Urogynecology and Reconstructive
Aram Bonni, M.D., offers state-of-the-art treatments for a wide range of pelvic floor disorders that affect patients. Everything from simple office procedures to minimally invasive outpatient surgeries to more complicated and reconstructive surgeries are available and tailored to fit your need. Dr. Bonni is dedicated to help you return to your normal activities comfortably and confidently.
If you have any suggestions, questions or concerns or if you want to schedule an appointment after browsing the following topics in our pelvic surgery section, please contact Pelvic Pro. We have availabilities in Los Angeles, Orange County, and San Bernardino.
- Sling Revision / Removal
- Vaginal Mesh Complications
- Vesicovaginal Fistula Repair
Hysterectomy, the surgical removal of the uterus, is the second most common surgical procedure for women. It may be indicated for women suffering from chronic pelvic pain, endometriosis, pelvic prolapse, fibroids, uterine cancer, or abnormal uterine bleeding. With offices in Los Angeles and Orange County, Aram Bonni, M.D., believes in taking minimally invasive approach to pelvic surgery whenever possible, which is why he prefers the laparoscopic hysterectomy over its open abdominal counterpart.
This usually refers to repair of the area between the vagina and the rectum. Childbirth, weight gain , aging, trauma and prior surgery can cause the perineal muscles of the vagina to weaken or tear. Because these muscles are responsible for keeping the opening of the vagina narrow, patients with damaged perineal muscles often are troubled by the loss of function and weakened anatomy. The repair of the perineal muscles and perineal body would restore normal anatomy and function is also known as perineoplasty. it is frequently performed in conjunction with vaginal rejuvenation and pelvic prolapse surgery.
Sling Revision / Removal
Slings are usually performed to attend to urinary incontinence. There are many different types of slings but nowadays most commonly used Slings are synthetic tension free type tapes that are placed underneath the urethra. In some patients these slings could cause problems such as retention, incomplete emptying and other dysfunctional voiding symptoms. In some circumstances they would need to be removed and in some other situations they could be preserved but revised. These procedures are often time difficult and complicated secondary to extensive scarring and delicate surrounding tissues specially the urethra ( the tube that connects bladder to outside). Suburethral slings remain highly successful and sought after procedures for urinary incontinence. Insertion of these kinds of tapes in expert hands is safe. Placement of these kinds of meshes is different than those in FDA warning. Sling revisions and removals should be done by experts who are familiar with and have performed many of these procedures.
Vaginal Mesh Complications
For many years repair of the prolapsing pelvic organ would be carried out using the native tissues. There has been a surge in usage of vaginal meshes in the past ten years. The main advantage of these graft augmented repairs seems to be decreased chance of recurrence of the prolapse. These procedures unlike the push in the market are not simple operations that could be done on all prolapse cases by inexperienced surgeons. Unfortunately this has resulted in an increased number of mesh related complications. These include but are not limited to bleeding, infection, injury to bladder and surrounding viscus organs, pelvic pain, buttock, painful intercourse, buttock and leg pain, dysfunctional urinary symptoms and graft erosion to vagina or other surrounding organs. Repair and removal of these meshes and correction of their complications are difficult surgeries that need expertise in female pelvic medicine and reconstructive pelvic surgery. Dr. Bonni is fellowship trained in this area and has the skills and surgical experience necessary to treat mesh complications and restore the normal function and anatomy to the pelvic floor.
Vesicovaginal Fistula Repair
A vesicovaginal fistula is an abnormal connection between the bladder and the vagina. This type of fistula is usually caused by complications of child birth in developing countries. In US they are mostly secondary to trauma, injury or complication of pelvic surgery in women. They may cause pain, bloody vaginal discharge, and urinary incontinence. Many different types of repair is available. If possible Dr. Bonni repairs these using a vaginal approach and if not then laparoscopic or open routes are chosen on a case by case basis. The fistula and the connection is identified and meticulously separated from the surrounding viable organs and tissues. It is then resected and the openings are closed in layers.
Pelvic organ prolapse occurs when the muscles or connective tissues that support a woman’s pelvic organs become weakened or damaged. It is a common disorder especially among women over 50. It is essentially a herniation of the affected organ through the path of least resistance. As a result, the organs may move out of place.
Chronic straining, repeated heavy lifting, obesity, chronic constipation, multiple vaginal deliveries, genetics, smoking and aging are factors that can weaken the fascia and cause the organs to reposition. To better understand this condition think of the vaginal canal as an empty chamber. Imagine that the door to this chamber is the vaginal opening. This chamber would have two side walls, a back wall , a roof and also a floor. When these walls are weakened or damaged the organ(s) that remain behind these walls are the ones that would prolapse and herniate into this hollow room.
The prolapse is then named after the protruding pelvic organ. In a supine ( lying back down) position usually bladder is on top of the roof. Behind the back wall is usually the uterus or the intestines in women who have had hysterectomy. This is called enterocele. End portion of the large intestine is called rectum. This is under the flooring of the vagina. Its prolapse is called rectocele.
You have state of the art treatment choices when it comes to pelvic prolapse treatment at our practice serving Los Angeles, Orange and San Bernardino Counties . Dr. Bonni offers a range of specialized solutions that can be customized to your unique needs.
- Colpocleisis for Uterine or Vaginal Vault Prolapse
- Cystocele Repair
- Enterocele Repair
- Rectocele Repair (Posterior Repair)
- Uterine Suspension
- Vaginal Vault Prolapse Treatments
A cystocele is a prolapsed bladder, the intrusion of the bladder into the vagina. Cystocele may result when the pubocervical fascia breaks away from the pelvic side walls. This tear is known as a paravaginal defect. They could also result from midline defects.There are several options when it comes to treating cystoceles:
Anterior colporrhaphy is performed through the opening of the vagina. The defect in the pubocervical fascia is identified and repaired.
Graft augmented Prolapse Repair Systems
The past decade has seen a huge surge in many minimally invasive procedures for pelvic floor reconstruction with different graft systems. Sophisticated non absorbable or absorbable synthetic or cadaveric surgical grafts are used to provide a framework of support for the prolapsed organ. The advantage is usualy a decrease in recurrence rate. They can be interposed to support the repair of almost all types of pelvic organ prolapses. They are indicated only in a select group of patients. Their insertion requires expertise in female pelvic medicine and reconstructive pelvic surgery. Graft related erosions and complications may happen. These complications also need a very careful evaluation and proper treatment in expert hands.
Laparoscopic Paravaginal Repair
During this minimally invasive procedure, reconstructive repairs of the defect is done by using sutures to mend the tears, restoring the bladder to its natural position.
Graft removal or revision
We have seen tremendous increase in usage of synthetic grafts and meshes for female pelvic medicine and reconstructive pelvic surgery in the past ten years. Lack of accurate selection of patients, controlled studies and proper fellowship trained professionals to do these procedures has led to an increase in number of complications attributed to interposition of these materials at the time of pelvic surgery. Often time a poorly selected patient with some type of a prolapse receives a graft augmented repair. This in turn results in complications such as pelvic pain, pain with intercourse, bleeding, erosion of the mesh material through the vagina or into the viscus organ to name a few. Repair, revision or removal of this inserted mesh material is a tedious work that needs excellent understanding of urogynecology and pelvic surgery. Regional anatomy is often times very distorted and chances of injury to neighboring organs is high. Careful protection of these organs as well as a meticulous dissection in expert hands is necessary to remove the mesh completely or partially. At times repair or revision may just be enough.
An enterocele occurs when the small bowel descends and pushes against the vaginal wall. It is also known as small bowel prolapse. Enterocele repair involves suturing together the pubocervical and rectovaginal fascia, the supportive layers of the vagina. This should be done after the enterocele sac is carefully identified dissected and removed. The bowels are then pushed back inside and away from the harms way. This could be accomplished laparoscopically, vaginally or rarely through an open procedure with or without usage of synthetic supportive grafts and materials.
Rectocele Repair Surgery (Posterior Repair)
Through various approaches and techniques the tears and defects in the supportive layer of tissue (fascia) that separates the vagina from the rectum is identified and the rectal bulge into the vagina is reduced. Layers are repaired. Grafts could be used in select group of patients to reinforce the repair. Procedure is done vaginally.
Also called a dropped womb, uterine prolapse is a condition in which the uterus slides out of its proper place and descends into the vaginal canal. For women who suffer from uterine prolapse but do not wish to undergo hysterectomy, uterine preservation and suspension may be recommended. Uterine preservation surgery is a procedure by which the uterus or portion of it is saved. Many different technics have been identified. During uterine preservation surgery, usually a surgical mesh is secured to the sacrum (tailbone) and to the posterior aspect of the uterus to lift the uterus to its normal place within the pelvis and provide lasting support. This procedure is also known as sacral colpohysteropexy, hysteropexy, or uterine suspension.
Vaginal Vault Prolapse Treatments
Vaginal vault prolapse is the collapse of the upper portion of the vagina (the apex) into the vaginal canal. This condition is usually after a patient has had a hysterectomy. Many different surgical repairs for vaginal vault prolapse have been identified. More common ones include the following vault suspension procedures:
Colpocleisis for Uterine or Vaginal Vault Prolapse
Colpocleisis is a vaginal procedure used to treat uterine or vaginal vault prolapse. In patients with uterine prolapse, the procedure is known as a LeFort colpocleisis. It is referred to as a total colpocleisis in women who have undergone hysterectomies. It prevents prolapse by closing down the vaginal canal so it is only appropriate for women who are not sexually active and plan to remain celibate.
Sacral Colpopexy (Laparoscopic)
This is a highly successful treatment for vaginal vault prolapse. Laparoscopic sacral colpopexy restores the vagina to its correct anatomical position. During this minimally invasive procedure, Dr. Bonni creates a supportive bridge of surgical mesh from the vaginal apex to the longitudinal ligament running on top of the periosteum of the sacrum (the thick, triangular bone at the base of the spine). This procedure could also be done using the Da Vinci robotic system.
Sacrospinous Ligament Suspension
Sacrospinous ligament suspension or fixation is a surgical procedure to correct vaginal vault prolapse. The treatment involves suturing the vaginal vault to one or both sacrospinous ligaments (bilateral ligaments that connect each pelvic bone to the sacrum and coccyx). Although it provides a vaginal approach to the repair but because of its distortion of the anatomy and the change in vaginal vectores it is not very widely used in modern pelvic surgery.
High Uterosacral Ligament Suspension (Laparoscopic)
Laparoscopic uterosacral ligament suspension is a treatment for vaginal vault prolapse that uses the uterosacral ligaments to support the apex of the vagina. Designed to hold the uterus in place, the uterosacral ligaments are fibrous bands that extend from the cervix to the pelvic wall. During the procedure, these ligaments are delicately identified as high as possible where they attach to pelvic side walls and are sutured to the vaginal apex.