you feel have not been answered and need
explaining, please contact the following:
Worcester Royal Hospital

• Gynaecology Nursing Staff, Lavender Ward (phone 01905 760586)
• Hospital Switchboard (phone 01905 763333)

Alexandra Hospital

• Gynaecology Nursing Staff, Ward 9 (phone 01527 45786)
• Hospital Switchboard (phone 01527 503030)

Kidderminster Treatment Centre

• Gynaecology Nursing Staff, Lavender Ward (phone 01905 760586)
• Hospital Switchboard (phone 01562 823424)

Other information
The following internet websites contain information that you may find useful.

• www.patient.co.uk
  Information fact sheets on health and disease

• www.rcoa.ac.uk
  Information leaflets by the Royal College of Anaesthetists about ‘Having an
  anaesthetic’

• www.nhsdirect.nhs.uk
  On-line health encyclopaedia

• www.worcsacute.nhs.uk
  Worcestershire Acute Hospitals NHS Trust

If your symptoms or condition worsens, or if you are concerned about anything,
please call your GP, 111, or 999.

Patient Experience
We know that being admitted to hospital can be a difficult and unsettling time for you
and your loved ones. If you have any questions or concerns, please do speak with a
member of staff on the ward or in the relevant department who will do their best to
answer your questions and reassure you.

Feedback
Feedback is really important and useful to us – it can tell us where we are working well
and where improvements can be made. There are lots of ways you can share your
experience with us including completing our Friends and Family Test – cards are
available and can be posted on all wards, departments and clinics at our hospitals. We
value your comments and feedback and thank you for taking the time to share this with
us.

Patient Advice and Liaison Service (PALS)
If you have any concerns or questions about your care, we advise you to talk with the
nurse in charge or the department manager in the first instance as they are best placed
to answer any questions or resolve concerns quickly. If the relevant member of staff is
unable to help resolve your concern, you can contact the PALS Team. We offer informal
help, advice or support about any aspect of hospital services & experiences.

Our PALS team will liaise with the various departments in our hospitals on your behalf,
if you feel unable to do so, to resolve your problems and where appropriate refer to
outside help.

If you are still unhappy you can contact the Complaints Department, who can investigate
your concerns. You can make a complaint orally, electronically or in writing and we can
advise and guide you through the complaints procedure.

How to contact PALS:
Telephone Patient Services: 0300 123 1732 or via email at: wah-tr.PALS@nhs.net

Opening times:
The PALS telephone lines are open Monday to Friday from 8.30am to 4.00pm. Please
be aware that you may need to leave a voicemail message, but we aim to return your
call within one working day.

If you are unable to understand this leaflet, please communicate with a member of staff.

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