Chapter 34: Apical Procedures

APICAL PROCEDURES

Introduction and Indications

Restoring apical support is increasingly recognized as an essential component of any surgical procedure for pelvic organ prolapse. Although the anterior vaginal wall is the most common clinically recognized site of prolapse,¹ recent clinical and radiographic studies have demonstrated that support of the vaginal apex plays a critical role in anterior wall support.^2-5

Surgeries for correction of apical prolapse generally involve a vaginal or an abdominal route, or a combination of these methods. The surgical approach is often chosen based on prolapse severity, risks of recurrence, surgeon comfort, patient preference, and surgical goals.⁶

ABDOMINAL SACROCOLPOPEXY

Abdominal sacrocolpopexy (ASC) is considered by many to be the “gold standard” procedure for apical prolapse repair and can be performed via laparotomy, conventional laparoscopy, and with robotic assistance. Most commonly a synthetic graft is used to augment native tissues and suspend the vaginal vault to the sacrum. Success rates of 78% to 100% have been reported,^7,8 and optimal results depend on a number of factors including patient characteristics, graft properties, and surgical technique.^8-11

Graft dimensions are not standardized and surgeons often tailor the graft based on patient anatomy and prolapse severity. Many different graft configurations have been described, including folded grafts, Y-shaped grafts, and separate strips of mesh with varying extension down the anterior and posterior vaginal walls.⁸ Of these, separate strips of mesh are commonly used to reduce the amount of foreign body at the vaginal apex.¹² A broad vaginal attachment is also typically employed to reduce failures.^13,14 The distal extent of attachment of the anterior and posterior strips of mesh is often guided by the extent of anterior and posterior vaginal wall prolapse noted on preoperative evaluation. A sacrocolpoperineopexy is a variation of the ASC where the posterior strip is attached to the posterior vaginal wall down to the perineal body.

Preoperative

Patient Evaluation

All patients should have a routine history and physical examination, including POP-Q examination. Since significant apical descent is frequently present with both anterior and posterior wall prolapse,⁵ the relative contribution of each compartment should be evaluated with simulated apical support to determine the need for concomitant procedures.³ A stress test, with and without prolapse reduction, and complex urodynamic testing can help determine suitable patients for additional anti-incontinence procedures. Preoperative estrogen may increase vaginal wall thickness and facilitate the procedure, but no randomized controlled trials exist evaluating the efficacy of this treatment.

Consent

Patients must be counseled on the operative risks of transfusion from presacral space hemorrhage, and potential injury to the urinary and gastrointestinal tracts. Upper and lower extremity neuropathies may result from retractor and patient positioning, especially during ...