Surgery

Stress urinary incontinence is the inability to control the flow of urine, which leads to the leakage of urine when you sneeze, cough or laugh. Vaginal sling is a minimally invasive surgery performed to treat stress urinary incontinence.

• Conventional sling: Sling made of body tissue or synthetic material, which is secured with stitches.

• Tension-Free sling: A mesh sling, which is held in place with the surrounding tissue.

• The MiniArc Precise Single-Incision Sling system is a mid-urethral sling that is used to treat female urinary incontinence. It offers more accurate delivery and control. It is quite safe and is a minimally invasive procedure that has minimal risk of tissue injury and bleeding.

The procedure is performed under general or spinal anaesthesia. Dr Alexander makes a small incision inside your vagina and under the urethra. A catheter is inserted into your bladder to drain urine.

The sling is passed through the incision and secured under the urethra. This helps in lifting and supporting urethra and bladder neck ( where urethra meets the bladder ). You may be discharged from the hospital on the same day or you may have to stay for 1 or 2 days after the surgery.

Possible Complications with Sling Procedures

As in all surgical procedures, sling procedure may also be associated with certain complications, which include:

• Break down of the artificial material of the sling (long term)

• The synthetic material of the sling can be rejected by the vagina tissue (long term)

• Damage to the bladder, urethra or vagina, bleeding (during procedure)

• Irritation in the bladder (long term)

• Voiding dysfunction

Tension-Free Vaginal Tape (TVT) placement is a procedure employed to control stress urinary incontinence caused by sagging of the urethra.  

What is Stress Incontinence?

Stress incontinence refers to the leakage of small amounts of urine during physical movement such as coughing or laughing that suddenly increases the pressure over your urinary bladder.

About the Procedure

TVT placement is a relatively simple procedure requiring a short hospital stay with a quick recovery compared to retropubic suspension surgery.

The TVT provides support to the sagging urethra so that it remains closed during coughing or sudden movement, preventing the accidental leak of urine.

Inserting a TVT usually takes about 30 minutes and is performed under general or local anaesthesia. Dr Alexander will make small incisions over your abdomen and vaginal wall.

A mesh tape is then passed under the urethra, like a hammock, to maintain its normal position. No stitches are required to keep the TVT in place.

Recover after Tension-Free Vaginal Tape Procedure

Patients undergoing TVT placement may experience slight pain and discomfort. Following the procedure, you will be asked to empty your bladder to see the reaction of the bladder and urethra to the surgery.

Patients may go home on the same day or the next day. A catheter (thin flexible tube) may be inserted in your bladder to drain the urine during the recovery period. Patients may resume normal activities within 1 to 2 weeks. However, you may need to avoid driving for 2 weeks, and sexual activity or strenuous activities for up to 6 weeks.

The most common risks associated with TVT placement include injury to the bladder or urethra, difficulty emptying the bladder and risk of infection. The mesh tape used in the surgery may cause erosion of the pelvic tissue.

CYSTOSCOPY

A cystoscopy is an examination of the inside of the bladder and urethra, the tube that carries urine from the bladder to the outside of the body.

[doctor] performing the examination uses a cystoscope, a long, thin instrument with an eyepiece on one end and a tiny lens and a light on the other end that is inserted into the bladder.

[doctor] inserts the cystoscope into the patient’s urethra and the small lens magnifies the inner lining of the urethra and bladder allowing the [doctor] to see inside the hollow bladder. Many cystoscopes have extra channels within the sheath to insert other small instruments that can be used to treat or diagnose urinary problems.

Why have a Cystoscopy?

Dr Alexander may perform a cystoscopy to find the cause of many urinary conditions, including:

• Frequent urinary tract infections

• Blood in the urine, called haematuria

• Frequent and urgent need to urinate

• Unusual cells found in a urine sample

• Painful urination, chronic pelvic pain, or interstitial cystitis/painful bladder syndrome

• Urinary blockage caused by prostate enlargement or some other abnormal narrowing of the urinary tract

• Stone in the urinary tract, such as a kidney stone

• Unusual growth, polyp, tumor, or cancer in the urinary tract

People scheduled for a cystoscopy should ask [doctor] about any special instructions.

Cystoscopy Procedure

[doctor] gently inserts the tip of the cystoscope into the urethra and slowly glides it up into the bladder. A sterile liquid salt water called saline flows through a channel in the scope to slowly fill the bladder and stretch it so [doctor] has a better view of the bladder wall.

As the bladder is filled with liquid, patients feel some discomfort or pressure and the urge to urinate. [doctor] may then release some of the fluid, or the patient may empty the bladder as soon as the examination is over.

Possible risks of a cystoscopy include:

• Infection

• Bleeding

• Rupture of the bladder wall

WHAT IS COLPOSCOPY?

Colposcopy is a procedure in which a special magnifying instrument called a colposcope is used to look into the vagina and into the cervix. The colposcope gives an enlarged view of the outer portion of the cervix.

Why would a Colposcopy be necessary?

Colposcopy is done when there are abnormal changes in the cells of the cervix as seen on a Pap test. Further, it may be done to assess problems such as genital warts on the cervix, inflammation of the cervix, benign growths or polyps, pain and bleeding.

How is the Colposcopy procedure done?

During a colposcopy, you will lie on your back with feet raised just as you do when you have a regular pelvic examination. The doctor uses an instrument called a speculum to hold the walls of the vagina apart. Then the colposcope is placed at the opening of your vagina.

A mild solution may be applied to the vagina and cervix with a cotton swab. This makes abnormal areas to be seen easily. The doctor will look inside the vagina to locate any problem. If there are any abnormalities, the doctor may take a small tissue sample called a biopsy.

You may feel a mild pinch or cramp while the biopsy sample is taken. The tissue is then sent to a laboratory for further study.

What to expect after the Colposcopy procedure?

Your gynaecologist will talk to you about any problems detected during colposcopy. If a sample of tissue was taken from your cervix (biopsy), the laboratory results should be ready in 2 to 3 weeks.

Most women feel fine after colposcopy. You may feel a little lightheaded and if you have had a biopsy, you may have some mild bleeding. Talk to your gynaecologist about how to take care of yourself after the procedure and when you need to return for a check-up.

What are the risks of colposcopy?

There may be a risk of infection when you have a colposcopy. Mild pain and cramping during the procedure and mild bleeding afterwards are common. This most often happens when a biopsy is done. If there is heavy bleeding, fever, or severe pain after the procedure, contact your gynaecologist immediately.

TUBAL REVERSAL RECONSTRUCTIVE SURGERY

Sterilization is a permanent method of contraception for women desiring not to become pregnant in the future. Laparoscopic technique is a minimally invasive procedure and in recent years laparoscopic sterilization has gained popularity owing to its advantages over the traditional approach. Laparoscopic sterilization is a technique of tubal ligation to block or close the fallopian tubes, the pathway for sperm to reach eggs for fertilization.

Fallopian tubes, located on either side of the uterus, pick up eggs released from the ovaries and transfer them to the uterus. If these tubes are blocked, sperm fail to reach the eggs and fertilization will not occur.

Sterilization Reversal Surgery

Reversal after sterilization is a surgical procedure to restore fertility by restoring the normal functionality of the fallopian tubes that were blocked during sterilization.  

About 5-10% of women may require reversal of sterilization, due to various reasons such as having a new partner and desire for additional children. Women whose tubes were removed during the sterilization cannot have a reversal.

Factors influencing reversal of sterilization

The major factors that may affect the results of reversal after sterilization are as follows:

• Age

• Condition of the tubes

• Regularity of the menstrual cycle

• Fertility of partner

• Problem with other parts of the reproductive system

• Prior to the reversal surgery, patients should undergo a screening that includes:

• Physical examination

• Medical history

• Series of laboratory tests

• Review of the medical reports of sterilization methods

• Evaluation of the partner’s fertility

Procedure for Sterilization Reversal Surgery

Reversal after sterilization is a safe procedure that involves the following steps:

• The operation is performed under general anesthesia

• A small incision, approximately 10-12 cm in length, is made across the lower abdomen and a laparoscope is inserted.

• The fallopian tubes are identified and isolated.

• Magnification and microsurgical techniques are used to repair the fallopian tubes.

• The ends of the tubes are trimmed to remove any damaged tissue.

• The inner open space of the tube, called the lumen, is exposed.

• These openings are then fused using microscopic sutures, followed by the suturing of the outer covering of the tubes called serosa.

• The repaired fallopian tubes are placed back into their respective positions and the incision is closed.

Postoperative care after Sterilization Reversal Surgery

The procedure may take a few hours and the patient is usually discharged on the same day of the procedure. Patients are advised to follow the instructions given by their surgeon, along with recommended diet and prescribed medications. Patients can perform their routine activities such as driving, walking etc., after a few days of the surgery. Complete recovery of the patient may take a few days to a few weeks.

Risks and complications Sterilization Reversal Surgery

The possible risks associated with reversal of sterilization include:

• Infection

• Bleeding

• Scarring of the tissue

• Chances of ectopic pregnancy

VAGINAL NATIVE TISSUE PELVIC FLOOR SURGERY

The pelvic floor is made up of pelvic muscles, ligaments, connective tissues, nerves and arteries. It contains organs such as the rectum, uterus, vagina, and bladder.  

Causes of Pelvic Floor Problems

Several factors such as vaginal birth, trauma during childbirth, repeated lifting of heavy objects and chronic disease or surgery may weaken or stretch the pelvic floor.

When the pelvic floor can no longer hold the pelvic organs in place, the pelvic organs come down and bulge into the vagina. This condition is referred to as pelvic organ prolapse.

Pregnancy and childbirth are the most important risk factors for prolapse. Pelvic organ prolapse is asymptomatic in most patients. However, in a small percentage of patients it causes symptoms that vary from vaginal discomfort to difficulties in sexual, urinary and defecatory activities.

Symptoms of Pelvic Floor Problems

Asymptomatic patients do not require treatment.

Symptoms in most of the symptomatic patients can usually be managed by pelvic floor exercises and use of removable vaginal inserts (pessaries).

Treatments for Pelvic Floor Prolapse

In rare cases, when even after conservative treatment the symptoms are unmanageable and result in significant impairment of the quality of life of the patient, surgery is advised.

The aim of the surgery is to correct the prolapse and maintain urinary and faecal continence and preserve coital and reproductive function.

Native Tissue Surgery

Pelvic organ prolapse was traditionally treated surgically using native vaginal tissue (NT). It involved the use of the patient’s own tissue and sutures to restore the vagina to a natural position by reattaching it to the various supportive structures.  

Reports in the literature of high recurrence rates associated with vaginal native tissue repair led to the development of alternative techniques, such as synthetic mesh.

However, the newer current data obtained from large population studies with long term follow up periods show that the recurrence rate with NT is much lower than was earlier predicted.

Native tissue repairs have similar outcomes to synthetic mesh without the risks inherent in mesh use.

Native Tissue Surgery Complications

The most common complication associated with mesh repair is erosion or protrusion of the mesh from the soft tissues in the vaginal wall leading to discomfort in intercourse and blood spotting and may require additional surgery. Thus, newer isn’t always better. Native vaginal tissue repair is still the standard of care for the typical patient with pelvic organ prolapse.

Surgery for pelvic organ prolapse is optional. Decision about the surgery should be made only after proper discussion of the risks and benefits of the possible procedure with your Urogynecologist.

MYOMECTOMY

Myomectomy is a surgical procedure to remove uterine fibroids, benign or noncancerous growths appearing in your uterus  

Uterine Fibroid Symptoms

Many women with uterine fibroids do not experience any symptoms. However, some women may experience symptoms that are

• mild and they include heavy and prolonged menstrual bleeding,

• bleeding between periods,

• pelvic pain,

• lower back pain,

• pain during intercourse and

• urinary problems.

In rare cases, some women may  

• have difficulty emptying the bladder,

• difficulty moving the bowels,

• anaemia due to heavy menstrual bleeding and

• reproductive problems such as infertility.

Treatment for Uterine Fibroid

Myomectomy is the treatment of choice in women with fibroids who are planning to have children in the future. Myomectomy removes only the fibroids and leaves your uterus intact and increases your chances of pregnancy.

Before your surgery, a chemical releasing analogue (GnRH-a) therapy which lowers oestrogen levels may be used to shrink the uterine fibroids, thus reducing the risk of excessive bleeding during the surgery.

Depending on the size, location and number of fibroids, Dr Alexander may choose one of three surgical approaches to remove the fibroids:

• Hysteroscopy - hysteroscopic myomectomy is the removal of fibroid growing in the cavity of the uterus. A thin telescopic instrument called hysteroscope is inserted into the uterus through the vagina to view the internal structures.

• Laparoscopy - laparoscopic myomectomy procedure is a minimally invasive surgery during which a laparoscope, a long thin instrument attached with a camera is used. A small incision is usually made below the navel and a laparoscope is inserted through this incision. Carbon dioxide gas is injected into the abdominal cavity using a special needle to create more space to work. Dr Alexander identifies and removes the fibroids. During the procedure, tissue samples can also be taken for biopsy. This procedure is the preferred option to remove one or two fibroids up to 5.1 cm across that grow on the outside of the uterus. ... more

• Laparotomy - is an open multiple myomectomy, removal of 4 or more fibroids followed by reconstruction of the uterus. This is performed as an open procedure. ... more

When is a Myomectomy Required?

Myomectomy is a treatment option if

• you have anaemia and pain or pressure not relieved with medications.

• the fibroids have changed the uterus so as to cause infertility or

• repeated miscarriages as this method improves your chances of becoming pregnant even after the procedure.

Recovery from Myomectomy

After myomectomy surgery, your pelvic pain and bleeding from fibroids are reduced and your chances of having a baby are improved. If the fibroids are large and are more in number, they can re-grow after surgery.

Complications with Myomectomy

The possible complications of myomectomy include

• infection,

• scar tissue formation,

• damage to the bladder or bowel, and

• rupture of the uterine scars in late pregnancy or during labour.

Rarely, a myomectomy causes uterine scarring that can lead to infertility.

Fibroids and Pregnancy

Because fibroids can grow back, those women who are planning to become pregnant in the future must try to conceive as early as possible after the myomectomy procedure. However, following surgery, Dr Alexander will advise you to wait for 4 to 6 months until the uterus heals.

Before undergoing any treatment for infertility, Dr Alexander may recommend a hysterosalpingogram, an X-ray test to check the uterus and fallopian tubes.

The incisions made in the wall of the uterus to remove fibroids may cause placental problems and improper functioning of the uterus during labour may need a caesarean delivery. In rare cases, a hysterectomy may be needed if the uterus has grown too large with fibroids.