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Colporrhaphy
Colporrhaphy
Colporrhaphy
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Colporrhaphy
Other namesVaginal wall repair
SpecialtyGynecology

Colporrhaphy (also vaginal wall repair, anterior and/or posterior colporrhaphy, anterior and/or posterior vaginal wall repair, or simply A/P repair or A&P repair) is a surgical procedure in women that repairs a defect in the wall of the vagina. It is the surgical intervention for both cystocele (protrusion of the urinary bladder into the vagina) and rectocele (protrusion of the rectum into the vagina).[citation needed]

The repair may be to either or both of the anterior (front) or posterior (rear) vaginal walls, thus the origin of some of its alternative names.[1][2][3]

References

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Colporrhaphy

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Colporrhaphy is a surgical procedure designed to repair defects in the vaginal wall caused by weakening of the supporting tissues and muscles, most commonly to treat (POP), a condition where pelvic organs such as the or descend into the vaginal canal. This surgery aims to restore the normal anatomy and function of the vaginal walls, alleviating symptoms including pelvic pressure, urinary or fecal incontinence, and discomfort during intercourse. It is typically performed on individuals assigned female at birth who experience moderate to severe prolapse that does not respond to conservative treatments like exercises. The procedure is categorized into two main types: anterior colporrhaphy, which addresses of the front vaginal wall (often associated with or prolapse), and posterior colporrhaphy, which corrects of the back vaginal wall (commonly linked to or ). Anterior repair involves plicating the pubocervical to support the , while posterior repair focuses on reinforcing the rectovaginal to prevent rectal bulging. In some cases, both anterior and posterior repairs are combined, and the surgery may be performed alongside other procedures such as or sacrocolpopexy for comprehensive management. Traditional colporrhaphy is a native tissue repair that does not involve synthetic mesh; transvaginal mesh for POP was banned by the U.S. in 2019 due to associated risks. Potential risks include , , urinary retention, constipation, and recurrence of , with anterior repairs showing higher recurrence rates (up to 40% or more) compared to posterior repairs. Long-term success depends on factors like the patient's age, severity, and adherence to postoperative therapy.

Definition and Types

Definition

Colporrhaphy is a surgical procedure designed to repair weaknesses or defects in the vaginal walls, thereby restoring structural support to the pelvic organs. It primarily addresses (POP), a condition where pelvic structures descend due to weakened supportive tissues. This surgery is commonly employed to treat specific forms of POP, such as , which involves bulging of the anterior vaginal wall caused by bladder descent, and , characterized by posterior vaginal wall protrusion due to rectal descent. By reinforcing the vaginal walls, colporrhaphy helps reposition and stabilize the affected organs, alleviating the mechanical strain on the . The core technique of colporrhaphy involves plication, or the folding and suturing of the vaginal fascia and underlying muscles, to tighten and strengthen the supportive layers, which may include excision of excess vaginal tissue if necessary. This approach preserves the natural while enhancing durability against further . Colporrhaphy is performed exclusively in females, most often in those who are postmenopausal or have experienced multiple vaginal deliveries, as these factors contribute to weakening.

Types of Colporrhaphy

Colporrhaphy is classified into types based on the segment of the vaginal wall being repaired, primarily anterior, posterior, or a combination of both, with native tissue repair as the standard approach. Following the 2019 FDA ban on transvaginal mesh for pelvic organ prolapse, colporrhaphy relies exclusively on native tissue repair. Anterior colporrhaphy addresses of the anterior vaginal wall, specifically targeting by reinforcing the pubocervical that supports the . This procedure involves a transvaginal incision to access the pubocervical , followed by plication using absorbable or permanent sutures to tighten and restore support, thereby preventing descent. Posterior colporrhaphy focuses on the posterior vaginal wall to repair , involving plication of the between the and to reestablish anatomical integrity and support. The technique typically includes a posterior vaginal incision and suturing of the to narrow the rectovaginal space, reducing symptoms associated with rectal bulging. Combined or total colporrhaphy performs simultaneous anterior and posterior repairs for patients with extensive affecting multiple vaginal wall segments. This approach plicates both the pre-vesical and pre-rectal tissues, often excising excess , and is one of the most common surgeries in the United States.

Indications and Diagnosis

Indications

Colporrhaphy is primarily indicated for the treatment of moderate to severe (POP), classified as stages II through IV according to the Pelvic Organ Prolapse Quantification (POP-Q) system, particularly when symptoms persist despite initial conservative management such as exercises, pessaries, or topical therapy. This surgical repair targets weaknesses in the anterior or posterior vaginal walls, addressing conditions like (bladder prolapse) or (rectal prolapse). Common symptoms prompting colporrhaphy include a sensation of vaginal bulge or , as if something is falling out; urinary issues such as incontinence or retention; or ; (painful intercourse); and lower , all of which significantly impair . These symptoms arise from the descent of pelvic organs into the vaginal canal, often exacerbated by daily activities. Patient factors increasing the likelihood of requiring colporrhaphy include postmenopausal status, a history of vaginal deliveries (especially multiple or complicated births), , chronic conditions causing increased intra-abdominal pressure such as persistent coughing or , and disorders that weaken pelvic support structures. These risk factors contribute to the progressive weakening of vaginal walls and ligaments. Colporrhaphy is generally not indicated for mild POP (stage I), where symptoms are minimal or absent, as conservative measures often suffice without surgical intervention. Additionally, it is typically avoided in women planning future pregnancies, due to the high risk of recurrence following .

Diagnostic Evaluation

The diagnostic evaluation for colporrhaphy candidacy begins with a thorough patient history, focusing on symptoms such as pelvic pressure, bulging, or discomfort, often exacerbated by standing or straining, alongside obstetric history including parity and mode of delivery. Validated questionnaires like the Pelvic Floor Distress Inventory-20 (PFDI-20) are commonly employed to quantify symptom severity and impact on , assessing domains such as urinary distress, prolapse-specific bother, and colorectal-anal symptoms. This tool, comprising 20 items scored from 0 to 300, helps differentiate prolapse-related distress from other disorders. Physical examination remains the cornerstone of diagnosis, typically performed in the lithotomy position with the patient bearing down or performing a Valsalva maneuver to replicate prolapse symptoms and reveal organ descent. The exam involves inspection of the anterior, apical, and posterior vaginal walls, often using a speculum to assess compartmental involvement, followed by bimanual palpation to evaluate uterine or adnexal abnormalities.00699-6/fulltext) Severity is graded using standardized systems: the Baden-Walker Halfway Scoring System, which categorizes prolapse from 0 (normal) to 4 (maximum descent beyond the hymen) across compartments, or the more precise Pelvic Organ Prolapse Quantification (POP-Q) system, which measures distances from a hymenal reference point in centimeters during rest and straining. The POP-Q, endorsed by the International Continence Society, provides objective, site-specific staging (stages 0-IV) and is preferred for its reproducibility in clinical trials. For cases where physical findings are equivocal or to assess dynamic function, imaging modalities such as dynamic pelvic (MRI) or translabial may be utilized. Dynamic MRI, performed in open-configuration scanners during straining, visualizes multi-compartmental and integrity without radiation, aiding in preoperative planning for complex cases. , a less costly alternative, employs endovaginal or transperineal probes to measure hiatal dimensions and organ descent, correlating well with exam findings in ambulatory settings. These are generally reserved for inconclusive exams or suspected , as routine use is not recommended by guidelines. Urodynamic testing is indicated when concomitant or voiding dysfunction is suspected, evaluating bladder pressure, urethral function, and urine flow rates to identify masked by . This involves multichannel cystometry, uroflowmetry, and pressure-flow studies, often with prolapse reduction to simulate post-surgical conditions, though its routine role in isolated remains debated due to variable predictive value for outcomes. Post-void residual urine measurement via complements this assessment to rule out retention.

Surgical Procedure

Preoperative Preparation

Preoperative preparation for colporrhaphy aims to enhance , minimize complications, and improve surgical outcomes by addressing modifiable risk factors and implementing preventive measures. Patients undergo a comprehensive medical evaluation to optimize their health status, including at least 4-8 weeks prior to , as tobacco use is associated with increased risks of postoperative infections, wound complications, and readmissions in pelvic organ prolapse repairs. Weight management is also emphasized, with recommendations for obese patients to lose excess weight through diet and exercise, given that higher correlates with elevated risks of surgical failure and erosions in vaginal mesh procedures. Additionally, any active urinary tract infections or chronic should be treated beforehand to reduce intra-abdominal pressure and risks, often involving antibiotics for confirmed infections and dietary adjustments or laxatives for bowel regularity. Anesthesia evaluation is conducted by an anesthesiologist, who selects the most appropriate type based on the patient's comorbidities, surgical extent, and preferences, with options including for complete and muscle relaxation, spinal or regional for lower body numbness while awake, or with sedation for shorter procedures. is obtained during preoperative counseling, where the surgeon discusses procedure details, potential risks such as bleeding or infection, benefits like symptom relief, and alternatives including conservative management or use. For postmenopausal patients with vaginal , topical therapy is often prescribed 4-6 weeks preoperatively to improve tissue quality and , facilitating better surgical . Bowel preparation is tailored to the procedure type, particularly for posterior colporrhaphy involving rectocele repair, where a single enema or mild laxative may be used the evening before to empty the rectum and enhance visualization, though routine mechanical bowel preparation is not recommended for vaginal gynecologic surgeries due to lack of benefit in reducing complications and increased patient discomfort from hunger and cramping. Prophylactic antibiotics, typically a single intravenous dose of cefazolin (2 g, or 3 g for patients over 120 kg) administered 30-60 minutes before incision, are standard to prevent surgical site infections in this clean-contaminated procedure. Thromboembolism prophylaxis is individualized using risk assessment tools like the Caprini score; low-risk patients may receive mechanical measures such as intermittent pneumatic compression stockings, while higher-risk individuals could benefit from low-molecular-weight heparin, as venous thromboembolism rates in vaginal prolapse surgery are low (approximately 0.2%) but prophylaxis reduces incidence without excessive bleeding risk.

Operative Technique

The operative technique for colporrhaphy involves native tissue repair of the vaginal walls to address , primarily targeting the anterior or posterior compartments. The procedure is typically performed under regional (spinal or epidural) or general to ensure patient comfort and muscle relaxation. The patient is placed in the dorsal , with legs supported in stirrups and the table tilted to a mild Trendelenburg angle for optimal exposure of the vaginal canal; a Foley urinary is inserted prior to incision to decompress the and facilitate intraoperative monitoring. Access to the vaginal wall begins with insertion of a weighted speculum to visualize the , followed by infiltration of the with a local containing a vasoconstrictor (such as saline with epinephrine) to minimize . For anterior colporrhaphy, a transverse or midline incision is made in the , usually 1-2 cm proximal to the urethral meatus and extending cephalad to the vaginal apex or vault; the incision is carried through the using or . The vaginal wall is then sharply or bluntly dissected from the underlying pubocervical , mobilizing the tissue laterally to the sulci while preserving the integrity of the and . In posterior colporrhaphy, a similar transverse incision is made in the posterior vaginal wall, starting just above the hymenal ring and extending to the apex, with dissection separating the from the rectovaginal to expose the defect. The core repair entails plication of the weakened to restore vaginal support. For the anterior compartment, the pubocervical is imbricated in the midline using interrupted or continuous absorbable sutures, such as 0 or 2-0 polyglactin (), placed 0.5-1 cm apart to approximate the fibromuscular layers without over-narrowing the vaginal caliber; this reinforces the vesicovaginal . Posterior repair follows analogously, with plication of the using similar sutures to obliterate the pouch and support the rectovaginal . An optional perineorrhaphy may be incorporated by midline plication of the perineal body muscles with additional absorbable sutures to enhance posterior introitus support, particularly if perineal descent is present. and suturing are performed under direct visualization to avoid injury to adjacent structures like the or . Closure completes the procedure by trimming excess to reduce redundancy and prevent postoperative recurrence, followed by of the mucosal edges with a running locked or interrupted absorbable suture (e.g., 2-0 or 3-0 polyglactin or Monocryl) to achieve a tension-free vaginal introitus. The entire operation, when performed as an isolated colporrhaphy, typically requires 30-90 minutes, depending on the extent of and whether anterior, posterior, or combined repair is undertaken. Variations include double-layered plication for enhanced strength, where a continuous basal suture is overlaid with interrupted l bites, or site-specific repairs targeting paravaginal defects. Mesh augmentation with synthetic grafts may be used in cases of insufficient native tissue, involving placement of a lightweight between the and before closure; however, this approach is controversial due to elevated risks of into the , reported in up to 10-15% of cases, leading to FDA warnings against routine transvaginal use for repair.

Postoperative Care and Recovery

Immediate Postoperative Care

Following colporrhaphy, patients may be discharged the same day or remain in the hospital for 1 to 2 days to allow for close monitoring of , vaginal bleeding, and urinary output. With enhanced recovery after (ERAS) protocols, many patients are discharged the same day. Healthcare providers assess for signs of excessive hemorrhage or during this period, with routine checks of the surgical site to ensure stability. Pain is managed with a multimodal approach, including nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen for mild to moderate discomfort and short-term opioids like for more severe pain in the initial 24 to 48 hours. A , placed during to drain the , is usually removed after 24 hours to promote normal voiding, though some protocols extend this to 48 hours if residual is a concern. Vaginal packing, often inserted at the procedure's conclusion to apply gentle pressure and minimize formation, is typically removed within 24 hours postoperatively. Upon removal, patients receive instructions for perineal , including gentle cleansing with mild and water during showers, while avoiding baths or douching to prevent irritation. Light activity is encouraged, such as short walks around the hospital room, but strenuous efforts are prohibited to support . Dietary progression begins with clear liquids in the recovery room to assess tolerance and reduce risk, advancing to a regular, high-fiber diet by discharge to prevent . Early ambulation, starting within hours of , is promoted to enhance circulation and lower the risk of deep vein thrombosis. Stool softeners are routinely prescribed to facilitate bowel movements without straining. A follow-up clinic visit is scheduled within 1 to 4 weeks postoperatively for evaluation of wound healing, suture integrity if nonabsorbable materials were used, and initial assessment of prolapse resolution. This appointment allows for early detection of any healing issues and adjustment of care plans as needed.

Long-term Recovery

Following colporrhaphy, patients are advised to adhere to activity restrictions for several weeks to support tissue healing and prevent strain on the repaired vaginal walls. Heavy lifting exceeding 5 pounds, strenuous exercise such as jogging or weightlifting, and activities involving straining, such as vigorous coughing or constipation, should be avoided for at least 6 weeks. Vaginal intercourse and the use of tampons or douches are prohibited for 6 to 8 weeks to minimize infection risk and allow mucosal recovery. Stool softeners may be recommended for up to 3 months to facilitate gentle bowel movements and reduce intra-abdominal pressure. A gradual return to normal exercise is encouraged after this period, often starting with light activities like walking, under medical guidance. Symptom resolution typically progresses over the ensuing months, with most patients experiencing significant improvement in prolapse-related discomfort, such as pelvic pressure or bulging, within 3 months postoperatively. Vaginal and discharge generally subside within 4 to 6 weeks, while full of the vaginal tissue occurs in 6 to 12 weeks, though more extensive repairs may extend this to 3 months. exercises, such as Kegels, are often initiated early and continued long-term to enhance muscle strength and sustain surgical outcomes. By 3 months, the majority of patients report restored daily function, aligning with the procedure's goal of alleviating symptoms without impeding . Follow-up monitoring is essential to assess and detect any recurrence. A is routinely scheduled at 6 weeks to evaluate wound integrity and symptom status. Subsequent visits at 6 months and annually thereafter allow for ongoing surveillance of recurrence through clinical assessment and patient-reported outcomes. These appointments also provide opportunities to address any persistent issues and reinforce lifestyle modifications, such as maintaining a healthy weight and avoiding chronic straining. Long-term success rates for colporrhaphy demonstrate 80% to 90% relief of symptoms, with anatomical cure rates around 70% to 85% at 5-year follow-up, though anterior repairs may have higher recurrence in the front vaginal wall. Approximately 10% to 15% of patients may require reoperation due to symptom recurrence or progression at 5 years, influenced by factors like age and preoperative severity. Overall patient satisfaction remains high, exceeding 80% in most cohorts, underscoring the procedure's durability when combined with postoperative adherence.

Complications and Risks

Intraoperative and Short-term Complications

Intraoperative complications of colporrhaphy are relatively uncommon but can include significant bleeding and injuries to adjacent structures. Excessive bleeding requiring occurs rarely, with an incidence of less than 1% in native tissue repairs. Bladder or rectal during dissection of the vaginal wall is reported in 1-2% of cases, often recognized and repaired intraoperatively to prevent further issues. Short-term complications, typically arising within the first few weeks postoperatively, encompass infectious and urinary issues as well as localized collections. Urinary tract infections (UTIs) occur in 2-17% of patients and wound infections in approximately 2-5%, often managed with antibiotics and contributing to prolonged stays if severe. necessitating recatheterization occurs in up to 10-20% of cases, particularly following anterior repairs, and usually resolves with conservative measures. formation in the pelvic or vaginal space is infrequent but can lead to pain, infection, or the need for drainage if symptomatic. Anesthesia-related short-term complications include and , which are common but transient, affecting a substantial portion of patients under general or regional . Allergic reactions to anesthetics are rare, occurring in less than 1% of gynecologic procedures. Deep vein thrombosis (DVT) risk is mitigated by routine prophylaxis with anticoagulants and mechanical devices, reducing incidence to approximately 0.3% in the early postoperative period. The overall incidence of intraoperative and short-term complications for colporrhaphy ranges from 10-20%, with higher rates observed when synthetic mesh is incorporated into the repair. These events are generally manageable, though they underscore the importance of vigilant monitoring during and after surgery.

Long-term Complications

Recurrence of remains one of the most common long-term complications following colporrhaphy, with anatomical recurrence rates reported between 20% and 40% within five years post-surgery. These rates are influenced by patient-specific factors, including , which has been associated with increased odds of anatomic recurrence due to elevated intra-abdominal pressure and tissue strain. Reoperation for prolapse recurrence can occur in up to 20% of cases after anterior colporrhaphy, highlighting the procedure's variable durability over time. Dyspareunia and vaginal shortening or narrowing are additional persistent issues, affecting 5% to 15% of patients in the long term, often resulting from excessive plication of vaginal tissues or postoperative scarring that alters vaginal anatomy and sensation. These complications can impact sexual function and quality of life, with resolution sometimes requiring additional interventions such as dilation or revision surgery. Although transvaginal synthetic mesh for pelvic organ prolapse repair has been banned by the U.S. Food and Drug Administration (FDA) since 2019 due to safety concerns and is similarly restricted in many countries, historical data from procedures involving synthetic mesh augmentation show long-term mesh-related complications include erosion into the vaginal wall or adjacent structures like the bladder, occurring in 2% to 10% of cases and potentially leading to chronic pain, infection, or dyspareunia that necessitates mesh removal. Erosion rates vary by mesh type and surgical approach, with polypropylene meshes showing higher risks in some studies, underscoring the need for careful patient selection when mesh is employed. Colporrhaphy can also affect urinary continence, with new-onset stress urinary incontinence developing in approximately 10% of patients postoperatively, possibly due to alterations in urethral support or bladder neck position. Similarly, posterior colporrhaphy may contribute to worsening bowel function, including increased or defecatory dysfunction, in a subset of women through changes in rectovaginal support and perineal mechanics.

History

Early Developments

The origins of colporrhaphy trace back to ancient civilizations, where treatments for , including vaginal wall descent, relied on non-surgical interventions. The , dating to approximately 1550 BC, documents remedies for a "displaced womb," recommending applications of mixed with and manure to the patient's body for correction. Around 400 BC, described the use of pomegranate-based pessaries to reduce by supporting the vaginal walls, marking an early recognition of mechanical aids for symptom relief in anterior and posterior compartment issues. In the , surgical approaches to colporrhaphy emerged as gynecology advanced, with initial focus on repairing vaginal wall defects through vaginal incisions. The first documented anterior colporrhaphy was performed by in 1866, involving wedge-shaped excision of the vaginal mucosa and plication to address ; however, Sims' contributions are controversial due to his experimental surgeries on enslaved African American women without . Refinements continued into the late 1800s with techniques emphasizing mucosal denudation and edge approximation, as described by surgeons like Thomas Emmet in 1871. Early posterior repairs for also developed during this period, originating in the early 1800s as extensions of perineal repair for obstetric tears; by mid-century, procedures incorporated posterior vaginal wall plication and perineorrhaphy to narrow the introitus and support the rectovaginal septum. Key innovations included Marshall Hall's 1832 suggestion of vaginal narrowing through perineal suturing to alleviate symptoms by enhancing support. Prominent figures further shaped these techniques in the early . Howard A. Kelly, in 1913, modified anterior colporrhaphy by introducing the Kelly plication stitch—a horizontal mattress suture at the urethrovesical junction—to buttress the bladder neck and reduce recurrence, integrating it with paravaginal tissue approximation for improved anterior wall stability. Despite these advances, early colporrhaphy faced significant challenges, including high postoperative rates due to the absence of antibiotics until the mid-20th century and limited antisepsis before Joseph Lister's 1867 carbolic acid methods; surgeons prioritized symptom palliation, such as reducing bulging and discomfort, over standardized fascial plication, which contributed to variable outcomes and recurrence.

Modern Techniques

In the mid-20th century, colporrhaphy benefited from advancements in suture materials and perioperative care. Absorbable sutures, such as synthetic polyglycolic acid introduced in the 1970s, improved and reduced the need for suture removal in repairs, building on earlier use from the 1930s. Antibiotic prophylaxis became standard in gynecologic following the widespread availability of in the 1940s, significantly lowering postoperative rates in procedures like colporrhaphy. The Manchester operation, originally developed in 1888 and refined in the , integrated anterior and posterior colporrhaphy with cervical amputation and plication to address while preserving , offering a uterus-sparing alternative to . During the late , synthetic kits were introduced in the to reinforce vaginal walls in colporrhaphy, aiming to enhance anatomic durability for (POP) repair. However, reports of complications, including mesh erosion and exposure affecting up to 10-30% of cases, prompted the U.S. (FDA) to issue a 2011 safety communication classifying transvaginal mesh for POP as a high-risk device and recommending its use only when alternatives are unavailable due to greater risks compared to traditional repairs. This led to further regulatory actions, including a FDA order banning the sale and distribution of transvaginal mesh kits for POP repair in the United States. In the 21st century, colporrhaphy evolved toward minimally invasive techniques, including laparoscopic and robotic-assisted approaches, which reduce recovery time and blood loss while achieving success rates of 84-100% for anatomic correction in POP. The Pelvic Organ Prolapse Quantification (POP-Q) system, introduced in 1996, standardized prolapse assessment and facilitated site-specific repairs targeting defects like paravaginal detachment rather than plicating midline vaginal tissue. Current trends emphasize native tissue repairs over mesh in colporrhaphy, driven by comparable long-term outcomes and lower complication profiles. Randomized trials from the 2000s, such as those comparing native tissue vaginal repairs to mesh-augmented procedures, demonstrated similar reoperation rates (around 9-10% at 5 years) and functional results, with sacrocolpopexy emerging as a durable alternative for apical support. From 2020 to 2025, research has further reinforced native tissue repair as the first-line option for primary POP, with growing adoption of uterine-preserving techniques like the Manchester operation variants and paravaginal defect-specific repairs showing improved outcomes in symptom relief and sexual function, as evidenced by comparative studies and meta-analyses.

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