Wednesday, April 21, 2010

Can Bladder Prolapse Recur after Surgery- and Why

I have many female patients who see me after their bladder has been previously “lifted” surgically, that is, fixing a dropped bladder, and we find that it has dropped again. Many female patients are apprehensive about evening fixing their dropped/prolapsed bladder for the first time because they’ve heard from their friends/sister/others that it’ll drop again. Even others are proud to say in the exam room, that they’ve had their bladder “tucked up” 3 times and they need it done again because they feel it dropping once more.

Well, we all know that a cystocele is a dropped/prolapsed bladder that can occur in any woman, but there are risk factors for it occurring in the first place. Are these risk factors also important in leading to a recurrence even after surgery? Is fixing it a second time any better than the first? Is there a way to improve on surgical outcomes so we are not endlessly and repeatedly re-operating on everyone? Are these improvements worth it?

These are the questions I frequently ask myself, and patients ask me, as I constantly reassess pelvic floor technology. We must always strive to improve on our current technology in order to achieve better outcomes and less patient morbidity.

So, some common risk factors for cystocele, and for that manner, any vaginal prolapse are:
Chronic stress on the pelvis (chronic cough from smoking, asthma, bronchitis, constipation, high impact exercise)

But why do these lead to prolapse?

One well accepted theory is that the first step in the alteration of the pelvic floor is damage to the support muscles, the levator ani, that act to support the pelvic organs. If they become lax or loose or stretched, it leads to a widening of the “genital hiatus”, the opening essentially of the pelvis downward. The pelvic organs (bladder, rectum, uterus) sit on, and are supported by the levator muscles and the connective tissue fascia the covers them. When the muscles are strretched or weakened by childbirth, pelvic surgery, or other risk factors list above, this in turn leads to undue tension on all the connective tissue support structures (fascia, ligaments) that then tear, break, and stretch. This ultimately allows the bladder to push down on the vaginal wall, and try to push out the vagina leading to a bulge. The same mechanism of prolapse can also occur to the cervix/uterus, the vault/top of the vagina after hysterectomy, or rectum.

The bladder is uniquely at risk for prolapse, because when the woman is standing, the upper 2/3 of the vagina is almost completely horizontal, or laying flat. (The lower 1/3 of the vagina, or the opening, is mostly vertical.) Because the upper 2/3’s is horizontal, any force/strain/pressure/stress brought to bear on the pelvis pushes directly down and primarly onto the bladder. Even normal physical activities put more strain on it than the other compartments of the vagina.

Repair of any vaginal prolapse must meet surgical indications, but, it must essentially re-establish/recreate proper anatomy. However, with all surgery, there are pitfalls, riska, and the chance for recurrence.

Is recurrence dependent on the sugeon's choice of what to do? YES. Is it dependent on the route to access the body? YES. Is it dependent on the patient's body and tissue quality? YES. Is it dependent on what the patient does in her free time/work/smoking status/level of obesity? YES.

There are clearly multiple reasons which interconnect that can lead to recurrent bladder prolapse. Therefore, what can be done to lower the risk? What technologies are out there? Are they good long term bets? Are there complications that go along with it? All good questions to be answered in my next post.