Minimally Invasive Therapy for Urinary Incontinence and Pelvic Organ Prolapse (Current Clinical Urology) 2014th

20. Apical Repairs

Leon N. Plowright1 and G. Willy Davila 

(1)

Department of Gynecology, Cleveland Clinic Florida, Weston, FL 33331, USA

(2)

Department of Gynecology, Cleveland Clinic Florida, 2950 Cleveland Clinic Boulevard, Weston, FL 33331, USA

G. Willy Davila

Email: DAVILAG@ccf.org

Abstract

Pelvic organ prolapse (POP) is a common condition affecting adult women. Epidemiologic studies suggest the lifetime risk of prolapse or incontinence surgery is between 7 and 19 % [1]. The most common complaint reported by women with genital prolapse is a sensation of a vaginal bulge. Women may also report pelvic discomfort or pressure and may have associated voiding or defecatory dysfunction. Well established risk factors for POP development include pregnancy, vaginal delivery, increased parity, age, increased body mass index, race, chronic diseases associated with increased intra-abdominal pressure, postmenopausal status, and previous hysterectomy.

Presentation and Symptoms

Pelvic organ prolapse (POP) is a common condition affecting adult women. Epidemiologic studies suggest the lifetime risk of prolapse or incontinence surgery is between 7 and 19 % [1]. The most common complaint reported by women with genital prolapse is a sensation of a vaginal bulge. Women may also report pelvic discomfort or pressure and may have associated voiding or defecatory dysfunction. Well established risk factors for POP development include pregnancy, vaginal delivery, increased parity, age, increased body mass index, race, chronic diseases associated with increased intra-abdominal pressure, postmenopausal status, and previous hysterectomy.

POP can be categorized as an anterior or posterior vaginal wall defect, an enterocele, or a vaginal vault support defect. While listed separately, these sites of vaginal laxity are often found in combination. There is growing evidence in the literature that apical support is the key element in maintaining normal vaginal anatomy [24]. Given such evidence, it is of the utmost importance that patients being evaluated for POP undergo a proper inspection of the vaginal apex as identifying the sites of apical support can be challenging. In particular, any woman with an exteriorized, large cystocele should be assumed to also have some degree of apical support weakness, until proven otherwise on careful pelvic exam. Any degree of support weakness of the vaginal vault should be addressed at the time of anterior or posterior POP surgery.

Anatomy

Our current working understanding of pelvic organ support is that it requires a complex interplay of adequately functioning pelvic floor muscles, and intact ligamentous support and endopelvic fascia. In the early 1990s DeLancey popularized the concept of levels of pelvic support. Level I support encompasses the vaginal apex and cervix which are held in place by the surrounding endopelvic connective tissue which includes the cardinal and uterosacral ligaments. Level II support refers to the mid-vagina which is supported by the lateral connective-tissue attachments to the levator muscles while Level III support involves the distal connective-tissue attachments of the urethra to the pubic bone and levator muscle support to the distal hymen [5].

When we take a closer look at the supportive structures of the apex it becomes evident as to why it is such an integral component of vaginal support. The principal ligaments involved in cervical/vault support are the uterosacral and cardinal ligaments. The uterosacral ligaments are fibromuscular tissue bands extending from the apex to the sacrum while the cardinal ligaments extend laterally from the apex to the pelvic sidewall adjacent to the ischial spines. The coalescence of both ligaments is often referred to as the uterosacral–cardinal ligament complex. The cervix, if present, also acts as an attachment site for connective tissue and ligamentous fibers from the uterosacral-ligament complex. Women who have undergone a complete hysterectomy lose this pivotal supportive structure, which often leads to vaginal laxity and eventual prolapse [6]. It is thus crucial to methodically reattach the apical supports to the vaginal cuff during closure once the uterus is removed at the time of hysterectomy—regardless of the route utilized.

Another important supportive component to consider is endopelvic fascia. This supportive structure is the fibromuscular tissue layer that underlies the vaginal epithelium as an integral component of the vaginal wall. Endopelvic fascia can be found supporting the entire vaginal canal, extending from the apex to the perineum. A tear in this layer, whether anterior or posterior, typically presents as a detachment of endopelvic fascia from the apex resulting in subsequent herniation and subsequent downward displacement of the affected vaginal segment. This displacement can place undue strain on the vaginal apex and weaken apical support.

Proper understanding of the anatomy of normal vault support is therefore important in surgical planning. The complexity of vaginal support is being better understood today using a variety of tools including ultrasound and other imaging modalities. Current research is being focused on using modeling techniques, physics, and basic sciences to explain how the coalescence of ligaments, fascia, and neuromuscular tissue interact to maintain pelvic support.

Physical Examination and Diagnosis

In order to achieve successful restoration of pelvic anatomy, proper identification of vault support defects is as important as understanding normal vault support anatomy. Even for the experienced surgeon, this can represent a challenging endeavour. The key is a systematic and careful pelvic examination. Tools that may be used in evaluating apical support include a bivalve speculum and a right angle or Sims retractor.

The approach to vaginal vault assessment is dependent on the presence or absence of the uterus. When the uterus is present it is important to make the distinction between vault prolapse and cervical hypertrophy, as the cervix may be exteriorized while vault support is intact. First, the posterior blade of a speculum may be inserted into the posterior fornix, elevating the vault to its fullest extent. The patient is then asked to Valsalva while the speculum is slowly being removed. If a defect of vaginal vault support is present, descent of the uterus will be noted. Reinsertion of the speculum will re-suspend the uterus. If the vault is well supported the uterus and cervix will remain in place. The degree of apical prolapse can be measured using the POP-Q system (the difference between TVL and point D).

In a previously hysterectomized woman, the apical portion of the vagina is represented by a dense band of scar tissue horizontally across the top of the vagina. This represents the vaginal cuff. The previous apical attachments of the uterosacral–cardinal ligament complex are noted by “dimples” located at the lateral edges of vaginal cuff. These landmarks can be challenging to identify at times. Placing the posterior blade of the right-angle speculum to support the anterior vaginal wall, while using the index and middle finger of the right hand to support the posterior vaginal wall, the dimples can usually be identified. The patient is then asked to Valsalva and the degree of apical prolapse quantified. In some instances, complete evaluation of the vaginal vault requires an exam in the standing position. In addition, a bimanual and/or rectal examination may also be helpful in identifying the presence of an enterocele. An adequate evaluation of the vaginal vault cannot be overemphasized as this dictates surgical planning [6].

Assessing anterior and posterior vaginal wall support is then performed, with a focus on identifying fascial tears which require repair (Fig. 20.1). These are usually seen as areas where normal vaginal rugation is absent—representing separation of the endopelvic fascia from the vaginal cuff, lateral attachments, or perineal body.

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Fig. 20.1

Vaginal vault prolapse with associated anterior and posterior fascial tears off the apex (dark lines). (Courtesy of the Cleveland Clinic Foundation)

There are many effective approaches to restoring apical vaginal support. These include vaginal as well as laparoscopic/robotic approaches. Choice of the best approach for an individual patient should be based on a variety of individual factors as well as surgeon expertise (Table 20.1). Patient age may dictate anesthetic approach preference and as a consequence a choice for a vaginal approach under regional anesthesia for an elderly patient in order to avoid postoperative cognitive problems. A vaginal depth greater than 9 cm is unlikely to be maintained with a vaginal approach to apical prolapse—and may lead to a preference for an abdominal approach if sexual function is of key importance. Recurrent POP, especially when associated with a large cystocele, may dictate the need for mesh or biologic graft augmentation in order to optimize success.

Table 20.1

Factors in deciding the approach to vault suspension surgery

 1. Presence of the uterus

 2. Cervical hypertrophy

 3. Vaginal length

 4. Sexual activity

 5. Previous POP surgeries

 6. Previous abdominal surgeries

 7. Presence of vaginal atrophy

 8. Needed concomitant prolapse/incontinence procedures

 9. Patient age

10. Patient-associated morbidities

11. Patient’s degree of physical activity

Traditional surgical options for vault prolapse include vaginal and abdominal approaches. Minimally invasive options have been developed in an effort to improve surgical outcomes while reducing hospitalization and recovery times. Vaginal surgery—the ultimate natural orifice surgery—is appropriate for most postmenopausal women, but requires special training and expertise. Endoscopic approaches require prolonged general anesthesia and steep Trendelenburg positioning, and thus may be more appropriate for the younger patient. Since most techniques for apical support restoration are proven to be effective, individualization of the approach based on a patient’s specific functional and anatomic characteristics is the key consideration [7]. Of the many apical suspension procedures described, the following have acceptable published outcomes and are the most commonly used.

Minimal Invasive Surgery for Apical Prolapse

Laparoscopy

Laparoscopic techniques are typically an adaptation of the open abdominal surgical approaches used for vault prolapse. In order to attain equivalent outcomes, the surgeon must be proficient and experienced.

Open abdominal sacral colpopexy is considered to be gold standard for vault prolapse repair. Multiple publications have demonstrated its high efficacy and durability. Success rate is reported as ranging from 78 to 100 % [8]. The laparoscopic adaptation does not differ significantly from the open technique. In fact, laparoscopic sacral colpopexy is said to have comparable clinical outcomes [9].

One landmark study demonstrating this was a comparative cohort study done by Paraiso et al. [9]. This study investigated the efficacy and safety of laparoscopic versus open sacral colpopexy. While they concluded that the operative time was greater in the laparoscopic group the estimated blood loss and the hospital stay were significantly less in the laparoscopic group. In addition, complications and need for re-operation were the same between groups. Paraiso’s findings were upheld by a similar study in 2007 comparing laparoscopic and abdominal sacrocolpopexy for vault prolapse. In this study, Hsiao et al. compared 25 patients who underwent laparoscopic sacrocolpopexy to 22 patients who underwent open abdominal sacrocolpopexy. Again, the operative time was longer for the laparoscopic group but the mean estimated blood loss and length of hospital stay were significantly more for the open abdominal approach. The anatomical success rate at 5.9 months was 100 % for the laparoscopic approach and 95 % success at 11 months for the open approach [10]. With the recent decline in vaginal mesh use, there has been a resurgence of interest in the performance of laparoscopic sacrocolpopexy. Tools to facilitate performance of this technique will certainly become available in the near future, further increasing its popularity.

Does sacrocolpopexy require the use of synthetic mesh? This question has been asked by many patients who prefer to not have any synthetic mesh implanted, whether vaginally or abdominally. This question has been at least partially answered by studies performed by Culligan et al., looking at two biologic materials in an RCT study format. Processed fascia lata was found to be equivalent to polypropylene in terms of apical support with the only differences in POP staging being in the lower anterior points, which may have been affected by the performance of more anti-incontinence procedures [11]. Evaluating cross-linked porcine dermis in an RCT against polypropylene mesh, objective anatomic and clinical cure rates were similar at 12-month follow-up [12]. Thus, there are alternative available biologic materials for women who require a sacrocolpopexy and are opposed to receiving synthetic mesh.

Another laparoscopic procedure employed by some surgeons to elevate the vault is uterosacral ligament suspension. In this procedure the uterosacral ligaments are essentially sutured to the apex of the vagina thereby elevating the apex. A permanent suture is used for this purpose. In the literature there are several case series, retrospective trials, and some prospective studies. One study done in 2005 by Lin et al. reported on 133 laparoscopic uterosacral ligament vault suspensions. In their study, they found an 87 % anatomic success rate with a mean follow-up of 3.2 years [13]. Comparing laparoscopic uterosacral colpopexy at the time of vaginal hysterectomy to vaginal colpopexy, Rardin et al. found a higher recurrent symptomatic prolapse rate and increased risk of ureteral injury in the vaginal colpopexy group [14]. Though review of the literature revealed a variety of techniques used to suspend the uterus, taken together these studies make a strong case for laparoscopic uterosacral ligament suspension as a feasible safe and effective approach to treatment of vault prolapse.

Women requesting uterine sparing prolapse surgery may be candidates for sacrohysterocolpopexy or uterosacral ligament suspension. For this purpose, surgeons have employed a variety of laparoscopic techniques to re-suspend the vaginal vault [15]. The uterosacral ligaments can be plicated bilaterally from the level of the ischial spines to their insertion on the uterus. Diwan et al. reported on 25 patients who underwent the above procedure and were compared to 25 patients who underwent a total vaginal hysterectomy with vaginal vault suspension. There were a superior anatomic and clinical outcomes associated with laparoscopic uterosacral ligament uterine suspension compared to vaginal hysterectomy and vault suspension as demonstrated by a significant difference in points C and D, and the fact that three patients in the vaginal hysterectomy group required re-operation for recurrent prolapse [16]. These findings have been confirmed by several other articles in the literature making it a safe and effective option for women desiring uterine preservation [1718]. The use of permanent sutures is recommended, and the recent availability of barbed, self-fixating sutures has facilitated the performance of laparoscopic vault suspension surgery.

Robotics

Robotic surgery has rapidly emerged as a popular minimally invasive tool for prolapse repair. Robotic assistance adds yet another option to the minimally invasive armamentarium for apical POP. The use of robotics started to gain popularity in the early 2000s and today is a very popular component of the residency training curriculum. Due to its durability, robotic sacrocolpopexy is the most commonly performed robotic pelvic reconstructive procedure [19].

The first case series to evaluate the use of robotic-assisted laparoscopic sacrocolpopexy was published by DiMarco et al. [20]. They reported on 5 women who underwent the procedure, three with concomitant pubovaginal sling placement. The only complication encountered was associated with the sling placement. There was no recurrent, anterior, posterior, or vault prolapse at 4 months of follow-up. Since this study there have been several other case series and retrospective studies looking at anatomic and clinical outcomes. Robotic and laparoscopic surgery has demonstrated equivalent anatomic outcomes with shorter hospital stay and decreased blood loss when compared to open sacrocolpopexy [921]. To date the only prospective randomized trial comparing conventional laparoscopy to robotic-assisted laparoscopic colpopexy was published in 2011 by Paraiso et al. The study was a single-center randomized controlled trial of women with stage 2–4 posthysterectomy vault prolapse. There were 38 women in the laparoscopic group and 40 women in the robotic group. Though both groups demonstrated equivalent surgical and functional outcomes 1 year after surgery, robotic-assisted sacrocolpopexy resulted in longer operating time, increased pain, and increased cost when compared to traditional laparoscopy [22]. Cost being an increasingly important consideration, cost-minimization analysis has demonstrated that open ASC is less expensive then laparoscopic, and the robotic approach exceeded the cost of both [23]. While more long-term surgical follow-up is needed to clarify the role of robotic surgery, preliminary data seems to endorse its use for certain indications, POP management being one of them. Surgeon experience is a key factor in optimizing outcomes and reducing morbidity. Recently, the safety and cost-effectiveness of robotic surgery have been brought into question by professional associations and the FDA. The dust is yet to settle on this novel MIS approach.

Vaginal Mesh

Over the last several years vaginal mesh kits have also grown in popularity as a minimally invasive alternative to traditional native tissue POP repairs. The purpose of the kits was to provide a durable, standardized, reproducible, and effective product that can be easily placed after adequate training. Through the use of pelvic landmarks and employing principles of tradition repairs these mesh kits are used to augment or replace conventional vaginal repairs.

The Apogee system (American Medical Systems, Minnetonka, MN) was the initial kit to be widely marketed. It requires a transperineal trocar passage to suspend the apex via a mesh bridge from ischial spine to ischial spine. As with traditional sacrospinous fixation, a posterior dissection is first performed to the level of the apex. The para-rectal space is entered and the ischial spine identified. An incision is made on each buttock, 3 cm lateral and 3 cm posterior to the anus. A trocar is passed through this incision just lateral to the rectum and exits anterior to the ischial spine and into the arcus tendineus fascia pelvis. This is done bilaterally. Next, each of the mesh arms is fastened to the tips of the trocars and pulled through the para-anal incisions. The graft is then attached to the apex and the vault elevated accordingly. Concomitant anterior and posterior colporrhaphy can be performed. The remainder of the graft is trimmed to size and sutured distally, just before the hymen. This kit comes as a composite with polypropylene mesh arms attached to a biologic graft or simply polypropylene material is used throughout [6]. Review of the literature reveals an objective success rate ranging from 81 to 100 % [24].

The Prolift kit (Gynecare), also a trocar-based kit for anterior, posterior, and apical prolapse management, went on to become the most popular kit based on sales volumes. Multiple studies demonstrated its success in anterior compartment prolapse when compared to native tissue repairs. It was also studied in the population of patients in whom a synthetic mesh may be most clearly indicated, those with recurrent prolapse. In this population, this mesh kit was associated with a significantly better anatomic result relative to native tissue repair, but subjective outcome was no different at 12 months. Mesh exposure rates in the synthetic group were 16.9 % [25]. This kit was removed from the market by the manufacturer in 2012. Multiple other trocar-based kits were available and continue to be marketed.

Novel mesh kits utilize direct internal fixation techniques, and are thus trocar-free. They include the Elevate (AMS), Uphold, and Pinnacle (Boston Scientific). The Elevate kit system (American Medical Systems, Minnetonka, MN) which comes in a composite biologic graft/polypropylene mesh or total polypropylene mesh requires dissection down to the level of the ischial spine and identification of the sacrospinous ligaments. Once identified, a trocar is used to deploy a fixation soft tissue anchor into the ligament to which the graft is attached. After attaching the graft to the apex, it is then elevated using a pusher and locking eyelets. In a similar fashion the Uphold (Boston Scientific, Natick, MA) kit suspends the apex by using the sacrospinous ligaments.

The recent public health announcement released in 2011 by the Food and Drug Administration again called into question the use of transvaginal mesh. This was a follow-up to a 2008 notification. The associated risk of erosion, pelvic pain, and other morbidities as well as the lack of data demonstrating superiority to native tissue repairs led to the requirement that manufacturers perform a prospective surveillance program in order to be able to continue to market their products. This process is projected to last 3 years and requires methodical data collection. Due to this scrutiny, multiple other kits have been taken off the market over the past year, and are therefore not mentioned in this discussion. Moving forward there will be more studies focused on not only the efficacy but also the complication profile of transvaginal mesh. It is unlikely that mesh kits will regain a significant market share once the FDA’s 522 process is completed. It is very unclear what role mesh implanted via the vaginal route will have in future of POP surgery.

Native Tissue POP Repairs

Using a patient’s endogenous support structures via the vaginal approach has been the leading principle followed by traditional surgical practice for POP. Due to the lack of tools to accurately report outcomes, most of the older surgical reports were subjective, short term, and in small case series. As a consequence, the true success rates were unclear. Due to the recent controversies surrounding vaginal mesh, there has been a large degree of interest in performing native tissue repairs, but with improved techniques relative to older reports.

For apical support, various structures are available to anchor the vaginal apex. Reaching the sacral promontory—as for a sacrocolpopexy—via a vaginal approach has not been achievable until the present time. Thus, all vaginal vault suspension procedures are performed with either unilateral or bilateral attachment to a firm pelvic structure. In general, the available structures are connected to the ischial spines—landmark body structures located along the posterior lateral pelvis. The spines are located lateral to the site of cardinal ligament attachment to the cervix and thus are located along a physiological level in the pelvis. Successfully utilized support structures emanating from the ischial spine include the sacrospinous ligaments (thick bands extending to the sacrum), arcus tendineus fascia pelvis (extending laterally towards the pubic symphysis), and the ileococcygeus fascia (overlying the ileococcygeus muscle along the lateral pelvic sidewall, inferior to the arcus tendineus). These structures are readily accessible via a posterior or anterior pelvic dissection, and have been reported to allow effective apical support restoration by various fixation mechanisms. Among the accepted native tissue repair techniques for apical POP, the most commonly used ones are as follows:

Sacrospinous Ligament Fixation

Because these ligaments are predictably strong and easy to identify along the posterior margin of the para-rectal space, sacrospinous fixation is likely the most commonly performed minimally invasive native tissue apical suspension technique. The procedure was initially performed unilaterally on the patient’s right side. It has now been reported in a bilateral configuration in order to maintain vaginal symmetry (Fig. 20.2). There is, however, no objective data to demonstrate superiority for either approach. One or two sutures, preferably permanent monofilament, are placed thru the ligament approximately 1–2 cm from the ischial spine, using one of a variety of available suture passers. The suture is then passed through the apical cuff scar tissue (or posterior cervix if a hysteropexy is being performed) and then tied, elevating the apex to the ligament. If a bilateral approach is performed, the procedure is repeated on the opposite side. Correction of anterior and/or posterior vaginal prolapse is usually required and can then be performed.

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Fig. 20.2

Bilateral sacrospinous fixation maintains bilateral vaginal symmetry. (Courtesy of the Cleveland Clinic Foundation)

Complications of sacrospinous fixation include buttock pain and sciatic nerve pain if the fixation sutures are placed too deeply into the ligament, or distal to the ligament’s inferior edge. Since the procedure deviates the vaginal axis somewhat horizontally relative to the physiologic axis, cystocele formation is a recognized consequence of this procedure. The resultant cystocele rate is >20 %, but typically asymptomatic, not requiring re-operation. Sacrospinous fixation has been compared to mesh kit repair in a randomized, controlled format, with better success rate for the mesh kit (POP recurrence 39.4 % vs. 16.9 %), but a 20.8 % erosion rate was identified with the mesh kit [26].

Uterosacral Ligament Suspension

Perhaps the most physiologic approach to vault suspension is to suspend the vault to the ligaments which originally gave support to the uterus and vaginal apex, the uterosacral ligaments. Attaching the vault to a more proximal site along these ligaments can maintain a normal vaginal axis. When this procedure is performed at the time of a vaginal hysterectomy it is commonly termed a McCall culdoplasty. When performed for posthysterectomy vault prolapse, it is termed a high uterosacral vault suspension. Neither term is exclusive for that application. In either case, the ligaments can be plicated in the midline and attached to the midpoint of the apex or each ligament can be attached to the ipsilateral apex (Fig. 20.3). There is no data to specify which is more effective. The success rate of this technique is very high, and both anterior and posterior vaginal fascial defects should be corrected at the same time [27]. The technique can be accomplished via an intraperitoneal or retroperitoneal approach, the former recently being more commonly used. When performed in a posthysterectomy scenario, it may be challenging to identify the ligaments, especially if the prolapse is large and the apex wide. Care must be taken to avoid ureteral kinking or ligation, as rates of 2–12 % have been reported. The sutures should never be placed anterior to the ischial spines, and intraoperative cystoscopy is mandatory to confirm ureteral patency. A more recently recognized risk is sacral root nerve entrapment during this procedure. Although the risk is only 1.6 %, this complication requires suture removal and thus jeopardizes the success of the surgery [2829].

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Fig. 20.3

Uterosacral ligament suspension can be performed with midline (a) or bilateral (b) fixation. (Courtesy of the Cleveland Clinic Foundation)

Ileococcygeus Suspension

Utilizing the ileococcygeus fascia may be the safest means to achieve vault suspension. This support structure can be reached via a posterior vaginal dissection into the para-rectal space, identification of the ischial spine, and palpation of the fascia immediately below the arcus tendineus fascia pelvis. Permanent sutures can be placed through this fascia and attached to the ipsilateral vaginal apex. Acceptable success rates have been reported [30]. Vaginal depth may be difficult to maintain if the vagina has an original depth of >8 cm. Reported complication rates are very low as no major structures are located deep to the ileococcygeus fascia. This technique can be used as primary therapy, or as salvage therapy for a patient who underwent a unilateral sacrospinous fixation and weakness of the opposite apex is noted. In this scenario, a transmucosal ileococcygeus “hitch” can be performed with a monofilament suture.

Colpocleisis

Another minimally invasive surgery to address vault prolapse is a LeFort colpocleisis. This obliterative procedure was first described in 1877 by Leon LeFort. It is a minimal risk procedure requiring short operative time and can be performed under spinal or local anesthesia thereby decreasing anesthetic morbidity. Candidates for this type of surgery are elderly women who do not plan on having intercourse, and/or who may have significant medical comorbidities.

The surgical technique entails denuding rectangular segments of the anterior and posterior vaginal epithelium. The rectangles are sutured together in the midline from front to back, such that the middle portion of the vaginal canal is obliterated. A high perineoplasty is performed allowing the passage of only one finger into the vagina, exposing only the urethra. This procedure can be performed using the same technique regardless of the presence or absence of a uterus.

The largest published series confirmed the high success rate and satisfaction with this procedure [31]. We reported on 355 patients who underwent a LeFort colpocleisis. The mean age was 81.3 ± 5.3 years, and a mean follow-up of 45 weeks. Anatomic success rate and patient satisfaction were 98.1 % and 92.9 %, respectively. Using a protocol focused on regional anesthesia, careful preoperative clearance, and early ambulation, associated morbidity is minimal, despite the advanced age of these patients.

Summary

There are many safe and effective minimally invasive means for re-suspending a prolapsed vaginal apex. Individual patient characteristics should be considered primarily when selecting a surgical approach. Surgeon experience and comfort should also be realistically taken into account. As such, very active young woman for whom maintaining optimal sexual activity is important may best be served with a laparoscopic or robotic sacrocolpopexy, a postmenopausal woman may be optimally treated via a vaginal approach vault suspension, and an elderly woman who has not been, and will not be, sexually active with a colpocleisis.

Regardless of the approach, assessment of bladder function preoperatively, tissue preparation with local estrogen cream as indicated, and allowing unstressed healing during the early postoperative healing phase are all keys to optimizing surgical outcomes.

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