Female Pelvic Surgery

5. Transvaginal Prolapse Repair

Nitya E. Abraham  and Howard B. Goldman 

(1)

Female Pelvic Medicine and Reconstructive Surgery, Glickman Urology and Kidney Institute, Cleveland Clinic Foundation, Cleveland, OH, USA

Nitya E. Abraham

Email: nitya.abraham@gmail.com

Howard B. Goldman (Corresponding author)

Email: goldmah@ccf.org

Introduction

Transvaginal pelvic floor reconstruction can be divided by compartment: anterior repair, posterior repair, and apical repair. Approaches can be restorative, compensatory, and obliterative. Restorative repairs utilize native tissue to fix defects, while compensatory repairs utilize biologic or synthetic graft material to fix defects. It is critical to recognize that the presence of prolapse alone is not an indication for treatment. Up to half of women who have had a vaginal delivery will have prolapse to the hymen. Many, especially as they get older, will have prolapse beyond the hymen [1]. For a significant proportion of these patients the prolapse is asymptomatic and does not require intervention. Only symptomatic patients should be treated.

Anterior Repair

Background

Anterior compartment prolapse is herniation of pelvic organs into the anterior vaginal wall, including urethrocele (herniation of the urethra), cystocele (herniation of the bladder), and anterior enterocele (herniation of the small bowel) [2]. The prevalence and incidence of anterior compartment prolapse is not well described. In the Women’s Health Initiative, the prevalence of cystocele was 34 % in women age 50–79 years [3]. Risk factors for anterior compartment prolapse include increasing age, body mass index, and number of vaginal deliveries. Other possible risk factors include pregnancy, forceps delivery, young age at first delivery, prolonged labor, high infant birth weight, smoking, elevated intra-abdominal pressure (due to constipation, chronic cough, or occupations requiring heavy lifting), estrogen deficiency, previous hysterectomy, connective tissue disorders (e.g., Ehlers–Danlos syndrome, Marfan’s syndrome), muscular disorders (e.g., multiple sclerosis, muscular dystrophy), low socioeconomic status, ethnicity, family history, and history of prior prolapse repair [24]. The strongest risk factor is vaginal delivery with one study noting a 2.2 (1.8–2.7) times increased risk of cystocele after a single childbirth compared to nulliparity [3].

Evaluation

The first and most important step in evaluation of anterior compartment prolapse is a history and physical examination. Women with symptomatic anterior compartment prolapse may complain of a sensation of a vaginal bulge, pressure, or heaviness. They may visualize the protrusion. Urinary symptoms may include incontinence, frequency, urgency, obstructive voiding symptoms, or the need to manually reduce the prolapse to void. Patients may also complain of dyspareunia [3]. General symptoms can include low back pain, generalized pelvic pain, or bloody discharge due to ulceration of the prolapsed vaginal skin [2]. The history should thus elucidate the presence of risk factors and symptoms as listed above.

Physical examination is standardized by utilizing the Pelvic Organ Prolapse Quantification (POPQ) system, which involves the measurement of 9 points (Fig. 5.1):

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Fig. 5.1

POP-Q exam. Aa point A anterior, Ap point A posterior, Ba point B anterior, Bp point B posterior, C cervix or vaginal cuff, D posterior fornix (if cervix is present), gh genital hiatus, pbperineal body, tvltotal vaginal length

·               Aa—anterior vaginal wall 3 cm proximal to the hymen

·               Ba—most distal position of the remaining upper anterior vaginal wall

·               C—most distal edge of cervix or vaginal cuff scar

·               D—posterior fornix (not applicable if post-hysterectomy)

·               Ap—posterior vaginal wall 3 cm proximal to the hymen

·               Bp—most distal position of the remaining upper posterior vaginal wall

·               Genital hiatus (gh)—middle of external urethral meatus to posterior midline hymen

·               Perineal body (pb)—posterior margin of gh to middle of anus

·               Total vaginal length (tvl)—depth of vagina with prolapse reduced

The POPQ can be categorized into stages:

·               Stage 0—No prolapse

·               Stage 1—The most distal point of the prolapse is at least 1 cm above the level of the hymen

·               Stage 2—The most distal point of the prolapse is between 1 cm proximal and 1 cm distal to the level of the hymen

·               Stage 3—The most distal point of the prolapse is between 1 cm distal to the level of the hymen and 2 cm less than the tvl

·               Stage 4—The most distal point of the prolapse is equal to or beyond 2 cm less than the tvl, from the level of the hymen

Some clinicians simplify the POPQ exam and do not routinely measure Aa or Ap.

Other staging systems generally utilize the relationship of the leading edge of the prolapse to the hymenal ring or introitus.

Imaging is not routinely used in the evaluation of pelvic organ prolapse. However, it has been argued that clinical examination assesses surface anatomy and is more limited in assessing structural abnormalities [5]. Underestimation or misdiagnosis of the compartment that is prolapsed can occur in 45–90 % of cases [6]. What appears to be a cystocele could in rare cases be a urethral diverticulum, Gartner duct cyst, or anterior enterocele [5]. Thus, in ambiguous cases, translabial ultrasound or dynamic MR imaging can be utilized. However, this is not routine, requires trained personnel to interpret the imaging, and may be cost-prohibitive.

Surgical Repair

The patient is placed in the dorsal lithotomy position. The external genitalia is prepped and draped in the usual sterile fashion. Some choose to shave the perineum but it is not required. One dose of intravenous antibiotics is administered for prophylaxis prior to incision. As per the 2011 American Urological Association Guidelines on Antibiotic Prophylaxis, the antibiotics of choice for vaginal surgery are a first/second generation Cephalosporin or an Aminoglycoside (Aztreonam if the patient has renal insufficiency) plus Metronidazole or Clindamycin. Alternative antibiotics are Ampicillin/Sulbactam or Flouroquinolone [7]. A foley catheter is placed to drain the bladder. A weighted speculum is placed in the vagina. A Scott retractor or translabial sutures are used to retract and expose the prolapse. The anterior compartment prolapse repair is then performed using one of the following techniques: traditional anterior colporrhaphy, mesh-augmented colporrhaphy, or paravaginal defect repair.

Traditional Anterior Colporrhaphy

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Mesh-Augmented Colporrhaphy

Mesh placement for mesh-augmented anterior colporrhaphy can be performed using self-tailored biologic or synthetic mesh, a transobturator and/or transgluteal trocar-guided synthetic mesh kit, or a non-trocar synthetic mesh kit. (The objective outcome data is better for macroporous polypropylene synthetic mesh compared to biologic mesh. See section on Recent Randomized Trials on Outcomes)

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Paravaginal Defect Repair

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Recent Randomized Trials on Outcomes [9]

Several prospective trials have compared outcomes between these approaches. The first randomized trial comparing anterior colporrhaphy techniques was published by Weber et al. in 2001 [10]. Chmielewski et al. reanalyzed the data using a more clinically relevant definition of success, which included no prolapse beyond the hymen, absence of prolapse symptoms, and absence of retreatment. One hundred fourteen women were randomized to standard anterior colporrhaphy, ultralateral colporrhaphy, or anterior colporrhaphy with (absorbable) mesh, and were followed at 6 months, 1 year, and 2 years after repair. Eighty-eight percent of women with sufficient follow-up data at 1 year met the definition of surgical success. There was no difference between repair groups. The authors concluded that standard anterior colporrhaphy is appropriate for primary cystocele repair at 2 years follow-up [11]. Some have criticized this study as a reanalysis years after the original with changing definitions and relatively short follow-up given the length of time from the original study [12].

Several more recent randomized, controlled trials have compared anterior colporrhaphy with mesh-augmented colporrhaphy. Anatomical success rates for anterior colporrhaphy were 41–72 % versus 81–91 % for self-tailored synthetic mesh-augmented colporrhaphy and 87–91 % for synthetic mesh-kit-augmented colporrhaphy at 1 year follow-up. Vaginal mesh extrusion rates were 4–7 %. Rates of de novo dyspareunia were not significantly different between groups [1316].

The randomized, controlled study with the longest follow-up, 3 years, reported 59 % anatomical success in the traditional colporrhaphy group versus 87 % in the synthetic mesh-augmented colporrhaphy group (p < 0.0001). Symptomatic outcomes and rates of de novo dyspareunia were similar in both groups. The mesh extrusion rate was 19 % [17].

The largest randomized controlled trial compared 389 women who underwent trocar-guided, transvaginal polypropylene-mesh repair (Gynecare Prolift™ Anterior Pelvic Floor Repair System kit, Ethicon) to women who underwent traditional colporrhaphy. The primary outcome was a composite of anatomic and symptomatic success. At 1-year follow-up, 60.8 % of women treated with transvaginal mesh had no prolapse or vaginal bulge symptoms compared to 34.5 % of women who underwent traditional colporrhaphy (p < 0.001). The rate of reoperation for mesh exposure was 3.2 %. The mesh repair group also experienced more surgical complications such as longer operating time, increased blood loss, bladder injury, and mesh-related complications [18].

A criticism of several studies has been that anterior colporrhaphy has had worse anatomic outcomes compared to mesh-augmented colporrhaphy due to not addressing concomitant apical prolapse. Nguyen et al. performed a randomized trial comparing anterior colporrhaphy with synthetic mesh-augmented colporrhaphy. The majority of these women underwent uterosacral vault suspension. At 1-year follow-up, anatomic success (no stage 2 or greater anterior prolapse) was 55 % and 87 % in the traditional and synthetic mesh-augmented groups, thus demonstrating the superiority of mesh-augmented repairs even after addressing apical prolapse in both groups [15].

Given the risk of extrusion with synthetic mesh, three randomized trials have compared traditional colporrhaphy with biologic graft-augmented colporrhaphy. Meschia et al. utilized Pelvicol in their study of women with primary stage 2 or greater cystocele. At 2 years follow-up, the failure rate in the traditional group was 23 % versus 11 % in the Pelvicol group (RR 2.08, 95 % CI 1.08–4.01). One woman underwent graft removal due to “rejection.” Subjective outcomes at 2 years were not reported [19]. Dahlgren et al. performed a similar study utilizing Pelvicol® (Bard Medical) for women with recurrent cystocele. Recurrence rates at 3 years follow-up were 57 % without versus 62 % with Pelvicol (not significant). Symptomatic improvement and sexual function were similar in both groups [20]. The third randomized trial utilized cadaveric fascial lata (Tutoplast®, Davol) in women with primary or recurrent cystocele. At 13 months follow-up, there was no difference in objective and subjective outcomes [19]. Thus, it seems there is no functional or symptomatic advantage with the use of a biologic graft for colporrhaphy.

A randomized controlled trial comparing traditional colporrhaphy, xenograft-augmented, and synthetic mesh-augmented colporrhaphy has been conducted with 2 year follow-up. Anatomic failure rate was 58 %, 46 %, and 18 % in each respective group (p < 0.05). Symptomatic failure rates were not statistically different between groups. The mesh extrusion rate was 14 %. The authors concluded that synthetic mesh-augmented repair had the best anatomic outcome but symptomatic outcomes were similar between all groups [21].

Finally, a recent Cochrane review has noted that there are better outcomes for anterior repair with mesh augmentation than anterior colporrhaphy alone and that synthetic mesh does better than biologic mesh [19].

See Table 5.1.

Table 5.1

Success rates for pelvic organ prolapse repair

 

Objective success (%)

Subjective success (%)a

Anterior repair

 Traditional

41–89

81–100

 Paravaginal

83

93

 Synthetic mesh augmented

81–96

81–91

 Biologic mesh augmented

54–82

 

Posterior repair

 Traditional

75–91

80–93

 Site-specific

78

88

 Synthetic mesh augmented

78–96

79–96

 Biologic mesh augmented

54–88

97

Apical repair

 USVS

86–97

94

 SSLF

69

91

 Transvaginal mesh augmented

43

79

 Open ASC

76–94

94

 Laparoscopic ASC

77–91

87

 Robotic ASC

88–94

 

 Uterine sparing ASC

68

 

 Hysterectomy and A–P repair

87

 

 Colpocleisis

85–100

 

aSubjective outcomes not reported as a percentage for robotic ASC, uterine sparing ASC, hysterectomy and A–P repair, and colpocleisis, and thus not listed

Summary

The randomized controlled trials comparing colporrhaphy with and without mesh are heterogeneous. However, the consensus seems to be that mesh repair provides superior anatomic outcome but equivalent symptomatic outcome. While subjective outcomes appear similar in the short run, one cannot know at this point if that will remain so in the long run. Specifically, will those patients with asymptomatic anatomic recurrences now become those that have symptomatic recurrences in the future? Rates of de novo dyspareunia are not significantly increased with mesh repair, but mesh exposure rates and the increased surgical complication rates are not negligible. Given the risk of mesh extrusion, the FDA safety update on transvaginal mesh for pelvic organ prolapse [22], and after a recent $5.5 million settlement against the manufacturers of Avaulta mesh, surgeons must use caution when utilizing transvaginal mesh [23]. Does that mean there is no role for the use of synthetic mesh in transvaginal cystocele repair? The reality is that a percentage of women will fail primary traditional colporrhaphy and women with Stage 3 or higher prolapse are more likely to recur [24]. We thus recommend a pragmatic approach to the use of transvaginal mesh for prolapse repair [25], by carefully selecting women at high risk for recurrence and having an informed discussion of the postoperative risks and complications of synthetic mesh-augmented colporrhaphy. In addition, some women with significant apical prolapse with concomitant anterior vaginal wall prolapse may do well with an abdominal sacrocolpopexy. This is discussed further in the section on apical prolapse.

Key Points

·               Anatomic cure after traditional colporrhaphy is as high as 72 % compared to as high as 91 % after synthetic mesh-augmented colporrhaphy, even after addressing apical prolapse.

·               Biologic graft-augmented colporrhaphy is not superior to traditional colporrhaphy.

·               Early subjective outcomes and rates of de novo dyspareunia are similar for all types of colporrhaphy.

·               Synthetic mesh extrusion rates are 4–19 %.

·               Long-term anatomic durability and subjective outcomes are unknown.

·               Women with recurrent cystocele or Stage 3 or higher prolapse may benefit from a synthetic mesh-augmented repair if appropriately counseled.

Posterior Repair and Perineorrhaphy

Background

Posterior compartment prolapse is herniation of pelvic organs into the posterior vaginal wall, including rectocele (herniation of the rectum) and posterior enterocele (herniation of the small bowel) [2]. The prevalence and incidence of posterior compartment prolapse is also not well described. In the Women’s Health Initiative, the prevalence of rectocele was 19 % in women age 50–79 years [3]. Risk factors for posterior compartment prolapse are similar to those for anterior compartment prolapse (see above). The strongest risk factor is vaginal delivery with one study noting a 1.9 (1.7–2.2) times increased risk of rectocele after a single childbirth compared to nulliparity [3].

Evaluation

The first step in evaluation of posterior compartment prolapse is a history and physical examination. Women with symptomatic posterior compartment prolapse may complain of a sensation of a vaginal bulge, pressure, or heaviness. They may visualize the protrusion. Bowel symptoms may include incontinence of flatus or stool, feeling of incomplete emptying, straining to defecate, fecal urgency, digital evacuation of stool from rectum, splinting or manual reduction of prolapse to defecate, and feeling of obstruction during defecation. Patients may also complain of dyspareunia [3]. General symptoms can include low back pain, generalized pelvic pain, or bloody discharge due to ulceration of the prolapsed vaginal skin [2]. The history should thus elucidate the presence of risk factors and symptoms as previously described.

Physical examination is standardized by utilizing the POPQ system as detailed in the previous section.

Imaging is not routinely used in the evaluation of pelvic organ prolapse. However, transperineal ultrasound or MR defecography can differentiate a rectocele from an enterocele.

Surgical Repair

The patient is placed in the dorsal lithotomy position. The external genitalia is prepped and draped in the usual sterile fashion. One dose of intravenous antibiotics is administered for prophylaxis prior to incision. As per the 2011 American Urological Association Guidelines on Antibiotic Prophylaxis, the antibiotics of choice for vaginal surgery are a first/second generation Cephalosporin or an Aminoglycoside (Aztreonam if the patient has renal insufficiency) plus Metronidazole or Clindamycin. Alternative antibiotics are Ampicillin/Sulbactam or Flouroquinolone [7]. A foley catheter is placed to drain the bladder. A weighted speculum is placed in the vagina. A Scott retractor or translabial sutures are used to retract and expose the prolapse. The posterior compartment prolapse repair is then performed using one of the following techniques: traditional posterior colporrhaphy, site-specific posterior repair, or graft-augmented posterior colporrhaphy. Perineorrhaphy is often performed at the same time. The goals of posterior compartment prolapse repair are plication of the prerectal and pararectal fascia, narrowing of the levator hiatus, and repair of the perineal body [26].

Traditional Posterior Colporrhaphy

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Site-Specific Posterior Colporrhaphy

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Graft-Augmented Posterior Colporrhaphy

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Recent Randomized Trials on Outcomes [9]

There are two randomized controlled trials specifically studying transvaginal rectocele repair [2728]. Paraiso et al. randomized women to posterior colporrhaphy (n = 37), site-specific rectocele repair (n = 37), or site-specific rectocele repair augmented with a porcine 4 × 8 cm Fortagen graft (Organogenesis Inc, Canton, MA; n = 32). Anatomic cure was defined as POP-Q point Bp less than or equal to −2 at 12 months follow-up. Patients also completed validated questionnaires to assess subjective outcomes. At 1-year follow-up, the rate of anatomic cure was 86 % in the posterior colporrhaphy group, 78 % in the site-specific group, and 54 % in the porcine graft-augmented group. There was no significant difference in subjective outcomes or rates of de novo dyspareunia between the three groups. The authors concluded that porcine graft did not improve anatomic outcomes for posterior colporrhaphy and that all three methods provided symptomatic and quality of life improvement [28]. One criticism of this study is that the graft used may not be as durable as other commonly used biologic grafts, and thus may not have functioned as well. However, clearly the traditional colporrhaphy group did very well.

Sung et al. conducted a randomized controlled trial comparing native tissue rectocele repair and porcine subintestinal submucosal graft-augmented rectocele repair in 160 women with stage 2 or greater rectocele. Women in the control group underwent either midline plication of the rectovaginal connective tissue or site-specific repair at the discretion of the surgeon, whereas women in the study group similarly underwent midline plication or site-specific repair, augmented with a 4 × 7 cm porcine graft. Anatomic failure was defined as points Ap or Bp greater than or equal to −1 on POP-Q. Subjective symptoms were based on items taken from the Pelvic Floor Distress Inventory questionnaire. At 12 months follow-up, the rate of anatomic failure was 8.6 % in the native tissue repair group and 12 % in the graft-augmented repair group. There was no statistically significant difference between the groups regarding subjective symptoms or dyspareunia. The authors concluded that augmentation of posterior colporrhaphy with porcine graft did not provide any objective or subjective benefit over native tissue repair [27].

There are no randomized controlled studies solely comparing traditional posterior colporrhaphy with synthetic-mesh-augmented posterior repair. Two trials included outcomes on the posterior compartment [2930]. Sokol et al. compared traditional anterior–posterior repair and uterosacral ligament suspension with vaginal colpopexy using the Prolift® (Ethicon, Somerville, NJ) synthetic mesh. Overall objective recurrence was 69.7 % in the traditional repair group versus 62.5 % in the mesh repair group. Posterior compartment recurrence was 18.2 % in the traditional repair group versus 21.9 % in the mesh repair group (not significant). The mesh extrusion rate was 15.6 % [30]. This study has been criticized for the low number of patients enrolled, the few procedures performed per surgeon, and the short follow-up rate. Withagen et al. compared traditional vaginal prolapse repair with trocar-guided mesh repair. The posterior compartment recurrence rate was 24.5 % in the traditional repair group versus 4.1 % in the mesh repair group (p = 0.003). The mesh extrusion rate was 16.9 % [29].

There are two randomized trials comparing transvaginal and transanal rectocele repair[19]. Transvaginal repair was superior to transanal repair subjectively (RR 0.36, 95 % CI 0.13–1) and objectively (RR 0.24, 95 % CI 0.09–0.64) [19].

See Table 5.1.

Summary

Transvaginal repair is preferred over transanal repair of rectocele. Given the risk of mesh extrusion and the overall similar objective and subjective outcomes for mesh-augmented versus traditional repair noted in most studies, posterior compartment repair with native tissue is currently the gold standard [31].

Key Point

·               The gold standard for rectocele repair is transvaginal traditional posterior colporrhaphy.

Apical Repair

Background

Apical compartment prolapse is herniation of the cervix, uterus, or vaginal cuff into the apical vaginal wall [2]. In the Women’s Health Initiative, the prevalence of uterine prolapse was 14 % in women age 50–79 years [3]. Risk factors for apical compartment prolapsed are similar to those for anterior compartment prolapse (see above). The strongest risk factor is vaginal delivery with one study noting a 2.1 (1.7–2.7) times increased risk of uterine prolapse after a single childbirth compared to nulliparity [3].

Evaluation

The first step in evaluation of apical compartment prolapse is a history and physical examination. Women with symptomatic apical compartment prolapse may complain of a sensation of a vaginal bulge, pressure, or heaviness. They may visualize the protrusion. They may report urinary and bowel symptoms as detailed previously. Patients may also complain of dyspareunia [3]. General symptoms can include low back pain, generalized pelvic pain, or bloody discharge due to ulceration of the prolapsed vaginal skin [2]. The history should thus elucidate the presence of risk factors and symptoms previously described.

Physical examination is standardized by utilizing the POPQ system as detailed previously.

Imaging is not routinely used in the evaluation of pelvic organ prolapse. Transperineal ultrasound is least useful in the apical compartment [56].

Surgical Repair

The options for transvaginal apical repair can be divided into restorative, compensatory, and obliterative procedures. The restorative techniques include transvaginal sacrospinous ligament fixation (SSLF), transvaginal iliococcygeus suspension, or transvaginal uterosacral suspension.

The patient is placed in the dorsal lithotomy position. The external genitalia is prepped and draped in the usual sterile fashion. One dose of intravenous antibiotics is administered for prophylaxis prior to incision. As per the 2011 American Urological Association Guidelines on Antibiotic Prophylaxis, the antibiotics of choice for vaginal surgery are a first/second generation Cephalosporin or an Aminoglycoside (Aztreonam if the patient has renal insufficiency) plus Metronidazole or Clindamycin. Alternative antibiotics are Ampicillin/Sulbactam or Flouroquinolone [7]. A foley catheter is placed to drain the bladder. A weighted speculum is placed in the vagina. A Scott retractor or translabial sutures are used to retract and expose the prolapse.

Restorative Apical Prolapse Repair

Transvaginal Sacrospinous Ligament Fixation

SSLF can be performed unilaterally or bilaterally, using an anterior or posterior approach. SSLF is preferred if there is coexistent posterior prolapse. However, anterior prolapse can be exacerbated by SSLF.

Posterior Approach

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Transvaginal Uterosacral Ligament Suspension

Transvaginal uterosacral ligament suspension is preferred if concomitant hysterectomy is being performed and the vaginal cuff is open since uterosacral ligament suspension is best performed intraperitoneally. This may also be the preferred technique post-hysterectomy in the presence of a significant enterocele.

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Compensatory Apical Prolapse Repair

Compensatory techniques for apical repair entail the utilization of mesh to augment the repair. Mesh can be used via a transvaginal or transabdominal approach. Hysterectomy can be performed concomitantly or the procedure can be uterine-sparing.

There are several transvaginal mesh kits for apical repair including: Gynecare Anterior Prolift® (Ethicon, Inc. Somerville, NJ), the American Medical Systems Perigree (Minnetonka, MN), Boston Scientific Pinnacle and Uphold, AMS Elevate, and Ethicon Prosima. The mesh kits utilize delivery of mesh arms via transobturator trocars (Prolift, Perigee), fixation to SSL and/or ATFP with a Capio® (Boston Scientific, Natick, MA) needle driver (Uphold™, Pinnacle), with another anchoring system (Elevate®, AMS), or fixation utilizing a vaginal support device (Prosima™, Ethicon) [32]. For a number of reasons the Prolift and Pinnacle devices are no longer being manufactured or marketed.

Sacral colpopexy is performed transabdominally in women who have undergone hysterectomy. Two strips of polypropylene mesh or a preformed Y-shaped mesh is secured to the anterior and posterior vaginal wall with permanent or delayed absorbable sutures. The cranial ends are secured to the anterior spinous ligament on the sacral promontory. If uterine sparing is desired, only a posterior mesh strip is utilized or a Y-shaped strip of mesh is tunneled through the broad ligament bilaterally and secured anterior to the uterus. Abdominal sacral colpopexy (ASC) or hysteropexy can be performed open or more commonly today via a laparoscopic or robotic approach. These procedures are described in further detail in Chaps. 7 and 8.

Obliterative Apical Prolapse Repair

For women who are not sexually active or who have multiple comorbidities warranting a less complicated procedure, colpocleisis is a simple obliterative procedure that can be utilized for significant apical prolapse (anterior and posterior prolapse is needed as well to technically perform colpocleisis). Success rates are 85–100 % [26]. These procedures will be discussed in Chap. 6.

Recent Randomized Trials on Outcomes [9] (Table 5.1)

Transvaginal Repair with Versus Without Mesh

There is only one randomized controlled trial comparing transvaginal native tissue apical repair with mesh-augmented apical repair. Lopes et al. randomized 32 women to SSLF or mesh repair with Nazca R, Promedon (Cordoba, Argentina). After 1-year follow-up the rate of anatomic cure and quality of life measures were similar in both groups. However, there were five cases of mesh extrusion (35.7 %). This study is limited by its small sample size and use of a transvaginal mesh kit that is not commonly available [33].

Transvaginal Versus Transabdominal Approach

There are several randomized controlled trials comparing transvaginal to transabdominal approaches for apical repair. Maher et al. published an updated summary version Cochrane review of all the available studies up to 2010 [19]. The rate of recurrent vault prolapse was lower for ASC compared to vaginal SSLF (RR 0.23, 95 % CI 0.07–0.77). The risk of postoperative dyspareunia was also lower for ASC (RR 0.39, 95 % CI 0.18–0.86). However, operative time was longer for ASC (mean difference 21 min, 95 % CI 12–30), and ASC was more expensive (mean difference US$1,334, 95 % CI 1,027–1,641).

Of the studies included in the Cochrane review, the most recent was published in 2004 [34]. Ninety-five women were randomized to ASC or vaginal sacrospinous colpopexy and followed for 2 years. The subjective success rates were 94 % and 91 % (p = 0.19), objective success rates 76 % and 69 % (p = 0.48), and satisfaction rates 85 % and 81 % (p = 0.78) for ASC and sacrospinous colpopexy, respectively. There was no difference in sexual function and similar improvement in bladder and quality of life scales between the two groups. Postoperative anterior vaginal wall and vault prolapse (grade 2 or more) were significantly less (13 % versus 45 %) with the abdominal approach (p = 0.01). However, operative time and return to routine activities was longer for the abdominal approach. The authors concluded that abdominal sacrocolpopexy and sacrospinous colpopexy were equally effective for pelvic organ prolapse. However women with predominantly anterior and vault prolapse may benefit more from an abdominal sacrocolpopexy, whereas women with predominantly posterior and vault prolapse may benefit from vaginal sacrospinous colpopexy repair [34].

Maher et al. also performed a randomized trial comparing LSC versus total vaginal mesh (TVM) using Total Prolift® (Gynecare, Ethicon). 108 women were randomized with the primary outcome being objective success using POP-Q measurements. Secondary outcomes were perioperative outcomes, patient satisfaction, quality of life, complications, and reoperations. At 2 years follow-up the objective success rate (no vaginal prolapse ≥ grade 2 at any site) was 77 % for LSC versus 43 % for TVM (p < 0.001). Operative time was longer in the LSC group, but inpatient stay and time to return to activities was shorter. The reoperation rate was 22 % in the TVM group compared to 5 % in the LSC group (p = 0.006). There was no difference in symptomatic prolapse between the groups; however, patient satisfaction was higher in the LSC group (p = 0.002). Maher et al. concluded that LSC was superior to TVM based on higher objective success and satisfaction, and lower perioperative morbidity and rate of reoperation [35]. In the authors’ experience many of the mesh procedures that are designed to repair anterior vaginal wall prolapse are not as successful at reducing apical prolapse and when apical prolapse is present a concomitant sacrospinous or uterosacral suspension may be important to prevent apical recurrence.

Summary

There are many options for apical repair including restorative, compensatory, or obliterative, transvaginal versus transabdominal, concomitant hysterectomy versus uterine sparing, and open versus endoscopic repairs. The literature demonstrates that abdominal sacrocolpopexy has better anatomic results than vaginal sacrospinous ligament fixation. However, subjective success rates are similar. Robotic and laparoscopic ASC is gaining popularity as patients seek minimally invasive surgery. Women with predominantly anterior and vault prolapse may benefit more from an abdominal sacrocolpopexy, whereas women with predominantly posterior and vault prolapse may benefit from vaginal sacrospinous or uterosacral colpopexy. For elderly women who no longer desire to be sexually active, colpocleisis is a suitable repair option. There is no gold standard repair; the surgical approach must be customized to each patient.

Key Points

·               The procedures for apical repair are restorative, compensatory, or obliterative.

·               Rate of recurrent anatomic vault prolapse is lower for abdominal sacrocolpopexy compared to vaginal sacrospinous ligament fixation, but symptomatic outcomes are similar.

·               Colpocleisis is the least invasive repair option and has an 85–100 % cure rate, but is only feasible for women who no longer desire to be sexually active and have very significant prolapse.

Conclusion

Transvaginal prolapse repair should be tailored to the individual patient, making sure to factor in the degree of prolapse, risk for recurrence, and patient expectations. More prospective, randomized trials with longer follow-up are needed to determine the gold standard of care.

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Swift SE. The distribution of pelvic organ support in a population of female subjects seen for routine gynecologic health care. Am J Obstet Gynecol. 2000;183(2):277–85.PubMedCrossRef

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