Minimally Invasive Gynecological Surgery

16. Laparoscopic Approach to Pelvic Organ Prolapse

Catherine Hill-Lydecker1 and Jon Ivar Einarsson 

(1)

Brigham and women’s Hospital, Boston, MA, USA

Jon Ivar Einarsson

Email: jeinarsson@partners.org

16.1 Introduction

16.1.1 Diagnosis/Symptoms

16.1.2 Subtypes

16.1.3 Classification

16.1.4 Risk Factors for Pelvic Organ Prolapse

16.2 Pre-operative Considerations

16.2.1 Concomitant Hysterectomy

16.2.2 Vaginal Mesh

16.3 Surgical Repair

16.3.1 Anterior and Posterior Prolapse

16.3.2 Laparoscopic Apical Prolapse Repair

16.3.3 Uterosacral Ligament Suspension

16.4 Urinary Tract Considerations

16.5 Postoperative Management

16.6 Conclusions

References

16.1 Introduction

Pelvic organ prolapse (POP), or pelvic relaxation, is a common condition in which the uterus or vaginal apex and/or the vaginal walls descend into the vagina. Millions of women are afflicted with POP, and one facility has reported patient populations with rates of up to 37 % in women ages 20–80 (Progetto Menopausa Italia Study Group 2000). Cases of surgical management for pelvic organ prolapse are estimated to number as many as 350,000 annually in the USA (Subak et al. 2001). Just as concerning as the high incidence of prolapse are the reported rates of recurrence, which have reported to occur in up to 50–60 % of women following pelvic surgery (Whiteside et al. 2004).

16.1.1 Diagnosis/Symptoms

While up to 40% of women with pelvic organ prolapse (Swift et al. 2005) do not manifest specific symptoms, the majority of women experience multiple symptoms including pelvic pressure, urinary retention, dyschezia, dyspareunia, and in cases of severe prolapse bulging of pelvic organs protruding from the vagina (Hirata et al. 2004; Ellerkmann et al. 2001). In these women for whom symptoms are present, conservative management such as vaginal pessary use and Kegel and pelvic floor exercises frequently fail, and surgical treatment is indicated. While surgery for prolapse as the primary procedure is generally not recommended for women who are asymptomatic, it may be performed concomitantly with other pelvic surgeries, such as hysterectomy, if the patient possesses risk factors that indicate future exacerbation of prolapse.

16.1.2 Subtypes

Pelvic organ prolapse is a term that can refer to relaxation in many anatomical sites within the pelvic cavity. Both surgical and conservative treatments depend on the specific type of prolapse, and therefore prolapse degree and location should be elucidated upon an initial examination.

Anterior prolapse (cystocele) refers to the relaxation of the anterior vaginal wall and may be accompanied by sagging of the urinary bladder, which often results in symptoms of frequent urination or urinary retention. Protrusion of the rectum and/or the rectosigmoid into the posterior vaginal wall is identified as posterior prolapse (enterocele) and is associated with dyschezia and constipation. Anterior and posterior prolapse result from weakening in the muscles and connective tissues of the vaginal wall or endopelvic fascia. Apical prolapse occurs when to the uterus, cervix or vaginal apex, if posthysterectomy, herniates into the vagina. Generally, women do not report symptoms of apical prolapse until the uterus or vaginal vault has descended to the level of the hymen.

16.1.3 Classification

In an effort to standardize prolapse classification, several measurement tools are used to assess the severity and source of prolapse. The Pelvic Organ Prolapse Quantitation (POP-Q), established in 1996, continues to be the most commonly used classification system (Bump et al. 1996). The POP-Q system designates nine pelvic anatomical measurements expressed in centimeters that are used to assess an overall prolapse rating which establishes stages 0 (no prolapse) through IV (complete protrusion of pelvic organs). Numerical values for each individual compartment are taken during relaxation and Valsalva to obtain the greatest severity of the prolapse. The Valsalva maneuver is a position in which the patient forces an exhale into closed airways, thereby inducing a strain that allows for maximum prolapse to be visualized. A ruler or any instrument that has discernable centimeter increments can be used to determine the measurements. Positive measurements represent points that are distal to the hymen, whereas negative values are proximal to the hymen and indicate less severe prolapse. The values can also be used to determine specific locations of the prolapse (e.g., anterior or posterior) and give stages for each location.

An alternative classification tool is the Baden–Walker Halfway Scoring System, which defines the prolapse stage of each anterior, posterior, and apical prolapse relative to the hymen. Scoring ranges from 0 to 4. Normal positioning is given a score of 0, 1 represents descent halfway to the hymen, descent to the hymen scores as 2, 3 indicates descent halfway past the hymen, and stage 4, being the most severe prolapse, is complete eversion of pelvic organs (procidentia). The Baden–Walker System can be performed with in the dorsal lithotomy position under visual examination during both relaxation and Valsalva (Baden and Walker 1972).

16.1.4 Risk Factors for Pelvic Organ Prolapse

Not surprisingly, age plays a significant role in the development of prolapse (Swift et al. 2005). Increased age is associated with breakdown in collagen, muscles, and connective tissues, which weaken the support structures within the pelvis that lead to the descent of uterus or vaginal vault (Soderberg et al. 2004). The incidence of pelvic organ prolapse has been demonstrated to increase with parity as well, with vaginal delivery placing women at a significantly higher risk than cesarean deliveries. Higher birth weights of delivered fetuses also correlate with increased severity and incidence of prolapse. Other factors contributing to pelvic organ prolapse include prior hysterectomy, chronic constipation, obesity, heavy work, and genetic predisposition (Whiteside et al. 2004).

16.2 Pre-operative Considerations

Laparoscopic repair of apical, uterine or vaginal vault, prolapse should be considered in patients with troublesome symptoms. Appropriate candidates include those who have not achieved satisfactory results via conservative methods and are appropriate candidates for abdominal surgery or have declined nonsurgical treatment and desire surgical management.

Because POP presents in such a diverse fashion, a detailed discussion with the patient to determine the most concerning and bothersome symptoms is necessary. In patients presenting with urinary symptoms, urodynamic testing may be necessary to determine if a concomitant procedure for incontinence, such as transvaginal or transobturator tape, is indicated.

16.2.1 Concomitant Hysterectomy

While the role of hysterectomy in the success and longevity of prolapse repair has not been specifically addressed in the literature, the majority of prolapse repairs continue to include concurrent hysterectomies, if the uterus is present. Preserving the uterus also a valid option, however, since there is limited long-term outcome data on prolapse repair with uterine preservation, it is uncertain what effects this may have on the durability of the repair.

Patients of reproductive age should be counseled that there is limited data available regarding fertility prospects after pelvic reconstructive surgery involving uttering preservation. Reports of successful pregnancy after prolapse repair are limited to several small case studies and one trial demonstrating five vaginal deliveries out of nineteen attempting patients after sacrospinous uterosacral ligament suspension. Despite these studies, larger randomized trials are needed before woman can be counseled on the possibility of future fertility after prolapse repair (Kovac and Cruikshank 1993; Gadonneix et al. 2012).

16.2.2 Vaginal Mesh

Vaginal mesh kits were developed to reduce the significant prolapse recurrence rates after pelvic repair surgery with native tissue used as support and to facilitate mesh placement for the majority of practitioners. Mesh in prolapse surgery has created a significant controversy due to the serious complications reported to the Food and Drug Association and their subsequent advisory statement (Food and Drug Administration 2008). It is important to realize that the FDA advisory specifically pertains to vaginal mesh placement and is not directed at abdominal or laparoscopic mesh placement.

Some studies have reported very high success rates with use of vaginal mesh, up to 97 %, whereas others report no difference in recurrence or postoperative prolapse stage between mesh procedures and those with native tissue (Keys et al. 2012). A 2012 review demonstrated the incongruent and frequently contradictory nature of data from randomized trials that have so far looked into mesh complications and recurrence rates (Keys et al. 2012). One study suggests that mesh complication rates, including dyspareunia, occur in up to 17.6 % of patients. However, a widely accepted rate for mesh erosion and infection is between 1 and 3 % of cases (Jeon et al. 2008).

The inarguable existence of severe complications related to mesh warrants a thorough discussion, with appropriate patients, regarding the risks and benefits of vaginal mesh.

The American College of Obstetricians and Gynecologists (ACOG) and the American Urogynecologic Society (AUGS) recommend that vaginal mesh be used selectively in patients with severe cases to whom the most benefit may be conferred (Committee on Gynecologic Practice 2011).

16.3 Surgical Repair

Pelvic organ prolapse is rarely confined to one compartment, as relaxation represents weakening of connection tissue and collagen throughout the pelvis. A more common presentation is prolapse in multiple compartments, which typically necessitates one or more additional repairs. There is some question as to whether with sufficient apical repair anterior and posterior compartments may be adequately supported which may obviate multiple site repairs; however, there is little evidence to support this claim (Lowder et al. 2008).

16.3.1 Anterior and Posterior Prolapse

While typically repaired vaginally, anterior and posterior prolapse repairs can be performed laparoscopically and also concomitantly with laparoscopic apical prolapse repair, if indicated.

16.3.2 Laparoscopic Apical Prolapse Repair

Laparoscopic apical prolapse repair can be performed with or without mesh. Use of mesh is generally preferred in cases of significant prolapse, i.e., when the level of prolapse is at a stage II or higher. Sacrohysteropexy refers to support of the vaginal apex with the uterus intact. Sacrocervicopexy is support of the vaginal apex with conservation of the cervix, and sacrocolpopexy refers to suspension of the vaginal apex without a uterus or cervix in place. While the traditional proximal suspension point is described at the level of S2 on the sacrum, most surgeons will suspend the mesh to the sacral promontory due to better exposure and less risk of bleeding complications. If a concomitant hysterectomy is performed, it is preferable to conserve the cervix since this will reduce the risk of mesh erosion (Bensinger et al. 2005; Warner et al. 2012). There are some relative contraindications to preserving the cervix, which include cervical dysplasia and cervical elongation.

16.3.2.1 Procedure Summary

Following peritoneal insufflation and insertion of trocars, the peritoneum over the promontory is opened exposing the anterior longitudinal ligament. The incision is then carried into the pelvis along the right pelvic sidewall midway between the ureter and the rectosigmoid. The bladder is dissected anteriorly off the cervix and upper vagina. This dissection can be carried all the way down to the bladder trigone, but practices vary greatly and the extent of dissection may depend on the level of prolapse. Posteriorly, the rectum is dissected away from the cervix and vagina and this dissection can be taken all the way down to the levator ani. Again, the extent of the dissection may vary depending on physician preference and level of prolapse. An important guide to the correct dissection is to remember that fat belongs to the rectum and the bladder. Therefore, the surgeon should consider an alternative plane of dissection if fat is encountered. In addition, the correct plane of dissection should be relatively avascular and therefore if bleeding is encountered, the surgeon is probably either too close to the rectum, vagina, or bladder. A Y-shaped polypropylene mesh is then inserted and attached to the anterior and posterior aspect of the cervical stump and the upper vagina. The type of suture material varies greatly as does the suturing. Commonly used suture materials include prolene, Ethibond® (Ethicon Endo-Surgery, Cincinnati, OH, USA), and Gore-tex® (W. L. Gore & Associates, Inc., Flagstaff, Arizona, USA), although some surgeons prefer the use of delayed absorbable materials such as PDS. Sutures can be placed with extracorporeal or intracorporeal knot tying, or with the assistance of a suturing device. The number of fixation points also varies greatly; with most surgeons placing at least four to six fixation points on each portion of the mesh. The tail end of the mesh is then fastened to the sacral promontory with either tacks or sutures. Using tacks expedites the process, although some concerns have been raised on the risk of the development of osteomyelitis (Nosseir et al. 2010). In cases with limited exposure to the promontory, it may be advisable to avoid the use of mesh since visual exposure may be limited due the mesh and a vascular injury may result. The middle sacral vessels can be fulgurated prior to fastening of the mesh to decrease the risk of bleeding. In addition, the location of the left common iliac vein is highly variable and it sometimes lies fairly close to the promontory of the sacrum (Flynn et al. 2005; Wieslander et al. 2006). It is therefore mandatory to know the location of the common iliac vein prior to the placement of mesh at the sacral promontory. The tension on the mesh should be enough to retain the vaginal apex in its correct anatomic position, but the mesh should not be placed on too much tension as this can result in back pain and potential tearing of the mesh off the apical segment of the vagina. The peritoneum is generally closed overlying the mesh and reapproximating the anterior peritoneum and the posterior peritoneum from the cervicovaginal dissection, as well as the lateral sidewall peritoneum. Although there is no evidence to support this practice, it makes sense that it may reduce the risk of hernia formation and potentially bowel adhesions to the mesh.

16.3.3 Uterosacral Ligament Suspension

Uterosacral ligament suspension is an effective procedure for apical prolapse repair. It has the advantage of no risk of mesh exposure and associated complications and is generally considered to be effective in the long run, although there are no comparative studies available comparing long-term outcomes of uterosacral ligament suspension and apical suspensions using mesh (Margulies et al. 2010; Silva et al. 2006; Diwan et al. 2006). The use of uterosacral ligament suspension is often limited to milder forms of apical prolapse (stages I and II) or as a prophylactic procedure in an attempt to prevent the development of future prolapse.

16.3.3.1 Procedure Summary

A concomitant hysterectomy may or may not be performed. The uterosacral ligaments and the ureters must be identified. It is very important to delineate the ureter during the dissection and if it is in close proximity to the uterosacral ligament, a relaxing peritoneal incision may be required. A suture is then taken through the uterosacral ligament at the level of the ischial spine and this is in turn attached to the ipsilateral vaginal apex. The choice of suture material varies greatly, but most commonly a permanent suture such as prolene or ethibond is utilized. The sutures are then tied using either extracorporeal or intracorporeal suturing or with the assistance of a suturing device (Fig. 16.116.216.3, and 16.4).

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Fig. 16.1

Suturing mesh to vaginal apex

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Fig. 16.2

Opening peritoneum over the sacral promontory

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Fig. 16.3

Fastening the mesh to the sacral promontory with tacks

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Fig. 16.4

End of the procedure with mesh covered by peritoneum

16.4 Urinary Tract Considerations

Cystoscopy should be routinely performed in pelvic organ prolapse repair surgery to ensure excellent ureteral flow at the end of surgery. However, cystoscopy is not a perfect indicator of bladder injury; a reassuring cystoscopy does not guarantee the absence of bladder injury, especially in the case of thermal injury. The possibility of injury must not be ruled out if symptoms present postoperatively. Isolation of the ureters prior to initiating any energy sources as well as maintaining direct visualization throughout the procedure are key factors in avoiding bladder injury (Jabs and Drutz 2001).

16.5 Postoperative Management

Postoperatively, the majority of patients have an uneventful recovery. Following laparoscopic prolapse repair, patients receive nonsteroidal anti-inflammatory medications along with narcotics by mouth as needed. They are generally ready for discharge the following morning. A vaginal pack may be placed over night and a Foley catheter left in place until the following morning. It is good practice to perform a voiding trial the morning after surgery prior to discharge as there is a small risk of urinary retention in these patients. It is important to remain vigilant for possible urinary tract injuries and mesh-related complications. Complications resulting from mesh use may present as fever, infection, dyspareunia, and chronic bloody vaginal discharge, and exposed mesh may be visible if erosion has taken place.

16.6 Conclusions

Laparoscopic treatment of pelvic organ prolapse is a viable option for patients desiring minimally invasive surgical management of their symptoms while also achieving optimal long-term results. More research is needed to better determine the surgical procedures and techniques of choice for various clinical scenarios.

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