Vaginal Surgery

The vaginal route is an anatomically natural approach for pelvic surgery. It allows for correction of various conditions without abdominal incisions: through the vagina, surgeons can repair prolapse, remove the uterus, support the vaginal vault, or treat urinary incontinence. This approach shortens recovery time, reduces complication risks, and often does not require general anesthesia — procedures can be performed under regional anesthesia.

The key principle in managing pelvic organ prolapse is that surgery is performed not because prolapse exists, but because it causes symptoms. Even a pronounced prolapse may not require intervention if it doesn’t cause discomfort. For asymptomatic women, we usually recommend observation, pessaries, or pelvic floor muscle training. Surgery is considered only when there are complaints that affect quality of life: a bulging sensation in the vagina, pelvic pressure, difficulty urinating, urinary or fecal incontinence, defecation problems, or discomfort during intimacy.

Every procedure is tailored individually — depending on the anatomy, type of prolapse, age, reproductive plans, and the woman’s preferences.

2. Aesthetic Surgery

Aesthetic gynecology is a rapidly developing field, but it requires a particularly sensitive and ethical approach. According to a 2024 TOG review, most procedures — from "vaginal rejuvenation" to labiaplasty — are performed without clear medical indications and often lack sufficient evidence.

Figure 1: Schematic illustration of a labiaplasty procedure.

It is important to distinguish:

Functional surgeries — for example, correcting true prolapse or incontinence.
Cosmetic procedures — requested by the woman, without objective pathology.

While some women genuinely experience psychological or physical discomfort related to the appearance of their external genitalia, every case requires careful counselling, absence of pressure, and a clear understanding of potential risks. For instance:

Labiaplasty may lead to scarring and pain during intercourse.
Laser-based "rejuvenation" techniques lack strong evidence and are not recommended by major scientific bodies.

We always begin with a conversation: what exactly is bothering the patient, whether there are real functional concerns, and what safe, evidence-based options are available.

3. Vaginal Access in the Treatment of Genital Prolapse

The vaginal route is the primary approach for treating uterine, anterior, and posterior vaginal wall prolapse — especially in women who are not planning further pregnancies. Depending on the anatomy, different surgical techniques may be used:

Anterior colporrhaphy — for cystocele (bladder prolapse).
Posterior colporrhaphy — for rectocele (bulging of the rectum).
Vaginal hysterectomy — when the prolapse involves the uterus.
Vaginal vault suspension — for post-hysterectomy prolapse (vault descent).
Cervical fixation — in younger women with cervical elongation who wish to preserve the uterus.

Figure 2: Schematic representation of uterine prolapse.

Pessaries and pelvic floor muscle training are valid alternatives to surgery, especially in the early stages of prolapse. However, in the presence of significant symptoms, surgery can greatly improve quality of life.

4. Vaginal Access in the Treatment of Stress Urinary Incontinence

One of the most effective and well-studied treatments for stress urinary incontinence is the placement of a synthetic mid-urethral sling (TVT or TVT- O). These procedures are performed through small vaginal incisions and restore anatomical support to the urethra.

These techniques have been in use for about 30 years — the first TVT procedure was introduced in the mid-1990s. Today, the effectiveness of TVT/TVT-O is supported by numerous large studies and meta-analyses. Most women maintain continence even 5−10 years after the procedure.

Figure 3: Schematic illustration of sling positioning in TVT and TVT-O procedures.

Although the use of synthetic vaginal mesh has been restricted in some Western countries (such as the UK, Australia, New Zealand, and the USA) for legal reasons, this does not diminish the proven effectiveness of TVT and TVT-O. In many other countries, including Russia and throughout the post-Soviet region, these procedures continue to be widely used and are considered a reliable treatment option.

5. Vaginal Hysterectomy: When and Why

Vaginal hysterectomy — the removal of the uterus through the vaginal canal — is one of the oldest and most effective surgical techniques in gynecology. According to a major Cochrane review (2023), vaginal hysterectomy is the preferred method when it is technically feasible.

Its advantages over other routes include:

Faster recovery (by 10−18 days compared to abdominal hysterectomy);
Lower risk of postoperative wound infections;
Less blood loss;
Shorter hospital stay;
No visible scars.

Figure 4: Schematic view of the initial stage of vaginal hysterectomy.

When vaginal access is not feasible due to anatomical factors (e.g. extensive adhesions or a very large uterus), laparoscopic or open abdominal hysterectomy may be used instead. These approaches are described in their respective sections.

6. vNOTES — Modern Access Without Incisions

vNOTES (vaginal Natural Orifice Transluminal Endoscopic Surgery) is a minimally invasive technique in which laparoscopic surgery is performed through the vaginal canal, without any abdominal incisions. This approach combines the benefits of both laparoscopy and traditional vaginal access.

A specialized port is inserted through the vagina, pneumoperitoneum is created, and the operation is performed under laparoscopic guidance. Once the procedure is complete, tissues are removed through the same route, and the access site is closed internally.

vNOTES can be used for:

removal of ovaries or fallopian tubes,
hysterectomy,
selected cases of myomectomy,
prolapse surgery.

Figure 5: Schematic representation of vNOTES surgery.

This method is not suitable for everyone — in cases of advanced prolapse, previous rectal surgery, suspected malignancy, or significant adhesions, other approaches may be preferable.

The main advantages of vNOTES include the absence of visible scars, fast recovery, and low postoperative pain. The technique is actively developing in Europe and is gradually being introduced in countries with trained specialists and appropriate equipment.

Conclusion

Vaginal surgery encompasses a wide range of effective and safe procedures — from functional repairs to aesthetic interventions. Our core principle is that treatment should be based not solely on diagnosis, but on the woman’s symptoms and personal goals. That’s why it’s so important to explore all available options together and choose the solution that suits you best.