Pelvic Organ Prolapse
BS. Nguyễn Hồng Anh
KEY POINTS
1 Pelvic organ prolapse is an increasingly common condition seen in women commensurate with an aging population.
2 Causes of pelvic organ prolapse are multifactorial and contribute to the weakening of the pelvic support connective tissue and muscles as well as nerve damage.
3 It is important to understand the three levels of pelvic support in order to optimally identify defects in a consistent and individualized manner.
4 Physical examination includes thoughtful attention to all parts of the vagina, including the anterior, apical, and posterior compartments, levator muscle, and anal sphincter complex. Objective evaluation using the validated pelvic organ prolapse quantification system (POP-Q) allows the ability to follow prolapse over time and evaluate results of treatment.
5 Nonsurgical treatment options include pelvic floor muscle training and the use of intravaginal devices.
6 Surgical treatment involves an individualized, multicompartmental approach consistent with the patient’s previous treatment attempts, activity level, and health status. This involves consideration of approach (vaginal or abdominal), reconstructive versus obliterative, and use of native tissue versus graft augmentation. Increasing level I evidence exists to guide us in individualized treatment approaches.
INTRODUCTION
Pelvic organ prolapse (POP) is defined as the “descent of one or more of the anterior vaginal wall, posterior vaginal wall, the uterus (cervix), or the apex of the vagina (vaginal vault or cuff scar after hysterectomy),” correlated with symptoms, assisted by any relevant imaging (1). [1] It is the progressive herniation of the pelvic organs through the urogenital diaphragm that most commonly leads to vaginal bulge symptoms (2,3). Women with prolapse beyond the hymen may also report lower urinary tract (incontinence, urgency-frequency, or voiding difficulty) and bowel (obstructed defecation, fecal incontinence) symptoms.
Pelvic floor disorders, including POP, increase with age. Based on a crosssectional study of a nationally representative population of women in the United States, the prevalence of at least one pelvic floor disorder (PFD) was 23.7%; the prevalence more than doubled in women 80 years or older (4). Variations in the definitions of symptomatic POP (objective and subjective criteria), both in clinical practice and in the literature, create variability in estimates of prevalence and incidence. For instance, mild POP, defined as any degree of prolapse on examination, is practically universal in older women; but women may not have symptoms unless the prolapse is more severe. The reported prevalence of POP is thus impacted by the threshold used to define the condition (5). Age, as a risk factor for prolapse, plays an impactful role in the public health burden of pelvic floor disorders. The older population in the United States is expected to more than double to 88.5 million by 2050; the 85-and-older segment of the population is expected to triple to 19 million (5). With the aging population, health care utilization for pelvic floor disorders (including vaginal prolapse) is predicted to grow, resulting in a significant and growing burden on health services. POP is often managed surgically. The probability lifetime risk that a woman will undergo surgical correction of any primary surgery for stress urinary incontinence (SUI) or POP (repeat procedures excluded) by 80 years of age is estimated to be 1 in 5, the cumulative risk for POP surgery being 12.6% (95% confidence interval [CI], 12.4–12.7). The age-specific annual risk of POP increased progressively until 73 when the annual risk was 4.3 per 1,000 women.
A woman’s combined risk for either surgery is 11.4% by the age of 60, rising to 15.9% at age 70, and to 20.2% by age 80 (6). This is almost twice the risk
previously quoted (11% lifetime risk figure from a 1995 study) (7). Using the
U.S. Census Bureau population projections, it is estimated that the total number
of women anticipated to undergo surgery for POP from 2010 to 2050 will
increase by 46%, with predictions of up to one-third of the female population
suffering from at least one PFD in 2050. Estimated annual procedure rates will
increase from 166,000 to 245,970 for POP (8).
The economic burden of pelvic floor disorders on the health care system is
1744substantial. In 2006, the estimated direct annual cost of ambulatory care for PFDs
in the United States was $412 million (8). The 5-year risk of undergoing repeat
SUI or POP surgery is thought to be less than 10% (7.8% for women aged <65
years and 9.9% for women aged ≥65 years) with higher risks for women aged ≥65
years and for those who underwent an initial POP surgery (9). Prolapse
significantly impacts quality of life causing discomfort, urinary symptoms, and
psychosexual issues. A better understanding of the multifactorial etiology for
POP may help to reduce the numbers of POP surgery by means of primary
prevention.
In light of the increasing prevalence and social burden of this disorder,
researchers and surgeons continue to hope for a universally successful and riskminimizing solution for POP. A variety of surgical approaches have been
developed and optimized over the last half century to enhance durability,
minimize risks, and shorten recovery. [1] The treatment of prolapse remains a
matter of individualizing patient outcome goals while navigating the risks of
recurrence, surgical, and functional complications.
In the United States, 11% of women up to the age of 80 years have surgery for
POP or urinary incontinence, and nearly one-third of procedures are repeat
surgery (3). Data from the Women’s Health Initiative revealed anterior POP in
34.3%, posterior wall prolapse in 18.6%, and uterine prolapse in 14.3% of women
(10). In this study, a significant risk factor associated with prolapse was vaginal
delivery. After adjusting for age, ethnicity, and body mass index, women with at
least one vaginal delivery were twice as likely as nulliparous women to have
POP. Causes of pelvic support disorders are most likely multifactorial, however;
factors other than vaginal delivery are associated with the development of these
disorders. [2] In addition to parity and vaginal delivery, nonobstetric risk factors
for POP surgery include age, constipation, increasing weight, and chronic
obstructive pulmonary disease (11). Other reported risk factors for the
development of POP include history of hysterectomy, obesity, history of previous
prolapse operations, and race (10,12,13).
PATHOPHYSIOLOGY
The interaction between the pelvic floor muscles, fibromuscular connective tissue and intact innervation are key to maintaining support of the pelvic organs in their normal locations. The levator ani/coccygeus muscles hold the pelvic floor closed and provide lifting and closing forces to prevent pelvic floor descent. These muscles provide a supportive diaphragm through which the urethra, vagina, and rectum egress (Fig. 30-1). POP results from attenuation of the supportive structures, whether by actual tears or “breaks” or by neuromuscular dysfunction or both. Muscle damage (or weakening) allows the levator hiatus to enlarge, facilitating pelvic organ descent with one or both of the vaginal walls, allowing them to protrude through the levator hiatus. Birth-induced injury to the pubococcygeal portion of the levator ani muscles is seen in 55% of women with prolapse and 16% of women with normal support. Support of the vaginal canal is provided by the enveloping endopelvic connective tissue and its condensations at the vaginal apex, which form the cardinal uterosacral ligament complex. Failure of the connective tissue attachments between the uterus and vagina to the pelvic wall (cardinal, uterosacral, paravaginal) are strongly related with prolapse and are also highly correlated with one another (14).
[3] The support system for the uterus and vagina has been described as consisting of three levels (15).
Level I refers to the uterosacral/cardinal ligament complex, which serve to maintain the vaginal length and axis.
Level II support consists of the paravaginal attachments of the lateral vagina and endopelvic fibromuscular connective tissue to the arcus tendineus and levator fascia that maintain the midline position of the vagina.
Level III support pertains to the distal vagina and is made up of the muscles and connective tissue surrounding the distal vagina and perineum.
Definitions
Prolapse can involve three different compartments: anterior vaginal wall, posterior vaginal wall, and the apical compartment (uterus or vaginal apex). This condition is unique to women and is distinct from rectal prolapse, where the rectum protrudes through the anus and is seen in men and women. The common pelvic support disorders include rectocele, cystocele (Fig. 30-2), enterocele (Fig. 30-3), and uterine prolapse (Fig. 30-4); reflecting displacement of the rectum, bladder, small bowel, and uterus, respectively; resulting from failure of the endopelvic fibromuscular connective tissue, levator ani muscular support, or both (15).
A rectocele is a protrusion of the rectum into the vaginal lumen resulting from weakness in the muscular wall of the rectum and the paravaginal fibromuscular connective tissue, which holds the rectum in place posteriorly.
An enterocele is a herniation of the peritoneum and small bowel and is the only true hernia among the pelvic support disorders. Most enteroceles occur downward between the uterosacral ligaments and the rectovaginal space, but they may also occur primarily apically, especially in the setting of a previous hysterectomy.
A cystocele is descent of the urinary bladder with the anterior vaginal wall. Cystoceles usually occur when the pubocervical fibromuscular connective tissue weakens midline or detaches from its lateral or superior connecting points.
FIGURE 30-1 A sagittal view of the female pelvis with bladder and uterus removed (ureters, trigone, and cervix intact) illustrating anterior and posterior vaginal fibromuscular planes, their endopelvic fascial attachments, and a functional pelvic floor.
Uterine prolapse is generally the result of poor cardinal or uterosacral ligament apical support, which allows downward protrusion of the cervix and uterus toward the introitus. In women after hysterectomy, the vaginal apex can shift downward toward the introitus, which is referred to vaginal vault (or apical) prolapse in the absence of uterus. Procidentia is prolapse of the uterus and vagina, whereas complete vaginal vault prolapse, which can occur after hysterectomy, represents eversion of the entire vagina (Fig. 30-5).
These descriptive terms are somewhat inaccurate and misleading, focusing on the pelvic organs (bladder, rectum, small bowel, or uterus) rather than the specific defects responsible for the alterations in vaginal support. Specific defect support issues will be discussed in the Surgical Management section.
SURGICAL ANATOMY
Pelvic support structures include:
1. The muscles and connective tissue of the pelvic floor
2. The fibromuscular tissue of the vaginal wall
3. The endopelvic connective tissue
Endopelvic connective tissue includes:
1. The cardinal/uterosacral complex, which attaches the upper vagina and cervix posteriorly
2. Lateral connective tissue attachments of the anterior vaginal wall to the arcus tendineus pelvis and of the posterior vaginal wall to the fascia of the levator ani and to the posterior arcus tendineus near the ischial spine
3. Less dense areolar connective tissue surrounding retroperineal portion of the pelvic organs
The orientation of these structures is noted in Figure 30-1.
In general, an intact pelvic floor, including a functional puborectalis muscle and an intact cardinal/uterosacral complex, should prevent POP by allowing posterior deflection of the rectum and vagina and compression of these structures against the pelvic floor in the upright position (Fig. 30-6). The fibromuscular layer of the vaginal wall and the other endopelvic connective tissue attachments augment the support structure and are particularly important when pelvic floor function is compromised.
FIGURE 30-2 A: Sagittal section of the pelvis showing normal anatomy. B: Cystocele and rectocele.
Apical Compartment
Normal apical support includes the integrity of the cardinal/ uterosacral ligaments, the upper paravaginal fibromuscular connective tissue, and, when the uterus is present, the paracervical fascia. The fibromuscular tissue of the upper vagina blends in with the paracervical fascia. Both of these are attached laterally and posterior laterally to the cardinal ligaments and uterosacral ligaments (Fig. 30-1). The vaginal fibromuscular tissue is also attached to the upper anterior rectum at its sigmoid junction and forms the inferior border of the cul-de-sac of Douglas. The cardinal and uterosacral ligaments are condensations of areolar connective tissue and they contribute level I support for the vagina. Their origin is at the lateral borders of sacral vertebra 2 to 4, and they travel retroperitoneally to their insertion at the upper vagina and cervix (Fig. 30- 1). They serve as the anterior and lateral borders of the cul-de-sac and cross at or just anterior to the ischial spines. The ureter is closest to the uterosacral ligament at or just posterior to its insertion on the posterior lateral cervix. If anterior cephalad traction is placed on the ureter or cervix, frequently the cardinal uterosacral ligaments will stand out as ridges lateral to the cul-de-sac; however, peritoneal folds may have similar appearance. Therefore, placement of sutures in such structures based on visual appearance may not be reliable.
FIGURE 30-3 A: Posterior enterocele without eversion. B: Enterocele with eversion.
FIGURE 30-4 Uterine prolapse with apical detachment from the uterosacral ligament complex and lateral wall detachment from the endopelvic connective tissue.
FIGURE 30-5 Procidentia of the uterus and vagina.
FIGURE 30-6 Vaginograms from the same patient at rest (A) and during Valsalva maneuver (B). Illustrates posterior vaginal deflection maintained by apical cardinal/uterosacral posterior suspension and the anterior sling effect of the puborectalis muscle and more distal perineal structures. (From Nichols DH, Randall CL. Vaginal Surgery. 4th ed. Baltimore, MD: Williams & Wilkins; 1996:4–5, with permission.)
Defects in apical support include:
1. The loss of cardinal/uterosacral support with resultant cervical/uterine or vaginal cuff descent
2. The detachment of the fibromuscular vagina from the anterior rectum with resultant enterocele or, at times, sigmoidocele into the rectovaginal space
3. Tears or attenuation of the upper fibromuscular tissue, usually after hysterectomy, leading to a central apical descent that frequently presents as a ballooning defect
Often, these defects occur concurrently. Defects in cardinal/uterosacral attachment are at sites close to their insertion into the cervix and upper vagina where breaks or tears occur; in those with apical descent, condensations of cardinal/uterosacral tissue can be found adjacent to the peritoneum just cephalad to the ischial spines (16).
Anterior Compartment
The anterior vaginal compartment includes the anterior vaginal wall, its attachments, the urethra, and the bladder. When the anterior vaginal wall prolapses to the level of the hymen (point Ba = 0)—the point at which most women will become symptomatic—the apex is }4.5 cm inside the hymen (i.e., when a woman has clinically significant prolapse to the hymen, she will have nearly 5 cm of apical support loss) (17). The support structure for the bladder is the rhomboid-shaped anterior vaginal wall (specifically its fibromuscular layer), which is attached laterally to the arcus tendineus fascia (Fig. 30-7). Inferiorly, the fibromuscular layer blends in with the connective tissue, which spans the two bands of puborectalis and pubococcygeus muscles and the pubic rami. The urethra appears to be preferentially supported by these connective tissues and by the pubourethral ligaments. In the apical area, the vaginal fibromuscular layer blends in with the precervical fascia and the connective tissue of the cardinal ligament complex.
In the upright position, the rhomboid-shaped anterior vaginal wall is oriented approximately 30 degrees from the horizon (from pubis to ischial spines). There is some downward bulge of the central area of the rhomboid plate, which should be minimized by the back-stop effect of the posterior vagina and rectum if the pelvic floor anatomy and function are normal.
Defects of this support structure may include tears or attenuation of the vaginal fibromuscular wall, or detachment from the pelvic sidewalls, the cervix or cardinal ligament complex, or from the pubis. Specific sites of fibromuscular tears are frequently difficult to recognize.
FIGURE 30-7 View of the pelvic cavity with bladder, upper vagina, and sigmoid colon removed. The fibromuscular wall of the anterior vagina is attached to the arcus tendineus fascia pelvis by endopelvic connective tissue and supports the bladder. The pararectal fascia (Denonvillier fascia) includes the fibromuscular tissue of the posterior vagina and its lateral attachment to the fascia levator ani.
Physical examination may reveal the following findings:
1. The presence of a central ballooning-type defect
2. Descent of the area of the vaginal wall below the bladder neck
3. Descent of the cervix or apical vaginal area
4. The presence or absence of sulci extending lateroanteriorly, which would indicate that lateral detachment to the arcus is maintained or lost.
Posterior Compartment
The support of the rectum and posterior vagina includes the pelvic floor musculature and connective tissue posteriorly and Denonvillier (pararectal) fascia, which is the fibromuscular layer of the posterior vaginal wall and its lateral attachments to the lateral pelvic floor (levator) musculature and its fascia (Fig. 30-8). This lateral attachment site, the fascia levator ani, fuses with the arcus tendineus fascia pelvis at the middle to upper level of the vagina and continues to the level of the ischial spine. Less dense, areolar, connective tissue surrounds the rectum and vagina and may supply some support to these structures as well.
The fibromuscular layer at the upper vagina fuses with the paracervical fascia and the fan-shaped cardinal ligament structure. The integrity of the attachment of this posterior vaginal layer to the anterior rectal wall just below the rectal sigmoid junction prevents enterocele formation. In the distal vagina, the fibromuscular layer fuses laterally with the fascia of the puborectalis, pubovaginalis, and then the bulbocavernous muscles and centrally with the perineal connective tissue. Thus, normal posterior support includes a plate of connective tissue which includes the fibromuscular layer of the posterior vaginal wall that is attached laterally as noted, posteriorly toward sacral segments 2 to 4, and inferiorly to the perineum. This fibromuscular plane holds the rectum in place posteriorly, and aids in preventing perineal descent by suspending the perineum to the sacrum. The constant resting tone of the pelvic floor muscles, particularly the puborectalis, serve to close the genital hiatus, pulling the distal vagina and anorectal junction toward the pubic symphysis and creating an anorectal angle and a posterior deflection of the rectum, vagina, and bladder base.
It has been hypothesized, based on careful cadaveric dissections, that most rectoceles were caused by discrete tears in the Denonvillier fascia at its lateral, apical, and perineal attachments and centrally within the vaginal muscular connective tissue (18). Perineal detachment, along with a defect in the perineal membrane, has been described as a perineal rectocele, which is most commonly associated with reports of difficulty with defecation. Apical attachment defects are generally associated with enteroceles and occasionally sigmoidoceles.
EVALUATION
Approximately 10% to 20% of symptomatic women seek medical help, both conservative and surgical interventions have been shown to improve quality of life (19). The paucity of reported prolapse symptoms may result from a number of causes, including lack of symptoms, embarrassment, or misperceptions about available treatment options. Although POP is not lifethreatening, it can impose a significant burden of social and physical restrictions of activities, impact on psychological well-being, and overall quality of life.
FIGURE 30-8 Sagittal oblique view of the distal midvagina illustrating lateral connection of the posterior musculoconnective tissue wall to the fascia levator ani and anterior wall to the arcus tendineus pelvis. The attachment sites fuse together at a point closer to the ischial spine where the vagina assumes a more oval shape. (Modified by J. Taylor from illustration by Lianne Krueger Sullivan. From Cundiff GW, Fenner D. Evaluation and treatment of women with rectocele: Focus on associated defecatory and sexual dysfunction. Obstet Gynecol 2004;104:1403–1421, erratum in Obstet Gynecol 2005;105:222, with permission.)
Symptoms
POP often is accompanied by symptoms of voiding dysfunction, including urinary incontinence, obstructive voiding symptoms, urinary urgency and frequency, and, at the extreme, urinary retention and upper renal compromise with resultant pain or anuria. Other symptoms often associated with POP include pelvic pain, defecatory problems (e.g., constipation, diarrhea, tenesmus, fecal incontinence), back and flank pain, overall pelvic discomfort, and dyspareunia.
Patients seeking care for prolapse may have one or several of these symptoms involving the lower pelvic floor. Choice of treatment usually depends on severity of the symptoms, the degree of prolapse, and on the patient’s general health and level of activity (20).
Data relating to pelvic floor symptoms to the extent and location of prolapse are weak (21–23). Vaginal descensus 0.5-cm distal to the hymen was shown to most accurately predict bulge symptoms with the sensitivity and specificity 69% and 97%, respectively. However, the “threshold” of prolapse severity varies depending on the patient (24). In a study including 192 women, the symptom of a vaginal bulge was shown to have an 81% positive predictive value and 76% negative predictive value (25). Any symptoms associated with physical findings of lower-stage prolapse require careful evaluation, especially if surgery is being considered. [4] A retrospective study of 330 patients reported that women with more advanced prolapse were less likely to have symptoms of stress incontinence and more likely to use manual reduction of the prolapse to void. Therefore, careful consideration of lower urinary tract symptoms is important. Prolapse severity was not associated with bowel or sexual problems in this study (26).
Physical Examination
In evaluating patients with POP, it is particularly useful to divide the pelvis into compartments, each of which may exhibit specific defects. The use of a Graves speculum or Baden retractor can help to evaluate the apical compartment of the vagina. The anterior and posterior compartments are best examined with the use of a univalve or Sims speculum. The speculum is placed posteriorly to retract the posterior wall downward when examining the anterior compartment and placed anteriorly to retract the anterior wall upward when examining the posterior compartment. A rectovaginal examination may be useful in evaluating the posterior compartment to distinguish a posterior vaginal wall defect from a dissecting apical enterocele or a combination of both.
If an anterior lateral detachment defect is suspected, an open ring forceps (or a Baden retractor) may be placed in the vagina at a 45-degree angle posteriorly cephalad to hold the lateral fornices adjacent to the pelvic sidewall.
During the evaluation of each compartment, the patient is encouraged to perform Valsalva so the full extent of the prolapse can be ascertained. If the findings determined with Valsalva are inconsistent with the patient’s description of her symptoms, it may be helpful to perform a standing straining examination with the bladder empty (26,27).
Pelvic Organ Prolapse Quantification System
Many systems for staging prolapse have been described. Typically, it is graded on a scale of 0 to 3 or 0 to 4, with the grade increasing with the severity of prolapse (28). The system approved by the International Continence Society is the Pelvic Organ Prolapse Quantification system, or POP-Q (29). This standardized quantification system facilitates communication between physicians in practice and research and enables progression of these conditions to be followed accurately. In this system, anatomic descriptions of specific sites in the vagina are used in place of traditional terms. The system identifies nine locations in the vagina and vulva in centimeters relative to the hymen, which are used to assign a stage (from 0 to IV) of prolapse at its most advanced site (Fig. 30-9).
Although probably more detailed than necessary for general practice, clinicians should be familiar with the POP-Q system because most published studies use it to describe research results. Its two most important advantages over previous grading systems are (1) it allows the use of a standardized technique with quantitative measurements at straining relative to a constant reference point (i.e., the hymen); and (2) its ability to assess prolapse at multiple vaginal sites.
FIGURE 30-9 Standardization of terminology for female pelvic organ prolapse (POP-Q) classification. This diagram demonstrates the anatomic position of the POP-Q sites, including six sites involving the anterior (Aa, Ba), middle (C, D), and posterior (Ap, Bp) compartments with the genital hiatus (gh), perineal body (pb), and total vaginal length (tvl). (From Bump RC, Mattiason A, Bo K, et al. The standardization of terminology of female pelvic organ prolapse and pelvic floor dysfunction. Am J Obstet Gynecol 1996;175:10–17, with permission.)
The classification uses six points along the vagina (two points on the anterior, middle, and posterior compartments) measured in relation to the hymen. The anatomic position of the six defined points should be measured in centimeters proximal to the hymen (negative number) or distal to the hymen (positive number), with the plane of the hymen representing zero.
Three other measurements in the POP-Q examination include the genital hiatus, perineal body, and the total vaginal length (29). The genital hiatus is measured from the middle of the external urethral meatus to the posterior midline hymen. The perineal body is measured from the posterior margin of the genital hiatus to the mid-anal opening. The total vaginal length is the greatest depth of the vagina in centimeters when the vaginal apex is reduced to its full normal position. All measurements except the total vaginal length are measured during maximal straining.
The anterior vaginal wall measurements are termed Aa and Ba, with the Ba point moving depending on the amount of anterior compartment prolapse. Point Aa represents a point on the anterior vagina 3-cm proximal to the external urethral meatus, which corresponds to the bladder neck. By definition, the range of position of this point is –3 to +3. Point Ba represents the most distal or dependent point of any portion of the anterior vaginal wall from point Aa to just anterior to the vaginal cuff or anterior lip of the cervix. This point can vary
depending on the nature of the patient’s support defect. For example, point Ba is –
3 in the absence of any prolapse (it is never less than –3) to a positive value equal
to the total vaginal length in a patient with total eversion of the vagina.
The middle compartment consists of points C and D. Point C represents
the most dependent edge of the cervix or vaginal cuff after hysterectomy.
Point D is the location of the posterior fornix; it is omitted if the cervix is
absent. This point represents the level of the attachment of the uterosacral
ligament to the posterior cervix. It is intended to differentiate suspensory failure
from cervical elongation.
The posterior compartment is measured similarly to the anterior
compartment: the corresponding terms are Ap and Bp. The nine
measurements can be recorded as a simple line of numbers (i.e., –3, –3, –8, –10, –
3, –3, 11, 4, 3 for points Aa, Ba, C, D, Ap, Bp, total vagina length, genital hiatus,
and perineal body, respectively). The six vaginal sites have possible ranges that
depend on the total vaginal length (Table 30-1). After collection of the site-
1760specific measurements, stages are assigned according to the most dependent
portion of the prolapse (Table 30-2).
The POP-Q examination often appears confusing on initial review; however, a
measuring device (i.e., a marked ring forceps or marked cotton-tip applicator) can
assist in instructing those unfamiliar with this staging system. The POP-Q
examination provides a standardized measurement system to allow for more
accurate assessments of postoperative outcome and to ensure uniform,
reliable, and site-specific descriptions of POP. There is interest in using the
POP-Q examination to measure prolapse as a continuous variable rather than in
stages because it would provide greater statistical power in clinical research (30).
The American Urogynecology Society provides a video (31) that describes the
POP-Q examination and demonstrates its use.
Table 30-1 Possible Ranges of the Six Site-Specific Pelvic Organ Prolapse
Quantitative Examination Measurements
Points Description Range
Aa Anterior wall 3 cm from hymen −3 cm to +3 cm
Ba Most dependent portion of rest of anterior wall −3 cm to +TVL
C Cervix or vaginal cuff ±TVL
D Posterior fornix (if no prior hysterectomy) ±TVL or omitted
Ap Posterior wall 3 cm from hymen −3 cm to +3 cm
Bp Most dependent portion of rest of posterior wall −3 cm to +TVL
TVL, total vaginal length.
Adapted from Bump RC, Mattiasson A, Bo K, et al. The standardization of terminology
of female pelvic organ prolapse and pelvic floor dysfunction. Am J Obstet Gynecol 1996;
175:10–17, with permission.
In a clinical setting, at least three measurements should be obtained: the most
advanced extent of the prolapse in centimeters relative to the hymen that affects
the anterior vagina, the posterior vagina, and the cervix or vaginal apex.
Whether the older staging systems or the POP-Q system is used, it is important
to document the most pertinent findings on examination. This will help in
documenting the baseline extent of prolapse and the results of treatment.
Pelvic Muscle Function Assessment
1761Pelvic muscle function should be assessed during the pelvic examination.
Following bimanual examination with the patient in the lithotomy position, the
examiner can palpate the puborectalis and pubococcygeus muscles inside the
hymen along the pelvic sidewalls at approximately the 4 and 8 o’clock positions.
One can appreciate basal muscle tone and whether there is increased tone with
contraction as well as strength, duration, and symmetry of contraction (32). A
rectovaginal examination should also be performed to assess basal and
contraction muscle tone of the anal sphincter complex.
Table 30-2 Stages of Pelvic Organ Prolapse
Stage
0
No prolapse is demonstrated. Points Aa, Ap, Ba, Bp are all at –3 cm, and
point C is between total vaginal length (TVL) and –(TVL –2 cm)
Stage I
The most distal portion of the prolapse is greater than 1 cm above the level of the hymen
Stage II
The most distal portion of the prolapse is less than 1 cm proximal or distal to the plane of the hymen
Stage III
The most distal portion of the prolapse is less than 1 cm below the plane of the hymen but no further than 2 cm less than the total vaginal length
Stage IV
Complete to nearly complete eversion of the vagina. The most distal portion of the prolapse protrudes to greater than (TVL –2) cm
From Bump RC, Mattiassion A, Bo K, et al. The standardization of terminology of female pelvic organ prolapse and pelvic floor dysfunction. Am J Obstet Gynecol 1996; 175:10–17, with permission.
As a part of the POP examination, urethral mobility often is measured. Many women with prolapse will have urethral hypermobility (defined as a resting urethral angle greater than 30 degrees or a maximal strain angle greater
than 30 degrees). The presence of urethral mobility in combination with
symptoms of stress incontinence may help determine whether an incontinence
procedure should be performed. However, studies have shown that nearly all
women with stage II to IV prolapse have urethral hypermobility, and
asymptomatic parous women have an average maximum straining angle of 54
degrees (33,34). During pelvic examination, the urethra is typically swabbed with
Betadine, and lidocaine jelly is placed in the urethra or on a cotton-tip swab. The
swab is placed in the urethra at the urethrovesical junction and, with the use of a
goniometer (Fig. 30-10), the baseline urethral angle from the horizontal and
maximal strain angles is measured.
Bladder Function Evaluation
Patients with prolapse exhibit the full range of lower urinary tract
symptoms. Despite the fact that some patients may not have significant
symptoms, it is important to obtain objective information about bladder and
urethral function. With severe POP, the urethral kinking effect of the prolapse
may mask a potential urine leakage problem; therefore, basic office bladder
testing with prolapse reduction should be performed to mimic bladder and
urethral function if the prolapse were treated. At a minimum, the following
assessments should be performed: a clean catch or catheterized urine sample to
test for infection, a postvoid residual volume (PVR), and assessment of bladder
sensation, which can be performed as a part of office cystometrics. Although
there is no consensus as to what constitutes an abnormal PVR volume, provided
the patient has voided 150 mL or more, a PVR less than or equal to 100 mL is
acceptable (33). Reduction stress testing at the time of simple office cystometrics
can be performed with the use of a pessary, large cotton swab, ring forceps, or the
posterior blade of a speculum. Care should be taken that the urethra not be overly
straightened (with a resultant false-positive test result) or obstructed (with a
resultant false-negative test result), or that tension is not placed on the
puborectalis muscles by excessive posterior retraction. These risks can be
minimized by orienting the vaginal apex toward the sacrum.
Bowel Function Evaluation
When a decision is made to perform surgical repair of the posterior compartment
based on symptoms, type, and location of defects, an appropriate approach should
be determined and the patient should be made aware of the expected outcomes
and potential adverse effects such as pain and sexual dysfunction. If the patient
has defecatory dysfunction with a rectocele and symptoms of constipation,
pain with defecation, fecal or flatal incontinence, or any signs of levator
spasm or anal sphincter spasm, appropriate evaluation and conservative
management of concurrent conditions could be initiated before repair of the
rectocele and continued postoperatively (34).
1763FIGURE 30-10 Goniometer, which is used to measure baseline urethral angle and
maximal strain angle of the urethra with a cotton-tip swab in place.
Imaging
Diagnostic imaging of the pelvis in women with POP is not routinely
performed. However, if clinically indicated, tests that may be performed include
fluoroscopic evaluation of bladder function, ultrasound of the pelvis, and
defecography for patients in whom intussusception or rectal mucosal prolapse are
suspected. Magnetic resonance imaging is increasingly being used for the
evaluation of pelvic pathology such as mullerian anomalies and pelvic pain;
however, generalized use in women with prolapse is not clinically indicated and is
used primarily for research purposes.
[5] TREATMENT
Nonsurgical Therapy
Nonsurgical therapy of POP includes conservative behavioral management and the use of mechanical devices. A nonsurgical treatment approach is usually considered in women with mild to moderate prolapse, those who desire preservation of future childbearing, those in whom surgery may not be an option, or those who do not desire surgical intervention. As not all prolapse progresses over time, expectant management is an option for some women, especially if they are mostly asymptomatic. A 4-year prospective observational study of 259 postmenopausal women reported the maximum vaginal descent increased by at least 2 cm was seen in 11%. Three percent had at least 2-cm regression of prolapse (35).
Conservative Management
Conservative management approaches include alteration of lifestyle or physical intervention such as pelvic floor muscle training (PFMT). These approaches are used mainly in cases of mild to moderate prolapse; however, their true role in managing prolapse and associated symptoms is unclear (36). The goals of a conservative therapy approach to the treatment of prolapse are as follows (37):
Prevent worsening prolapse
Decrease the severity of symptoms
Increase the strength, endurance, and support of the pelvic floor musculature
Avoid or delay surgical intervention
Prevention of prolapse progression and life-altering interventions are lacking robust data.
Pelvic floor muscle exercises may limit the progression of mild prolapse and related symptoms; however, a lower response rate has been noted when prolapse extends beyond the vaginal introitus (38). A recent randomized trial evaluated the effectiveness of one-to-one individualized PFMT for the reduction of symptomatic stages I to III prolapse (39). Women in the intervention group reported fewer prolapse symptoms at 12 months compared to those provided a lifestyle advice leaflet without muscle training.
The efficacy of biofeedback therapy in the treatment of impaired defecation associated with a rectocele has been determined (40). Thirty-two female patients, median age 52 years (range, 34 to 77 years), experiencing impaired rectal evacuation with a rectocele greater than 2 cm at proctography underwent a structured behavioral retraining. Immediate and medium-term follow-up results were reported (median 10 months; range 2 to 30 months). Fifty-six percent of patients (n = 14) felt a little and 16% (n = 4) felt major improvement in symptoms, including 3 (12%) with complete symptom relief. Immediately after biofeedback there was a modest reduction in need to strain (67; 50%), feeling of incomplete evacuation (73; 59%), and need to assist defecation digitally (79; 63%) that was maintained at follow-up. Bowel movement frequency was significantly normalized at follow-up (p =.02). These investigators concluded that behavioral retraining, including biofeedback therapy, may be an effective primary therapy for some patients with a rectocele associated with impaired defecation (40).
Mechanical Devices
The use of mechanical devices such as pessaries is usually considered for women who cannot undergo surgery for medical reasons, desire to avoid surgery, or have a significant degree of prolapse that makes other nonsurgical approaches unfeasible. Some practitioners extend indications to include pregnancy-related prolapse as well as prolapse and incontinence in elderly women. Reports have shown that age older than 65 years, the presence of severe medical comorbidity, and sexual activity were associated with unsuccessful pessary usage (41,42). Unsuccessful use or a preference for surgery has been associated with a shortened vaginal length (≤6 cm), a wide vaginal introitus, sexual activity, stress incontinence, stage III or IV posterior compartment prolapse, and desire for surgery at a first office visit (43).
Pessaries provide pelvic organ support within the vaginal vault. Two categories of pessaries—support and space filling—exist for prolapse. The ring pessary (with diaphragm) is a commonly used support pessary, and the
Gelhorn pessary is a commonly used space-filling pessary. Traditionally, the
ring and other support pessaries are used for stage I and II prolapse, whereas the space-filling pessaries are used for stage III and IV prolapse (44). In a randomized trial comparing ring with support versus Gellhorn for prolapse treatment in women with stage II to IV prolapse, no difference was noted between the two pessaries for the treatment efficacy in relieving symptoms of protrusion and voiding dysfunction. This trial reported older and more parous women preferred ring pessaries whereas those without prior pelvic surgery preferred Gellhorn. The continuation rate was 45% at 3 months (45).
It is unclear whether pessaries can prevent the progression of POP with regular use. A prospective cohort study addressed this issue in a series of 56 women who were fitted with a pessary, of which 33.9% (n = 19) continued use for at least 1 year (46). Baseline and follow-up pelvic examinations were performed using the POP-Q system. The women removed the pessary 48 hours before one visit, but there was no information to ascertain adherence to pessary use. No woman had worsening of the prolapse, and four women (21.1%; 95% CI, –0.2, 43.7%) had an improvement. Improvement overall was noted in women with anterior compartment prolapse (46). No consensus guidelines on the care of pessaries (i.e., intervals between changes), the role of local estrogens, or the type of pessary indicated for specific types of POP (47). Different pessary types can be seen in Figure 30-11. After 2 to 6 months, 77% to 92% of women with a successful pessary fitting were satisfied and, using intention-to-treat analysis, 44% to 67% of all women who were treated initially with a pessary for prolapse were satisfied. There is a paucity of long-term follow-up data on pessary use, however, the continuation rate of 14% at 14 years has been reported (41,43,48).
Possible complications associated with pessary use include vaginal discharge and odor. Failure to retain the pessary may occur or, conversely, the pessary may be too large, which could lead to excoriation or irritation. With reduction of vaginal prolapse, de novo or increased stress incontinence may occur, and in rare instances, more severe complications, including vesicovaginal or rectovaginal fistula, small bowel entrapment, hydronephrosis, and urosepsis, have been described (49–51).
Placement and Management
Pessary placement involves consideration of a number of issues, primarily the patient’s desire and motivation to use this type of device. Typically, if she has had previous surgery or strongly desires to avoid surgery, she may be motivated enough for a primary attempt at pessary placement. Other issues include current sexual function status, type and duration of exercise in which the patient engages, and the status of the vaginal walls and cervix. In hypoestrogenic women, treatment of the vagina with estrogen and maintenance of intravaginal estrogen treatment is recommended.
Fitting a Pessary
The patient should be examined in the lithotomy position after emptying her bladder. The clinician should use a dry glove to better grasp the pessary and water-soluble lubricants as needed. The size of the pessary is estimated after a digital examination and use of ring forceps to reduce the prolapse or bladder neck.
After the approximate size is determined, the appropriate type is selected based on the patient’s needs and activity level. When fitted, the patient is asked to stand, perform Valsalva, and cough to ensure the pessary is retained. The pessary should be assessed to ensure it is providing the desired support and leakage control. The patient should be able to void with the pessary in place before leaving the office. Proper size is ensured by the ability to sweep the index finger between the pessary and the vaginal wall. The patient should feel comfortable with the pessary in place.
Insertion of the pessary is eased by using a water-soluble lubricant for insertion, folding or collapsing the pessary to reduce its size, and when it is inside the vagina, pushing it high to an area behind the symphysis pubis and inserting the device more posteriorly to avoid the urethra. Instructing the patient how to insert and remove the pessary may be done with the patient in a standing or supine position, depending on her dexterity (52).
Ring pessaries, with or without support, are the most commonly used type. They are the easiest to fold, insert, and remove. Gellhorn and cube pessaries are typically more difficult to insert and remove by the patient. They are held in place by significant space occupation and suction and offer strong support. The suction of the cube pessary needs to be broken, facilitating removal. Cube pessaries should be removed daily; Gelhorns can stay in longer (up to 6 to 8 weeks). Donut pessaries, which are very popular, are considered a space-fitting pessary for large vaginal vault prolapse, complete procidentia with decreased perineal support, and good introital integrity. The patient should be questioned about a latex allergy and instructed to remove and clean the device every 2 to 3 days. Continence pessaries, rings, and dishes with support typically also are easy to fold, insert, and remove.
Follow-Up Recommendations
After the initial fitting, the patient should return in 1 to 2 weeks and then at 4 to 6 weeks, depending on her independence with the pessary, her proficiency in placement and removal, and her cognitive and motor abilities.
After this initial follow-up, follow-up should continue at 6- to 12-month intervals at the discretion of the provider and depending on the patient’s ability to insert and remove the pessary effectively. If the patient needs to return to the provider for removal and cleaning of the pessary, 4- to 12-week intervals are more appropriate.
On follow-up visits, proper placement of the pessary, support of the prolapse and continence efficacy should be ensured. Because pessaries are fitted through a process of trial and error, it is not uncommon to change the size or type at least once after the initial fitting. [6] The pessary’s integrity should be checked, and the tissues should be evaluated for irritation, pressure sores, ulceration, and lubrication.
FIGURE 30-11 Pessaries used to treat the various degrees of prolapse. (Milex Company, a Division of Cooper Surgical.)
Surgical Management
The primary aims of surgery are to relieve symptoms, which may be caused by prolapse, and, in most cases, to restore vaginal anatomy so that sexual function may be maintained or improved without significant adverse effects or complications. Occasionally, when sexual function is not desired, obliterative or constrictive surgery is more appropriate and may relieve symptoms. There is no steadfast rule as to when surgery is indicated. Many patients with more advanced prolapse have few or no symptoms, whereas some with lesser degrees of prolapse have what they describe as severe symptoms. This is confounded by the observation that many of the “symptoms” may not be specifically related to the anatomic defect or may be worsened by anxiety. In general, surgery should be offered to patients who have tried conservative therapy and were not satisfied with the results or who do not desire conservative therapy. The prolapse should be symptomatic or should be greater than or equal to stage II with apparent progression. All patients should be given the alternative of trying conservative treatments when applicable. A prospective study of 680 women with prolapse reported that women choosing surgical over conservative management tend to be younger, more bothered by lower abdominal pain, pressure, need for vaginal digitation, incomplete bowel emptying, and sexually active (53).
Approaches to surgery include vaginal, abdominal, and laparoscopic routes, or a combination of approaches. Depending on the extent and location of prolapse, surgery may involve a combination of repairs directed to the anterior vagina, vaginal apex, posterior vagina, and perineum. Concomitant surgery may be planned for urinary or fecal incontinence. The surgical route is chosen based on the type and severity of prolapse, the surgeon’s training and experience, the patient’s preference, and the expected or desired surgical outcome.
Procedures for prolapse can be broadly categorized into three groups: (1) reconstructive, which use the patient’s endogenous support structures (native tissue repair); (2) compensatory (augmentation), which attempt to replace deficient support with permanent graft material; and (3) obliterative, which close or partially close the vagina.
These groupings are somewhat arbitrary and not entirely exclusive. For example, grafts may be used to reinforce repairs, such as colporrhaphy, or to replace support that is deficient or lacking. Graft use in sacrocolpopexy substitutes for the connective tissues attachments (cardinal and uterosacral ligaments) that would normally support the vaginal apex. In addition to the primary goal of relieving symptoms related to prolapse, urinary, defecatory, and sexual function must be considered in choosing the appropriate procedures.
Whether to repair all defects is controversial. Restorative repairs may be less successful than compensatory repairs in patients with generally “poor tissue,” and at times one defect repair may exert more tension on the repair of another defect.
Management should be based on the patient’s presentation, expectations, the specific anatomical defects noted (preoperatively and, at times, intraoperatively), and on the presence or absence of lower urinary and bowel dysfunction.
Vaginal Procedures
The Apical Compartment
Apical support is the key to a successful prolapse repair. Multiple studies demonstrate that the apex descends with the anterior compartment and that correction of the anterior wall without addressing the apex increases the risk of recurrent prolapse. Despite compelling evidence as to the importance of suspending the apex, not all surgeons perform this critical portion of the surgery, suggesting an ongoing discrepancy between evidence-based medicine and adoption into clinical practice (54). Examination for apical defects is at times difficult. Such defects may be missed when large anterior or posterior defects are present. In cases when apical defects are suspected but not confirmed, surgeons should evaluate the apical support intraoperatively and plan for management of these defects when they are found. Traction on the cervix with a tenaculum or on the vaginal cuff both centrally and laterally with Allis clamps may reveal otherwise unrecognized defects.
Transvaginal repairs include extraperitoneal procedures such as sacrospinous suspensions, iliococcygeal suspensions, and high paravaginal suspensions of the apical vaginal fornices to the arcus tendineus at the level of the ischial spine or to the endopelvic fascia, and intraperitoneal suspensions such as uterosacral suspensions and McCall culdoplasties.
Accepted practice is that the vaginal apex should be resuspended in a posterior cephalad direction to a site or sites posterior and caudad to the sacral promontory.
Anterior apical suspensions change the direction of the vaginal axis and may be fraught with a greater incidence of posterior compartment defects, including rectoceles, enteroceles, and sigmoidoceles.
1. If present, the attenuated part of the upper vaginal wall (fibromuscular defect) should be repaired or covered by graft material. If the attenuation is severe and cannot be thickened by preoperative vaginal estrogen treatment, removal of that portion of the upper vaginal wall should be considered.
2. The vaginal cuff or, in some instances, the cervix should be suspended without excessive tension.
3. Any defect in the attachment of the upper vagina to the rectum at or below its sigmoid junction should be corrected.
Enterocele repairs may include:
1. Removal of the peritoneal sac with closure of the peritoneal defect, followed by closure of the fascial or fibromuscular defect or both below it
2. Dissection and reduction of the peritoneal sac and closure of the defect
3. Obliteration of the peritoneal sac from within with transabdominal Halban or Moschcowitz type procedures or transvaginal McCall or Halban procedures
4. If the posterior vaginal wall is significantly elongated and enlarged, excision of that area to establish an acceptable vaginal length and to eliminate redundancy
With increasing evidence that suspension of the apex plays an integral role in prolapse surgery, the focus is shifting to identifying the optimal procedure to suspend the apex. One aspect of apical support in women with uterovaginal prolapse is discussion of the role of hysterectomy versus uterine preservation at the time of prolapse repair. Perception by patients and physicians differ. Historically, the treatment for symptomatic uterine prolapse has been concomitant hysterectomy, which is performed vaginally or abdominally in combination with an apical suspension procedure, and repair of coexisting defects. As the focus on patient reported outcomes has become increasingly recognized, it became apparent that patient and surgeon expectations and goals of surgery were somewhat different, and that traditional methods of evaluating treatment success (i.e., physical examination findings) may not be sufficient to give a full representation of surgical outcomes and patient satisfaction. PFD treatment goals (referred to as patient-centered, patientidentified, or patient-selected goal) have been called the “fourth dimension” of assessment of PFD treatment outcomes. PFD treatment goal attainment is associated with improved condition-specific QOL and patient satisfaction (55).
Uterine Preservation
The number of women favoring uterine preservation is increasing. When presented with the choice to undergo a hysterectomy at the time of POP surgery, 36% to 60% of women presenting for POP care would decline a hysterectomy (56,57).
Although hysterectomy has been performed routinely at the time of uterovaginal prolapse repair (as a means to access the uterosacral ligaments), high-level evidence-based data regarding the potential benefits comparing uterine preservation versus hysterectomy are lacking in the literature. The proponents of uterine conservation might argue that disruption of the uterosacral/cardinal ligament complex may weaken the pelvic floor supports even further. Existing data suggest that uterine preservation POP surgeries reduced risk of mesh erosion, operative time, blood loss, and hospital stay compared to similar surgical routes with concomitant hysterectomy and do not significantly change short-term prolapse recurrence (58). A recent randomized trial, “Study of Uterine Prolapse
Procedures—Randomized Trial” or “SUPeR,” was designed to address the question regarding the benefits of concomitant hysterectomy versus uterine preservation at the time of uterovaginal prolapse repair. This is a multicenter, single-blinded trial which randomizes women to a vaginal hysterectomy with uterosacral ligament suspension versus a vaginal mesh hysteropexy. Results of this trial are expected to be available in 2018 (59).
Additional factors to be considered when planning uterine-sparing prolapse surgery would include: women with a history of cervical pathology or abnormal uterine bleeding who may not be good candidates for uterine preservation, or those women who are at high risk of uterine malignancy (and may be best served with a hysterectomy as part of their prolapse repair). Uterine preservation necessitates routine surveillance for malignancies (uterine, cervical), which may be more technically challenging as a result of anatomical position changes from surgery. Additional apical support procedures that have been described for use when the uterus or cervix is to be kept in place include Manchester and Gilliam procedures and fixation of the cervix to the sacrospinous ligament.
The other procedures described in this section may be used in women who desire uterine preservation. When the cervix is absent, in addition to repair of fibromuscular defects, both fibromuscular planes anterior and posterior to the vaginal cuff should be attached to whatever suspension is employed.
Sacrospinous Ligament Fixation
The fixation of the vaginal apex to the sacrospinous ligament, the tendineus component of the coccygeus muscle, was first described in 1958 and was subsequently modified in Europe and the United States (60–63). Access is traditionally extraperitoneal via the rectovaginal space with penetration of the pararectal (Denonvillier fascia) at the level of the ischial spine to expose the muscle and ligament. Variations in this approach to the ligament include entrances through an anterior lateral access, an apical passage posterior to the uterosacral ligament, and a laparoscopic approach (64–66). Bilateral sacrospinous ligament suspensions have been advocated; however, these techniques may impose a greater degree of tension on the sutures and, at times, create a band of apical vagina across the rectum at the level of the suspension.
Whether this can cause defecatory dysfunction remains unknown. The advantages of the sacrospinous fixation procedure include: (1) its transvaginal extraperitoneal approach; (2) resultant posterior vaginal deflection; and (3) the fact that it is a durable repair if performed correctly. Reported success for apical support has been good (89% to 97%) with follow-up times ranging from 1 month to 11 years (67). However, there have been subsequent reports of high rates of anterior vaginal prolapse. It is not clear whether this observation is related to the procedure and its exaggerated posterior vaginal deflection or to the fact that many patients with apical descent also have defects in the upper vaginal fibromuscular tissue. Failure to address an anterior defect concurrently with suspension of the posterior apical vagina may predispose the patient to such a defect postoperatively. Other disadvantages of the procedure include: (1) relative difficulty in adequately exposing the ligament; (2) an unnatural lateral vaginal deflection toward the fixation site; (3) an inability to perform without excessive tension when the vaginal length is compromised, as may be the case in repeat procedures; (4) potential risk for injury to the sciatic nerve or pudendal nerve or vessel; and (5) occasional need to shorten or narrow the upper vagina when a fibromuscular defect involves much of the apical area.
Iliococcygeal Vaginal Suspension
Iliococcygeal vaginal suspension involves the attachment, usually bilaterally, of the vaginal apex to the iliococcygeus muscle and fascia (68,69). Extraperitoneal access is achieved via the posterior vagina. Compared with other vaginal suspension procedures, the iliococcygeal suspension has the fewest case series in the literature (68–72); however, cure rates appear comparable to the sacrospinous suspension technique. The dissection of the area to the ischial spine is approached from a midline posterior vaginal wall incision using the ischial spine as a landmark for identifying the sacrospinous ligament and the iliococcygeal fascia anteriorly and caudad to it. A polydioxanone suture is placed through the fascia and attached to the vaginal apex as a pulley stitch. This procedure is more easily performed bilaterally than the sacrospinous suspension and should be considered preferentially in the presence of a shortened vagina.
Risk of major vessel, nerve, or ureteral injury should be relatively low compared with other transvaginal suspensions.
Uterosacral Ligament Suspension
Surgical variations of the uterosacral ligament suspension originally described in 1938 have been used prophylactically during hysterectomy or therapeutically for
vaginal apical suspension (68,71). A therapeutic procedure in which the
vaginal apex is suspended to the uterosacral ligaments above the level of the
ischial spines had excellent success rates in an observational study of 302
participants (72). When access to the posterior cul-de-sac is attained, the
uterosacral ligament remnant can usually be found adjacent to the pelvic sidewall
peritoneum just cephalad to the palpable ischial spine. Up to three sutures are
placed in each ligament and incorporated into the anterior and posterior
fibromuscular layer of the vagina. Some surgeons approximate the ligaments in
the midline to close the cul-de-sac with the intention to treat or prevent enterocele
formation (73). Other surgeons suspend the right and left vaginal apex to the
ipsilateral uterosacral ligament, leaving the cul-de-sac open to avoid impinging on
the rectum and adversely affecting bowel function.
The most common serious complication was ureteral obstruction secondary to
ureteral kinking or incorporation of a ureter in a suspension stitch. This occurs in
approximately 2% to 3% of the cases, however as high as 11% of intraoperative
ureteral kinking has been reported (74,75). Intraoperative cystoscopy—with
1774documentation of ureteral patency whereby such a problem can be corrected—is
recommended.
Multiple sutures may increase the incidence of tissue devascularization
and necrosis, resulting in failure of the suspension. One case series of bilateral
single suture uterosacral suspensions demonstrated a 15% stage I and no stage II
recurrence among 71 women with a mean follow-up of 21.3 months (76).
Exposure can be accomplished through the vaginal cuff after hysterectomy, a
transverse incision at the vaginal cuff in cases of vaginal vault prolapse or
descent, and, rarely, through a posterior colpotomy when uterine or cervical
conservation is desired. When the apical vaginal wall is attenuated, it is excised.
The pelvic sidewall, lateral to the sigmoid colon, is exposed using Breisky–
Navratil retractors and a pack to hold the small bowel cephalad and to place the
sigmoid colon and sidewall peritoneum on stretch (Fig. 30-12A). After palpation
of the ischial spine, single permanent sutures of 0 or 1 polypropylene are placed
through the peritoneum and adjacent ligament approximately 1-cm cephalad to
and at the same posterior level as the ischial spines. Traction on the sutures and
palpation of the site should reveal that the sutures are firmly attached to the
ligamentous structures. The sutures are tagged for use after repair of defects of the
anterior compartment. The peritoneum is dissected off the vaginal fibromuscular
wall posterior to the vaginal cuff. The suspension sutures are secured with large
bites into the posterior vaginal fibromuscular tissue and anterior fibromuscular
tissue, then locked in place to approximate anterior to posterior connective tissue
and to fix the suture to the vaginal apex so that it may be moved up to the
ligament (Fig. 30-12B). For large vaginal cuffs a second suspension suture
(delayed absorbable can be used on each side and tied after the prolene sutures are
secured. If a rectovaginal enterocele is present, it is dissected, reduced, and
closed, approximating the prerectal fascia or anterior rectal wall to the posterior
fibromuscular vaginal tissue just caudad to the suspension sutures. Absorbable
cuff closure sutures can be placed at each cuff angle and one to two bites are
taken to approximate anterior to posterior vaginal cuff over the suspension suture
sites. When indicated, plication of the central cuff anterior to the posterior
fibromuscular tissue with a box stitch is performed. These sutures are secured
after the suspension sutures are tied, then cuff closure is completed from each side
with the absorbable sutures in a running fashion. The closure of the cuff hides the
knots of the suspension sutures. Cystoscopy is performed to document ureteral
patency. Ureteral compromise has been noted in only 2 of 150 cases performed.
The procedure provides adequate support of POP-Q point C and D in all 58
subjects evaluated more than 1-year postoperatively (76).
FIGURE 30-12 Diagrams illustrating open vaginal apical area with (A) exposure of site for suture placement or lateral pelvic side wall and (B) suture placement through ligament then through the posterior and anterior paravaginal tissue where they are locked to enable pulley action to the ligaments when tied. (Redrawn from an image by J. Taylor.)
The two most commonly performed transvaginal native tissue apical prolapse repairs are the sacrospinous ligament suspension and uterosacral ligament
suspension. A randomized controlled trial in 374 women with POPQ stage II to
IV comparing the two vaginal approaches, or the Operations and Pelvic Muscle
Training in the Management of Apical Support Loss (OPTIMAL) trial, showed
that there was no difference in a composite surgical success defined as the
absence of: (1) vaginal apical descent to more than one-third of the total vaginal
length; (2) anterior or posterior vaginal wall descent beyond the hymen; (3)
bothersome vaginal bulge symptoms; and (4) retreatment of prolapse. The 2-year
success rate was 59% versus 61% for uterosacral and sacrospinous ligament
suspension, respectively. The success rates decreased overtime to 44% and 33%
at 5 years after surgery (77,78).
1777The Anterior Compartment
Anterior Vaginal Colporrhaphy
Anatomic correction of an anterior defect or cystocele will generally relieve
symptoms of protrusion and pressure and usually will improve micturition
function when abnormal micturition is associated temporally with the defect
and if there is no associated neuropathy. If a single, well-defined midline
defect is recognized, excision of the weak vaginal wall and an imbricating closure
of the defect may be performed. Most central anterior defects require a more
extensive dissection of the vesicovaginal space. Following this dissection, many
surgeons separate the vaginal mucosa and submucosal layers from the
fibromuscular layer out to a point lateral to the defect, followed by midline
plication of this tissue, then excision of excess epithelium, and closure (79–84). It
appears important to maintain the continuum of repaired fibromuscular tissue to a
well-supported vaginal apex. If the repair is being performed simultaneously with
a vaginal apical suspension, the anterior colporrhaphy is typically performed after
the apical support sutures have been placed and prior to tying them down. The
dissection is carried out starting from the everted vaginal cuff edge and dissecting
toward the bladder neck. A high central defect may be corrected via a
transabdominal approach by dissecting between the base of the bladder and the
upper one-third of the anterior vaginal wall. The defective tissue may be wedged
out and the defect closed with running or interrupted sutures. This approach may
be of use when performing transabdominal procedures for apical suspension.
If the patient has significant stress incontinence (based on report or the
presence of occult or potential incontinence), an appropriate incontinence
procedure may be performed simultaneously with the anterior repair. When
performing midurethral sling procedures, it is not preferable to extend the
repair procedure distal to the bladder neck, but instead to make a separate
incision for the sling. If the patient has voiding dysfunction (reports of
incomplete emptying and a high-residual urine) and stress incontinence,
appropriate urodynamic evaluation should be performed before a procedure
is selected, and the patient should be made aware of the potential for
continued problems after surgery (84).
Recurrence rates of traditional “fibromuscular plication” anterior repairs vary
from 3% to 92%; however, studies define recurrence in numerous ways, from
minimal prolapse to stage III descent (79–85). The clinical significance of
recurrent mild cystoceles (stage I) that are asymptomatic is debatable because
many of these defects do not progress to larger ones. When traditional anterior
repairs are performed in patients with POP-Q stage II or greater cystoceles
(frequently concurrently with other procedures), a 20% recurrence rate of stage II
1778or greater prolapse is not uncommon, although overall recurrence rates as low as
3% have been reported (82). Many studies do not define how the participants
were evaluated postoperatively and vary with respect to patient populations, type
and severity of defects, presence of concurrent defects, surgical technique, and
follow-up time and length. Some studies have suggested higher recurrence rates
when these repairs are performed concurrently with sacrospinous suspensions and
hypothesize that this type of apical suspension may predispose the repaired
anterior wall to greater pressure transmission (86). These studies may show
higher failure rates because patients having such concurrent repairs may be more
likely to have more complicated forms of prolapse or more extensive pelvic floor
defects than other patients.
Paravaginal Repair
The paravaginal or “lateral defect” repair involves reattachment of the
anterior lateral vaginal sulcus to the obturator internus fascia and, in some
cases, muscle at the level of the arcus tendineus pelvis (“white line”). It is
usually performed as a bilateral procedure via transvaginal or retropubic
(abdominal or laparoscopic) access. The procedure essentially restores normal
anatomy; however, because it is not practical to rebuild the defective endopelvic–
fascial bridge to the pelvic sidewall, it attaches the vaginal wall. Observational
studies have reported good success with this procedure (80% to 95%); however,
long-term data on durability and function are lacking (15,87,88). Most women
with anteriolateral detachments usually have separation of the upper vaginal
fornices from the arcus tendineus immediately adjacent to the ischial spine (Fig.
30-13) (89). Thus, it is important to resuspend those specific areas.
It is difficult to achieve optimal results when the paravaginal repair is used in
combination with traditional central repairs because of the creation of tension on
opposing suture lines. A repair that removes a weakened central vaginal wall may
decrease the side-to-side dimensions of the anterior vaginal wall, making it
difficult to suspend its lateral points more laterally. When large central defects
coexist with lateral defects, one option is an extensive central repair accompanied
by an apical support procedure. This changes the shape of the vagina to a more
cylindrical structure. Another choice is placement of a graft to span the entire
anterior rhomboid-shaped plate, thus augmenting anterior paravaginal tissue
strength. The graft with tension adjusted may be anchored to the arcus tendineus
along with the adjacent vaginal wall from the level of the pubic rami to the ischial
spine (88).
Although most reports indicate that repair of anterior defects with all of these
procedures relieves symptoms directly related to prolapse, there are very few data
on patient satisfaction and quality-of-life improvement over time (88).
1779The Posterior Compartment
As with the anterior compartment, restoring apical compartment support
frequently corrects posterior compartment prolapse.
Traditional Posterior Colporrhaphy
The first description of the posterior colporrhaphy involved plication of the
pubococcygeus muscles across the anterior rectum and perineal body
reconstruction (90). The technique has subsequently been modified in attempts to
preserve sexual function. Typically, a midline incision is extended from the
perineal body to the vaginal apex or to the cephalad border of a small or distal
rectocele. The Denonvillier fascia is mobilized from the vaginal epithelium,
leaving as much of this tissue as possible attached laterally to the levator
fascia. After obvious defects in the rectal muscularis are repaired, the fascia
is plicated in the midline with interrupted or continuous sutures. The authors
prefer delayed absorbable sutures for this plication. Permanent nonbraided suture
material can be used. Braided permanent suture material is associated with a
greater incidence of stitch infection and formation of granulation tissue (91). The
vaginal epithelium is trimmed and closed with absorbable sutures.
When a defective perineal body or perineal membrane is present,
reconstruction is performed after accompanying posterior colporrhaphy. The
superficial muscles of the perineum and bulbocavernous fascia are plicated in the
midline and the skin closed as in an episiotomy repair. Detachments of the
inferior portion of the Denonvillier fascia from the perineal body are corrected.
The puborectalis muscles are plicated concurrently with these procedures by some
surgeons, but this approach is associated with a high incidence of sexual
dysfunction and thus is not recommended routinely (91). It may be worth
consideration in patients who have severe prolapse accompanied by a large
genital hiatus with palpable levator weakness or who are unable to contract their
pelvic floor muscles. Sutures should be placed carefully through the puborectalis
muscles at least 3 cm or greater posterior to their insertion on the pubic rami,
thereby decreasing the tension of the plication. For those women with an enlarged
hiatus and weakened puborectalis muscles who desire sexual function, an attempt
can be made to plicate the muscles far enough posteriorly to allow two fingers to
easily pass through the vaginal introitus and to reconstruct the distal posterior
vagina and perineum, whereby there will not be a ledge at the site of the
puborectalis plication (91). Outcome data on such procedures are inadequate to
make conclusions regarding its efficacy; however, it is reasonable to postulate
that pelvic floor defects producing an enlarged genital hiatus are common reasons
for failure of support procedures, and puborectalis plication may decrease the
incidence of such failures.
FIGURE 30-13 Schematics illustrating normal attachments of the anterior fibromuscular vaginal plane (A and C) and bilateral detachments of that plane from the arcus tendineus up to the level of the ischial spines (B and D). Note: For B and D to occur, there will either be concurrent apical descent or a detachment of the upper fibromuscular plane from the apical structures. (From Delancey JO. Fascial and muscular abnormalities in women with urethral hypermobility and anterior vaginal wall prolapse. Am J Obstet Gynecol 2002;187:93–98, with permission.)
A complete review of rectocele, anorectal functional disorders, and various
repairs can be found elsewhere (92). Reported anatomic cure rates for traditional
posterior colporrhaphy have ranged from 76% to 90% with variable follow-up
intervals (93–96). Most studies show a benefit in ease of defecation if patients are
using splinting preoperatively; however, overall defecatory dysfunction (defined
as constipation) was not relieved in most patients and increased (approximately
30%) after the procedure in one study (94). These repairs appear to have little to
no benefit in the treatment of fecal incontinence. It is not surprising that the
1781repairs are not particularly effective for defecatory dysfunction related to
disorders of constipation or for fecal incontinence because these problems have
multifactorial causes. De novo dyspareunia is reported to occur in 8% to 26%
of sexually active patients who have traditional posterior colporrhaphy and is
not always associated with levator plication procedures (94,95,97). Potential
causes for dyspareunia, other than vaginal strictures or introital tightness, include
scarring with immobility of the vaginal wall, levator spasm, and neuralgia
associated with sutures or dissection. Dyspareunia may occur when a Burch
procedure or other procedures that anteriorly displace the vaginal canal are
combined with a posterior repair (95). Careful surgical technique and appropriate
choice of procedure should decrease the incidence of postoperative dyspareunia.
Defect-Specific Posterior Repair
Defect- or site-specific posterior repairs are restorative procedures by which
posterior defects are corrected. These repairs begin with midline posterior vaginal
incision through the epithelium and continue with separation of the epithelium
from the fibromuscular wall. After irrigation to provide better exposure, a finger
is inserted into the rectum to help define defects of the rectal wall and the
fibromuscular layer that has been dissected from the vaginal wall submucosa. The
specific defects are closed with either interrupted or running sutures (preferably
the delayed absorbable type). Defect closure is accomplished in such a way as to
minimize tension on the surrounding tissue and may involve vertical, horizontal,
or oblique approximation. When fibromuscular tissue has separated from the
perineum, the upper anterior rectum, or a well-supported cervix or vaginal cuff, it
is important to reapproximate these connections. Repairs of coexistent perineal
and apical support defects are important. The object of the surgery is to
reestablish an intact plane of connective tissue that positions the rectum
against the pelvic floor and obliterates any potential space between a wellsupported cervix or vaginal cuff and the cephalad edge of the tissue plane
and upper rectum. The technique should minimize tension and potential
strictures, which may be more likely to occur with traditional posterior
colporrhaphy (96).
Initial case series reveal anatomical cure rates with mean follow-up times less
than 18 months from 82% to 100% and de novo dyspareunia rates of 2% to 7%,
which are much lower than those seen with traditional repairs (97–100). Symptom
relief appears to be as good as that seen with traditional repairs. The greatest
concern with these and other procedures has been durability. A recent report
indicates that the recurrence rate of rectocele beyond the midvaginal plane was
higher with defect-specific posterior repairs than with side-to-side plication
procedures using laterally attached fascia pulled to the midline (33% vs. 14%) and
1782beyond the hymenal ring (11% vs. 4%) (96). The study was not randomized;
however, the procedures were performed during the same period with consistent
follow-up evaluations 1 year after surgery. Symptoms (dyspareunia, constipation,
and fecal incontinence) after surgery did not differ between the two groups. Longterm follow-up of previously reported case series that had good short-term
success or prospective randomized trials looking at modifications of traditional
repairs versus defect-specific repairs should clearly delineate durability of these
procedures.
Transanal Posterior Repair
The aim of transanal rectocele repair, usually performed by colorectal surgeons
rather than gynecologists, is to remove or plicate redundant rectal mucosa, to
decrease the size of the rectal vault, and to plicate the rectal muscularis. The
rectovaginal adventitia and septum are plicated as well, probably along with the
posterior vaginal muscularis. The vaginal epithelium is not incised or excised
with this procedure, which probably accounts for the reported lack of adverse
effects on sexual function in contrast to the vaginal approach to posterior repair.
Complications included infections and rectovaginal fistulas, which are rare.
Transanal posterior repair should be considered mainly for defecatory dysfunction
and not for prolapse of the posterior vaginal wall. The literature, including three
randomized controlled trials, suggests that a vaginal approach is more effective
than a transanal approach. The failure rate was 10% versus 42% (relative risk
0.24, 95% CI, 0.09–0.64). In addition, the vaginal approach resulted in superior
anatomic results. The risk of de novo dyspareunia was similar in both approaches
(101).
Transvaginal Mesh Procedures
Transvaginal mesh procedures use “bridging material to reinforce native
structures” (102). The patient’s own connective tissue may grow into the graft,
and, if the graft is degradable, replace the graft as a supportive structure. An ideal
graft material should be: (i) nonantigenic; (2) exhibit a low infection rate; (3)
decrease or negate recurrence of anatomic defects; (4) cause no harm with respect
to bowel or renal function; and (5) be relatively inexpensive. Graft materials
include autologous tissues, cadaveric allografts and fascia, dermis and other
connective tissues, xenografts from animal sources, and various synthetic
materials. Allografts and xenografts are treated with processes to remove living
cells, thus negating their antigenic potential and allowing them to serve as a
temporary connective tissue scaffold. It is assumed that fresh, autologous grafts
work similarly; however, there may be some fibroblast survival in fresh harvested
tissue. Autologous grafts have limitations in size and shape compared with tissue
1783taken from cadaveric or animal sources. Synthetic grafts are permanent and, as
long as the tissues to which they are secured retain their position and strength,
they should be durable. Autografts, allografts, and xenografts depend on
adequate tissue growth from the subject and may have higher failure rates
than synthetic ones. Synthetic grafts are more subject to exposure and
erosion. Graft exposure/erosion may produce bothersome discharge, pain,
and sexual dysfunction with vaginal scarring. Monofilament and large pore
size grafts (type 1) are the only synthetic-type mesh available in the United
States (103–110). In addition to exposure and erosion, other mesh-related
complications can result from a potential injury to pelvic structures during
mesh augmentation surgeries. Pelvic pain, a potential complication of mesh
placement, can be related to mesh exposure or erosion. Given the unique
complication related to synthetic mesh, POP surgery using synthetic graft
should be limited to high-risk patients when the benefit of vaginal mesh
augmentation is greater than the risks involved. The high-risk population includes
women with recurrent prolapse (anterior or apical) or poor candidates for
prolonged, more invasive, surgery, such as abdominal and laparoscopic
approaches (111).
Midurethral sling procedures that use such mesh have reported exposure
rates of 1% to 2%; however, a wider range of exposure rates (2% to 19%)
have been reported with synthetic mesh augmentation for POP repair (106–
110,112). Level I data regarding the consensus on treatment approaches for mesh
exposure are lacking. Thus, management guidelines are based on expert opinion,
clinical experience, and data from observational studies. The treatment should be
tailored based on the individual’s symptoms and examination findings.
Asymptomatic exposures of type 1 meshes can be managed expectantly with
close observation. If the exposure is small, typically less than 5 mm, a trial of
vaginal estrogen is reasonable, typically 6 to 12 weeks. In case of a large mesh
exposure, having persistent symptoms, such as vaginal bleeding, discharge,
infections, or protracted pain, mesh revision/removal should be considered. A
multicenter trial reported that 60% of women with mesh complications after POP
surgery required at least two interventions; nearly half of these women underwent
surgery as the first intervention (113). As pain after mesh augmentation is
typically multifactorial, it often requires multidisciplinary approach including
conservative management with pelvic floor physical therapy, trigger-point
injections, and/or medications. Surgical management for pain after mesh
augmentation can alleviate symptoms. Prior to surgery, the goals and expectations
of surgery should be discussed with the patients as pain may persist after mesh
removal.
An exposed polypropylene graft may be removed with the surrounding tissue
1784to the point where there is good tissue growth into the graft, and the defect can be
closed. Graft erosion into the bladder, urethra, or rectum is less common than into
the vagina. When erosion occurs, management is more difficult and long-term
adverse effects more common. Numerous surgeons have been reticent to use
synthetic graft materials to augment paravaginal fibromuscular connective tissue
support because of complications from erosion. There remains a need for longterm follow-up on patients who have repairs with graft material, to assess
anatomical results and complications, including subsequent sexual function,
presence and absence of pain, and patient satisfaction. A Cochrane Review noted
that low-to-moderate–quality evidence reflects advantages of using transvaginal
permanent mesh compared to native tissue repair, including lower awareness of
prolapse, repeat surgery for prolapse, and objective prolapse recurrence.
However, there are risks of repeat surgery for mesh exposure (114). The U.S.
Food and Drug Administration (FDA) has issued two final orders on surgical
mesh for transvaginal POP repair (January 2016), including the reclassification of
the synthetic mesh from class II to class III (“high-risk” devices) and requiring
manufacturers to submit a premarket approval (PMA) application to support the
safety and efficacy of surgical mesh for transvaginal POP repair. It is important to
make the distinction between synthetic meshes for transvaginal prolapse surgery
and midurethral slings for SUI as the latter (full-length midurethral sling) remain
class II devices and do not require a PMA (115). The American Urogynecologic
Society released guidelines for transvaginal and abdominal placement of surgical
mesh for POP. These guidelines emphasize the importance of informed consent
including potential benefits and complications of the approach (unique
complications related to mesh placement), alternative options, including
nonsurgical, and specialized training to acquire surgical skills ensuring patient
safety and the ability to recognize and manage intraoperative and postoperative
complications (116,117).
In summary, transvaginal mesh procedures utilize predominantly
synthetic polypropylene mesh. This material may reduce recurrence of POP
and is associated with some risk of vaginal mesh extrusion and chronic pain
or dyspareunia. Patients should be counseled extensively about the risks and
benefits of the use of mesh augmentation. Surgeons who use synthetic mesh
should carefully follow their patients to identify complications.
Abdominal Procedures
Abdominal Uterosacral Suspension
Abdominal uterosacral colposuspension has been used prophylactically after
hysterectomy and therapeutically for apical prolapse with
1785cardinal/uterosacral defects (118). It can be performed through laparotomy
incisions or by laparoscopic techniques. For the therapeutic procedure, a no. 1
polypropylene or delayed absorbable suture is placed cephalad and at the same
level posterior as the ischial spines, which may be palpated transabdominally or
with a vaginal finger to push a vaginal fornix to the spine under observation with
a laparoscope. One technique is to place one or two permanent sutures through
one ligament, then, after reefing across the cul-de-sac peritoneum at the sigmoid
border, through the contralateral ligament, and through the fibromuscular tissue
just anterior to the vaginal cuff. Tying the suture suspends the vaginal cuff and
obliterates any enterocele defect. Another technique employs separate sutures
placed at the same level into each uterosacral ligament and anchored anteriorly
and posteriorly to the ipsilateral side of the vaginal cuff, similar to procedures
performed transvaginally. Cystoscopy is performed after the procedure to
document ureteral patency. One study found subjective and objective recurrence
rates to be low (12% and 5%, respectively) (118).
Abdominal Approach to Posterior Repair
When abdominal sacrocolpopexy is planned for apical vaginal prolapse and
concomitant rectocele is present, some have advocated extending the
posterior graft down the posterior vaginal wall to correct the defect. The
technique of sacral colpoperineopexy is used to replace the normal vaginal
suspensory ligaments and to augment or replace the posterior fibromuscular plane
with graft material that runs from the sacrum to the perineal body (119). Its
purpose is to correct the posterior compartment defects and to suspend the
perineal body, thus preventing descent and opening of the genital hiatus.
Laparoscopic Approach to Posterior Repair
Laparoscopic rectocele repair involves the dissection of the rectovaginal space to
the perineal body with either plication of levator fascia or suturing absorbable or
permanent mesh in place (120). A few small case series have been reported with
variable results.
Abdominal Sacrocolpopexy
These procedures use graft material attached to the prolapsed region of the
anterior and posterior vaginal walls at or encompassing the vaginal apex and
suspended to the anterior longitudinal ligament of the sacrum. Cervical sacral
suspensions may be performed when uterine or cervical conservation is desired.
Surgical variations abound and include configuration of the graft on the vagina,
the extent to which the anterior and posterior vagina are attached to the graft,
variable graft and suture materials, presence or absence of peritoneal closure over
1786the graft, and obliteration of the cul-de-sac for treatment or prevention of the
enterocele or sigmoidocele. A thorough preoperative evaluation is important
to exclude more distal defects or stress incontinence, which should be
repaired concurrently, and other lower urinary tract or anorectal problems.
In published reports, cure rates for apical prolapse range from 78% to 100% (most
greater than 90%); when cure is defined as no postoperative prolapse, the range
widens from 56% to 100%, although subsequent anterior or posterior vaginal
prolapse has not been as consistently reported as has apical prolapse (121–123).
Potential advantages of this procedure over transvaginal procedures are less
paravaginal scarring and denervation than may be present with transvaginal
approaches, and fixation of the entire vaginal apical area by a permanent piece of
material to a stable structure (the anterior sacral ligament), which may be more
durable than transvaginal techniques that use the patient’s own connective tissue.
Long-term outcomes of abdominal sacrocolpopexy with or without concomitant
urethropexy have been described and are notable. Estimated probabilities of
treatment failures for anatomic POP were 0.27 and 0.22 for the urethropexy and
no urethropexy groups (treatment differences, 0.05, 95% CI, –0.161 to 0.271).
Mesh erosion probability at 7 years was 10.5% (95% CI, 6.8, 16.1) (124).
Complications of these procedures include: (1) erosions of graft material or
suture material, which may be caused by graft or suture infection usually
secondary to vaginal wall penetration, or performing the procedure adjacent to a
vaginal incision, or securing the graft to an attenuated avascular wall with
inadequate fibromuscular tissue (3.4%); (2) significant intraoperative hemorrhage
(especially in the presacral space) (4.8%); (3) postoperative ileus, which may be
secondary to the need for excessive packing of the bowel or to extensive Halban
or Moschcowitz culdoplasty procedures (3.6%); (4) small bowel obstruction,
requiring reoperation (1.1%); (5) development of intra-abdominal adhesions with
resultant pain and bowel dysfunction (unknown incidence); and (6) wound
complications, such as seromas and infections (4.6%) (120).
Several management techniques have been advocated to minimize these
problems. Empiric ways to prevent graft erosions include: (1) preoperative tissue
optimization with vaginal administration of estrogen and treatment of vaginitis
and infection of eroded areas; (2) the use of small-gauge monofilament sutures
placed in the fibromuscular tissue, thus avoiding full-thickness passage; and (3)
excision of a portion of the vaginal apex when the vaginal wall is thin and
depleted of its fibromuscular layer and vascularity. Graft attachment to “healthy”
fibromuscular tissue rather than to thin avascular tissue should help prevent
erosion. If such excision is necessary, or if the suspension is to be performed
concurrently with a hysterectomy, good approximation of the fibromuscular
layers above the mucosa, thorough irrigation, prophylactic use of antibiotics,
1787and avoidance of graft placement across the suture line may decrease the
likelihood of graft erosion. Choice of graft material may be important. One
would expect synthetic grafts to have greater durability than tissue grafts;
however, erosion rates are more serious with the synthetic grafts. Less porous
graft material, such as GORE-TEX, has a greater likelihood of becoming infected
and eroding than do macroporous, filamentous polypropylene meshes. Numerous
case series report serious episodes of hemorrhage from the presacral venous
plexus (mean incidence 4.8%; range 0.18% to 16.9% of sacrocolpopexies
requiring, at a minimum, transfusion) (121). This problem is less likely if
dissection and graft fixation is limited to the level of S1 and S2 just caudad to the
promontory and with the use of good light and meticulous dissection techniques
to expose the anterior sacral ligament.
Careful tissue handling and packing technique may minimize
postoperative ileus and adhesions. Incorporation of the sigmoid into a
closure of the cul-de-sac posterior to the graft may slow bowel function
postoperatively. Small bowel obstruction has resulted from direct adhesive
processes involving grafts to small bowel (120). Complete
extraperitonealization of the graft using flaps of peritoneum dissected from the
prolapsed area and the peritoneum anterior to the sacral promontory and lateral to
the right side of the sigmoid colon should prevent this complication. However,
loops of bowel have been seen to prolapse through small defects in peritoneal
closure with the same effect. Careful technique with adherence to basic surgical
principles may help prevent this and other complications related to laparotomy.
Laparoscopic and Robotic Techniques
As with most pelvic operations, sacrocolpopexy has been successfully
accomplished by the laparoscopic and robotic route and has the potential to
offer patients the benefits of less postoperative discomfort, faster recovery
and potentially lower risks for adhesions and ileus. Outcomes depend on the
expertise and experience of the surgeon; “cutting corners” to shorten the
procedure could affect anatomical success. The applicability of the laparoscopic
technique is limited by the need for a relatively high level of technical skill. The
authors have found that straight self-righting–needle drivers and nonself-righting–
curved needle drivers are useful in attaching the mesh to the vagina. The Carter–
Thompson suturing device is sometimes helpful to aid in elevating the sigmoid
colon away from the pelvic cul-de-sac by tagging the peritoneal edge. The robot
has provided an easier platform for a minimally invasive approach to the
sacrocolpopexy. It has been noted that clinical outcomes of prolapse repair are
similar with robotic-assisted laparoscopic sacrocolpopexy versus laparoscopic
alone however the robotic approach may be less efficient with respect to cost
1788(125,126). For sacrocolpopexy, whether through laparotomy or laparoscopy,
the pelvis should be completely exposed with the lower sigmoid colon
stretched cephalad (Fig. 30-14).
1. With a vaginal obturator (an EEA sizer) placed vaginally to visualize the area
that is not covered by the bladder or rectum, the peritoneum is dissected from
the underlying vaginal fibromuscular layer anteriorly to bladder reflection and
posteriorly at least to the level of the sigmoid rectal junction, creating bilateral
peritoneal flaps. Laterally, vascular bundles are visible.
2. Two separate loosely woven polypropylene mesh grafts are shaped similar to
boat paddles. Alternatively, a prefabricated “Y-shaped” mesh graft may be
used. The “paddle” portions are shaped to cover the areas anterior to the apex
and posterior to the apex, respectively, and the long sacral tail (or “handles” if
using 2 separate grafts) is anchored to the anterior sacral ligament. The paddle
portions are affixed circumferentially to the anterior and posterior vaginal
fibromuscular layers with six to eight monofilament sutures and one or two
sutures placed centrally (Fig. 30-14A).
3. When the fibromuscular tissue in the area is attenuated, a portion of the
vaginal wall is excised and closed. The graft should not be attached to the
closure line.
4. The peritoneum overlying the sacral promontory is incised while retracting the
sigmoid colon to the left. Careful dissection is employed to expose the anterior
longitudinal ligament. Care is taken to stay medial to the right ureter and
hypogastric vessels. Hemoclips are placed caudad and cephalad on the middle
sacral vessels if it is felt that this will allow more optimal suture placement.
The peritoneal incision is extended into the cul-de-sac area to the right to the
sigmoid aimed at the posterior vagina.
5. Closure of the cul-de-sac lateral to the sigmoid on the left and approximation
of the distal presigmoid fat to the distal edge of the posterior graft is
accomplished with box stitches of 0-delayed absorbable sutures. It is thought
that these procedures and the retroperitonealization of the graft through the
right side of the cul-de-sac will prevent posterior enterocele and sigmoidocele
as well as a Halban or Moschcowitz procedure.
6. The two “handle” ends of the graft are then brought to the point of sacral
attachment, where their length is adjusted to remove any tension on the
vaginal sutures and secured to the anterior longitudinal ligament with 2 to 3
monofilament sutures (Fig. 30-14B).
7. Reperitonealization of the graft is performed using the right cul-de-sac
peritoneum and peritoneal flaps dissected from the vaginal apical area.
1789Following this procedure, adjunctive procedures, such as paravaginal repair,
Burch procedure, midurethral sling, and any transvaginal procedure that is
indicated, are performed. When rectocele and pelvic floor defects are present, one
option is the sacral colpoperineopexy, as discussed in the posterior compartment
section. A vaginal pack is inserted to ensure that the graft is well applied to the
fibromuscular layer at points other than where sutures are placed.
Vaginal Obliterative Procedures
Colpocleisis or vaginal narrowing procedures may be appropriate choices for debilitated patients who do not desire vaginal function, because complete vaginal reconstructive procedures take longer and are associated with potentially higher blood loss and increased morbidity. Obliterative surgery does not appear to alter body image, and regret after the procedure is rare (127,128).
Many variations exist, from partial colpocleisis (where some portion of the vaginal epithelium is left to provide drainage tracts for cervical or upper genital discharge) to total colpectomy (where all of the vaginal epithelium is removed from the hymen posteriorly to within 0.5 to 2 cm of the external urethral meatus anteriorly). If hysterectomy is performed, blood loss is greater and operative time is longer than procedures without hysterectomy (129).
These techniques should include a high perineorrhaphy and often a plication of the puborectalis muscles to reinforce posterior support and to reduce the genital hiatus, with the goal of decreasing the chance of recurrent prolapse. Case series have reported success rates as high as 100%, although the population of patients, by nature of their relatively short-life expectancy and limited activity, are probably at lower risk for recurrence. In some instances, in which most of the defects are anterior and posterior, a modified anterior and posterior colporrhaphy may be performed, whereby relatively large portions of the anterior and posterior vaginal wall are removed and closed, creating a narrow (1 to 2 cm diameter) cylindrical vagina. As with the colpocleisis, the success of the procedure is augmented by an extensive perineorrhaphy and puborectalis plication. Such a procedure may be performed quickly and with relatively low morbidity. The prevention or treatment of stress incontinence, voiding dysfunction, and colorectal dysfunction in the context of these procedures can be problematic. Careful preoperative history and evaluation, if indicated, is important so that additional conservative therapies or operative techniques such as midurethral slings may be employed.
Management of Urinary Symptoms With Pelvic Organ Prolapse Repair
All women who are undergoing surgery for repair of POP should be evaluated for urinary incontinence. Women who report SUI and who demonstrate it on preoperative examination and have no contraindications to a continence procedure should have concomitant procedures for the treatment of these symptoms. The management for women with symptomatic prolapse but without symptoms of SUI is challenging, especially those with advanced prolapse. Surgeons often perform a reduction stress test to finalize the surgical plan. The literature supports a continence procedure at the time of surgery regardless of preoperative prolapse reduction stress test (the “universal” approach) for women with stage II to IV prolapse undergoing abdominal sacrocolpopexy as reported in the Colpopexy and Urinary Reduction Efforts (CARE) trial (130). The best approach for the management is more controversial in women undergoing vaginal prolapse surgery without SUI symptoms. A randomized controlled trial, the Outcomes Following Vaginal Prolapse Repair and Midurethral Sling (OPUS) trial, showed similar outcomes to the CARE trial, where the rates of de novo SUI were lower in women having a concomitant midurethral sling procedure. However, the sling group had higher rates of complications including bladder perforation, UTI, bleeding, and transient postoperative voiding dysfunction. The rate of de novo SUI was higher in women with occult SUI demonstrated on preoperative reduction stress test (131). Based on these data, surgeons often prefer a selective approach, where a concomitant continence procedure is suggested if occult SUI is detected on reduction stress test.
Comparison of Abdominal Versus Vaginal Approaches
There has been controversy as to whether transvaginal or transabdominal procedures are better for prolapse. One should not discern which is optimal from reports of retrospective and prospective case series because of the considerable differences in numerous factors, including follow-up, characteristics of the subjects, definitions of success and failure, and the expertise or experience of the surgeons performing the procedures.
A recent meta-analysis comparing abdominal sacrocolpopexy to transvaginal apical repairs, mostly sacrospinous ligament fixation, concluded that sacrocolpopexy is likely to result in lower rates of “bulge” symptoms and recurrent prolapse. However, the quality of evidence included in the analysis ranged from low to moderate (132). The abdominal approach resulted in longer procedure times and greater delay in resumption of activities, higher-associated costs. Although rare, the intraperitoneal access can result in potential serious adverse events including bowel injury and sacral osteomyelitis. Transvaginal surgery is the most commonly performed approach for POP repairs in the United States, given the minimally invasive nature of the surgery, and the ability to address all three vaginal components more efficiently than with an abdominal approach. Native tissue vaginal surgery eliminates the risk of mesh-related complications associated with abdominal support procedures, which is important in women at higher risk of mesh exposure or erosion.
Older, less healthy individuals who are more likely to have surgical and medical complications and cannot or will not tolerate a pessary would derive greater benefit from transvaginal approaches and as indicated, obliterative approaches, and relatively healthy, sexually active women with relatively short vaginas and apical prolapse would derive greater benefit from sacrocolpopexy. For the remainder of the patients with apical prolapse, with or without more distal defects, most surgeons choose the approach based on the individual’s skills, training, and past experience. High-quality long-term data are urgently needed to better understand and compare the efficacy of each approach. A three-arm randomized controlled trial of three apical suspension approaches in women with posthysterectomy vaginal vault prolapse is being performed comparing sacrocolpopexy, transvaginal mesh augmentation repair, and native tissue apical repair (ASPIRe trial; NCT02676973).
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