Benefit of keeping cervix, having lapro rather than vag surgery

[inkydoo]

Here I am about ten days out from surgery and I'm still thinking up questions, all of which I will ask my urogyn when I have my preop appt on Tuesday. I thought I'd post two of my questions here to see if anyone wants to weigh in from personal experience, or knowledge or .....

I am scheduled to have a TVH and currently have a prolapsed uterus and a very small rectocele. Originally I was scheduled for sacrocolpopexy, got scared of the mesh, and then signed on for the TVH. Now I am wondering if it wouldn't make more sense for this surgery to be done laproscopically with me keeping my cervix (it's healthy, just had a Pap smear). My reasoning is that I would think lapro would allow the surgeon to better visualize the ligaments she is trying to suture the vaginal vault to. With a vaginal procedure I'd think that you are totally blind and operating mostly on the basis of feel. With the ureters nearby, I'm not sure I feel really good about that, no matter how good my surgeon is. I've also heard that the lapro allows the surgeon to attach the vag vault up higher on the ligaments, which leaves the vagina in a more normal position and also tends to keep it from shortening. That all sounds like reasons to do it laproscopically to me.

Secondly, when I was scheduled for the sacro, she was going to leave the cervix because it provides a thicker anchoring base for the mesh. What I'm wondering is why it wouldn't provide a thicker anchoring base for sutures too? In some ways I would think that sutures would put a greater stress on the vaginal vault because there are just several places on each side that are under stress, while with mesh the stress is more dispersed. Not sure why they would take the cervix in one surgery and not in the other. Sounds to me like it could be a matter of wanting to do one vaginally and one laproscopically?

As I said, will ask my urogyn these questions, but does anyone have thoughts and/or knowledge of these issues?

Thanks!

[sherrieP]

I am so glad to hear you are going into this eyes wide open-I agree, healthcare practitioners can sometimes be a bit cavelier with POP procedures. The more careful you are post procedure, the more likely it is to "stick". I am pretty shocked they aren't limiting stair activity and driving at 4-5 days seems yikes to me too. Not surprised by the up so soon post surgery, that is pretty much standard procedure for any surgery they can pull it off with. NO LIFTING, no vacuuming, if you need to do laundry, either use a wagon or sled to pull the clothes to laundry room. No one is a better judge than you! Icing really made a huge difference for me that 1st week, then I shifted to heated bean bag for comfort.


It's a shame all urogyns don't need to have this procedure, they'd have a better idea best thing to tell patients. :)

[inkydoo]

Thanks for your reply Sherrie! Talked to my urogyn and I am going ahead with surgery as planned. She indicated that she feels she can get better suspension and alignment with a vaginal approach, though she does do lapro if someone is totally committed to it. She said there is question about the benefit of keeping the cervix, which I still think could be either true or not. We have talked about the fact that this is a less sturdy approach than mesh...we did that several appts ago...but I decided I would like to try this route first. After I have been through the surgery I may wish otherwise as I know the recovery isn't going to be fun. Though I do have to say, she and her nurse made it sound like it is a piece of cake.....they will have me up shortly after the anaesthesia wears off, don't think I will need the catheter for long, say I can drive after 4-5 days if I feel I can sit comfortably and am not on pain meds, aren't limiting me on stairs, are limiting me on lifting, housework, etc. I think I will be a bit more careful than they seem to indicate I need to be....want to optimize the chances this will work and that I will heal completely with no problems. I don't expect it to be a piece of cake....I think medical professionals sometimes under estimate these kinds of things.

[sherrieP]

Part of the picture is every urogyn has specific procedures that he/she feels is most beneficial-some urogyns like mesh, some don't, some urogyns prefer robotic procedures, some prefer lap. The specifics of your internal repair will make a difference in which path is most beneficial for you. We are all different shapes on the inside just like on the outside, what works for one woman does not work for another; and I can guarantee you that if you got a 2nd opinion, you'd probably get different answers between the 2 urogyns. This is such an evolving field, changes every day. Your questions make perfect sense and I'm sure your urogyn will address them well in your pre-op appt.

Additional info to muddy the waters (not trying to rattle the cage, but feel this is important to know so you can address it with your urogyn) is likelyhood of repeat surgery down the road with no mesh. The media is really tossing incomplete info out there (or should I say the law firms are....), the problem with mesh isn't usually the mesh itself, it is WHO is putting the mesh in. Physicians who are not urogyns are doing procedures that they don't have proper training or experience to do and women are the ones who suffer. The benefit of mesh is it is typically a one time fix as opposed to stitching, which most often needs to be redone as our estrogen levels drop and our tissues get weaker.

Thicker anchoring base will not make up poor integrity of other soft tissues that are weak from estrogen loss as we age. I think it's a great idea to have the urogyn clarify all aspects of this issue for you.

I also don't believe the visual available with lap is better than with vaginal approach, no matter what technique drs use everything is all "bunched" together-the pelvic cavity has so many organs, soft, and structural tissues that touch on each other.

I speak with women every day regarding different types of POP procedures and have had repair of grade 3 POP (recto, cysto, entero), mesh was used for 2 of the 3 repairs. The most important thing you need to check into is the rating and backdrop of the physician doing the procedure, know what your choices are (sounds like that is pretty well clarified for you), and then do the right stuff post surgery so the heal curve goes smoothly. Every POP procedure has it's good point and it's bad points-for the best visual they should go in abdominally but the heal curve is worse for ab incision and you also have increased risk of other complications. There is no fool-proof path but in the hands of a good urogyn, once you get your answers to questions you still have, you should be able to go into your procedure knowing that you've made the right choice. Every woman's needs are a bit different because each of our scenarios are unique to us.

Good luck with your surgery, give a shout if you have other questions either prior to or post op. One piece of advice I can give you-make sure you have your house "prepped" prior to surgery so the post surgical curve is easier (sit on both bed and couch to see which is easier to get out of after surgery, preemie diapers ripped open at one end and filled with ice for swelling/pain, kid sippee cup for drink next to bed, wear comfy stretchy pants to hospital that will fit over a cath-you'll probably go home with one, that kind of thing).

Sher

It's a very good sign if your urogyn takes he/her time with you when addressing concerns/questions.