In preparing for prolapse surgery, the patient should have an understanding of the expected results, and the surgeon should have an understanding of the patient’s expectations. Treatment success varies widely based on the definition of success. Thus, the surgeon and the patient must agree on the desired results. Generally, patients seek relief of symptoms, whereas surgeons may view surgical success as restoration of anatomy. In the CARE trial, absence of vaginal bulge symptoms had the strongest relationship to a patient’s assessment of overall improvement and surgical success, whereas anatomic success alone did not (Barber, 2009). It is therefore recommended that surgical success be defined as absence of bulge symptoms in addition to anatomic criteria.
The two categories of prolapse surgery are obliterative and reconstructive. Obliterative approaches include Lefort colpocleisis and complete colpocleisis (Chap. 45). These can be performed for women with posthysterectomy prolapse or those retaining a uterus. These procedures involve removing vaginal epithelium, suturing anterior and posterior vaginal walls together, obliterating the vaginal vault, and effectively closing the vagina. Obliterative procedures are only appropriate for elderly or medically compromised patients who have no desire for future coital activity.
Obliterative procedures are technically easier, require less operative time, and offer superior success rates compared with reconstructive procedures. Success rates for colpocleisis range from 91 to 100 percent, although the quality of evidence-based studies supporting these rates is poor (FitzGerald, 2006). After colpocleisis, fewer than 10 percent of patients express regret, often due to loss of coital activity (FitzGerald, 2006; Wheeler, 2005). Thus, the consenting process must include an honest and thoughtful discussion with the patient and her partner regarding future sexual intercourse. Latent SUI can be unmasked with colpocleisis due to resulting downward traction on the urethra. However, the morbidity of a concurrent antiincontinence procedure may outweigh the potential incontinence risk and is considered before adding surgeries in women who may already be medically compromised.
In patients who still have a uterus, vaginal hysterectomy may be performed prior to colpocleisis. However, concurrent hysterectomy increases blood loss and operative time. Again, in compromised patients, this can counteract some of the major benefits of colpocleisis. If retention of the uterus at time of colpocleisis is planned, neoplasia is excluded preoperatively. For this, Pap testing for cervical neoplasia should be current. For endometrial neoplasia, endometrial sampling and/or sonographic interrogation of endometrial stripe thickness is performed.
These surgeries attempt to restore normal pelvic anatomy and are more commonly performed for POP than obliterative procedures. Vaginal, abdominal, laparoscopic, and robotic routes may be used, and in the United States, a vaginal approach is preferred by most for prolapse repairs (Boyles, 2003; Brown, 2002).
Approach selection is individualized and factors the patient’s unique characteristics and surgeon’s expertise. An abdominal approach may be advantageous for women with prolapse recurrence following a vaginal approach, those with a shortened vagina, or those believed to be at higher risk for recurrence, such as young women with severe prolapse (Benson, 1996; Maher, 2004). In contrast, a vaginal approach typically offers shorter operative time and a quicker return to daily activities. Laparoscopic and robotic approaches may offer smaller incisions, decreased hospital stay, and quicker short-term recovery compared with abdominal approaches.
Of these, laparoscopic and robotic approaches to prolapse repair are becoming more common. Procedures include sacrocolpopexy, paravaginal repair, and vaginal vault suspension to the uterosacral ligaments. One randomized trial in the United Kingdom compared open and laparoscopic sacrocolpopexy and found similar anatomic and subjective outcomes after 1 year (Freeman, 2013). Perceived advantages to the laparoscopic approach such as earlier return to usual activities were not seen. Several small RCTs have compared laparoscopic and robotic sacrocolpopexy (Anger, 2014; Paraiso, 2011). In general, these studies have found similar short-term outcomes but increased cost with the robotic approach.
The prolapse surgeon should be versatile. Procedure route selection is individualized, and compelling evidence does not support one approach as superior to another. Adoption of new surgical techniques should be driven by patient motives, as determined by evidence-based medicine (American College of Obstetricians and Gynecologists, 2015).
Reconstructive prolapse repair will often involve a combination of procedures in several vaginal compartments. However, the decision regarding which compartments to repair is not always straightforward. In the past, a defect-directed approach to prolapse repair was preferred. With this strategy, all current, latent, or potential defects are evaluated and repaired. However, current expert opinion suggests that asymptomatic areas of prolapse do not always warrant repair, and correction can lead to de novo symptoms in some cases. For instance, repair of an asymptomatic posterior wall prolapse may lead to dyspareunia. Thus, surgery in general is planned to relieve current prolapse symptoms.
Many procedures for anterior vaginal wall prolapse repair have been described. Historically, anterior colporrhaphy has been the most common operation, yet long-term anatomic success rates are poor. In a randomized trial of three anterior colporrhaphy techniques, Weber and associates (2001b) found a low rate of anatomic success. Specifically, satisfactory anatomic results were obtained in only 30 percent of their traditional midline plication group, 46 percent of the ultralateral repair group, and 42 percent of the group undergoing traditional plication plus lateral reinforcement with synthetic mesh. These differences were not statistically significant. Despite anatomic results that may appear suboptimal, symptom relief from anterior colporrhaphy may be acceptable. One reanalysis of data from this trial instead used clinically relevant definitions of surgical success that included no prolapse beyond the hymen, lack of prolapse symptoms, and no retreatment requested. With these, 88 percent of subjects met the definition of success (Chmielewski, 2011). Thus, if a central or midline defect is suspected, anterior colporrhaphy may be performed (Chap. 45).
Mesh or biomaterial may also be used in conjunction with anterior colporrhaphy or by itself. Mesh is used to reinforce the vaginal wall and is sutured in place laterally. However, the use of mesh and mesh kits for anterior vaginal wall prolapse remains controversial (American College of Obstetricians and Gynecologists, 2013b). Although recent studies show improved anatomic success when mesh is used for anterior wall repair, there are significant risks. These include mesh erosion, pain, and dyspareunia and are discussed on page 556 (Sung, 2008).
In many cases, anterior vaginal wall prolapse results from fibromuscular defects at the anterior apical segment or transverse detachment of the anterior apical segment from the vaginal apex. In these situations, an apical suspension procedure such as an abdominal sacrocolpopexy or uterosacral ligament vaginal vault suspension will resuspend the anterior vaginal wall to the apex and reduce anterior wall prolapse. With these procedures, continuity is also reestablished between the anterior and posterior vaginal fibromuscular layers to prevent enterocele formation.
Alternatively, if a lateral defect is suspected, paravaginal repair can be performed through a vaginal, abdominal, or laparoscopic route (Chap. 45). Paravaginal repair is performed by reattaching the fibromuscular layer of the vaginal wall to the arcus tendineus fascia pelvis.
Support of the vaginal apex is thought by many to be an essential cornerstone of a successful prolapse repair (Brubaker, 2005a). The vaginal apex can be resuspended with several procedures that include abdominal sacrocolpopexy, sacrospinous ligament fixation, or uterosacral ligament vaginal vault suspension. These are all illustrated in Chapter 45.
Of these, abdominal sacrocolpopexy suspends the vaginal vault to the sacrum using synthetic mesh. Advantages include the procedure’s durability over time and conservation of normal vaginal anatomy. For example, compared with other vault suspension procedures, sacrocolpopexy offers greater vaginal apex mobility and avoids vaginal shortening. In addition, sacrocolpopexy provides enduring correction of apical prolapse, and long-term success rates approximate 90 percent. This procedure may be used primarily or as a second surgery for women with recurrences after failure of other prolapse repairs. Sacrocolpopexy may be performed as selected an abdominal, laparoscopic, or robotic procedure. When hysterectomy is performed in conjunction with sacrocolpopexy, consideration is given to performing a supracervical rather than a total abdominal hysterectomy. With the cervix left in situ, the risk of postoperative mesh erosion at the vaginal apex is believed to be diminished (McDermott, 2009). In this case, the mesh is not exposed to vaginal bacteria, which occurs when the vagina is opened with total hysterectomy (Griffis, 2006). In addition, the strong connective tissue of the cervix allows for an additional anchoring point for the permanent mesh.
Another option, sacrospinous ligament fixation (SSLF), is one of the most popular procedures for apical suspension. The vaginal apex is suspended to the sacrospinous ligament unilaterally or bilaterally using a vaginal extraperitoneal approach. After SSLF, recurrent apical prolapse is uncommon. However, anterior vaginal wall prolapse develops postoperatively in 6 to 28 percent of patients and is thought to develop from redirection of abdominal forces anteriorly (Benson, 1996; Morley, 1988; Paraiso, 1996). Complications associated with SSLF include buttock pain from nerve involvement with supporting ligatures in 3 percent of patients and vascular injury in 1 percent (Sze, 1997a,b). Although infrequent, significant and life-threatening hemorrhage can follow injury to blood vessels located near the sacrospinous ligament.
Uterosacral ligament vaginal vault suspension is another apical surgery. With this procedure, the vaginal apex is attached to remnants of the uterosacral ligament at the level of the ischial spines or higher. Performed vaginally or abdominally, the uterosacral ligament vaginal vault suspension is believed to replace the vaginal apex to a more anatomic position than SSLF, which deflects the vagina posteriorly (Barber, 2000; Maher, 2004; Shull, 2000). This procedure has been adopted by many surgeons in the United States in attempts to reduce the rates of anterior vaginal prolapse recurrence following SSLF (Shull, 2000). Although uterosacral ligament vaginal vault suspension has gained popularity, studies supporting its use are limited to retrospective case series (Amundsen, 2003; Karram, 2001; Silva, 2006). In these studies and others, anterior vaginal prolapse recurrence rates range from 1 to 7 percent, and overall recurrence rates from 4 to 18 percent. One landmark RCT compared SSLF and uterosacral ligament vaginal vault suspension and did not find significant differences in anatomic or functional outcomes between the two procedures at 2 years (Barber, 2014).
Hysterectomy at the Time of Prolapse Repair
In the United States, hysterectomy is often performed concurrently with prolapse surgery. Conversely, in many European countries, it is rarely performed during pelvic floor reconstruction. Although this has not been compared in RCTs, arguments exist for both. If apical or uterine prolapse is present, hysterectomy will more readily allow the vaginal apex to be resuspended with the previously described apical suspension procedures. If hysterectomy is not performed in the context of apical prolapse, these procedures must be modified or specific uterine suspension procedures performed (not described in this text). Alternatively, if apical or cervical prolapse is not present, hysterectomy need not be incorporated into prolapse repair.
Posterior vaginal wall prolapse may be due to enterocele or rectocele. Enterocele is defined as herniation of the small bowel through the vaginal fibromuscular layer, usually at the vaginal apex. Discontinuity of the anterior and posterior vaginal wall fibromuscular layers allows for this herniation. Accordingly, enterocele repairs have as their goal reattachment of these fibromuscular layers. If posterior wall prolapse is due to enterocele, repair of this defect should reduce the posterior wall prolapse.
If due to rectocele, posterior vaginal wall prolapse is repaired with one of several techniques, which are illustrated in Chapter 45. Of these, traditional posterior colporrhaphy aims to rebuild the fibromuscular layer between the rectum and vagina by performing a midline fibromuscular plication. The anatomic cure rate is 76 to 96 percent, and most studies report a greater than 75-percent improvement rate of bulge symptoms (Cundiff, 2004). To narrow the genital hiatus and prevent recurrence, some surgeons plicate the levator ani muscle concurrently with posterior repair. However, this practice may contribute to dyspareunia rates of 12 to 27 percent (Kahn, 1997; Mellegren, 1995; Weber, 2000). Thus, it is best avoided in women who are sexually active.
Site-specific posterior repair is an approach based on the assumption that specific tears in the fibromuscular layer can be repaired in a discrete fashion. Defects may be midline, lateral, distal, or superior. This approach is conceptually analogous to a fascial hernia, in which the fascial tear is identified and repaired. Thus, its theoretical advantage lies in its restoration of normal anatomy rather than plication of tissue in the midline. Although site-specific repair has gained wide acceptance, anatomic cure rates range from 56 to 100 percent, similar to that with traditional posterior colporrhaphy (Muir, 2007). Moreover, anatomic and functional long-term outcomes are unknown.
Mesh reinforcement with allograft, xenograft, or synthetic mesh has been used in conjunction with posterior colporrhaphy and site-specific repair to help reduce prolapse recurrence. However, the efficacy and safety of graft augmentation in the posterior vaginal wall has not been established. Paraiso and coworkers (2006) randomly assigned 105 women to posterior colporrhaphy, site-specific repair, or site-specific repair plus a graft using porcine small intestine submucosa. After 1 year, those with graft augmentation had a significantly higher anatomic failure rate (46 percent) than those who received site-specific repair alone (22 percent) or posterior colporrhaphy (14 percent). More research is needed to determine the safety, efficacy, and optimal material for posterior wall graft augmentation. Until then, the use of mesh in the posterior vaginal wall should generally be avoided.
Last, sacrocolpoperineopexy is a modification of sacrocolpopexy. It may be selected for correction of posterior vaginal wall descent when an abdominal approach is employed for other prolapse procedures or if treatment of perineal descent is necessary (Cundiff, 1997; Lyons, 1997; Sullivan, 2001). With this procedure, the posterior sacrocolpopexy mesh is extended down the posterior vaginal wall to the perineal body. In several case series, anatomic cure rates were greater than 75 percent.
The perineal body provides distal support to the posterior vaginal wall and anterior rectal wall and anchors these structures to the pelvic floor. A disrupted perineal body will allow descent of the distal vagina and rectum and will contribute to a widened levator hiatus.
To recreate normal anatomy, perineorrhaphy is often done in conjunction with posterior colporrhaphy (Chap. 45). During surgery, the perineum is rebuilt through midline plication of the perineal muscles and connective tissue. Importantly, overly aggressive plication can narrow the introitus, create a posterior vaginal wall ridge, and lead to entry dyspareunia. However, in a woman who is not sexually active, high perineorrhaphy with intentional introital narrowing is believed to decrease the risk of posterior wall prolapse recurrence.
Mesh in Reconstructive Pelvic Surgery
Approximately 30 percent of women undergoing surgery for prolapse will require a repeat operation for recurrence (Olsen, 1997). As such, continuous efforts strive to improve surgical procedures and outcomes.
Synthetic mesh for sacrocolpopexy and midurethral slings has been widely studied and is safe and effective. Mesh erosion develops in a small percentage of cases but can be managed with local estrogen therapy and limited vaginal wall mesh excision. Rarely is excision of the entire mesh warranted. In an attempt to limit erosion rates, surgeons have used biologic material grafts, including cadaveric fascia. However, high rates of prolapse recurrence are associated with this material (FitzGerald, 1999, 2004; Gregory, 2005). Therefore, synthetic mesh is recommended for sacrocolpopexy and midurethral slings.
The use of biologic grafts or synthetic mesh for other transvaginal reconstructive pelvic surgery has expanded rapidly and in the absence of supporting long-term safety and efficacy data. Some surgeons routinely use graft or mesh augmentation, others never use it, and some use it only for limited indications. Selective use may include: (1) the need to bridge space, (2) weak or absent connective tissue, (3) connective tissue disease, (4) high risk for recurrence (obesity, chronically increased intraabdominal pressure, and young age), and (5) shortened vagina.
Despite the common use of mesh or grafts, one systematic review on their use in transvaginal prolapse repair found a lack of high-quality scientific data to support this practice (Sung, 2008). Since this review, several RCTs have found that mesh use compared with no mesh for anterior colporrhaphy yields higher short-term rates of successful prolapse treatment. However, more surgical complications and postoperative adverse events are associated with mesh use in these studies (Altman, 2011). In 2011, the Food and Drug administration (FDA) reported the potentially serious complications associated with surgical mesh for transvaginal repair of POP. Noted complications include mesh erosion, scarring, pain, and dyspareunia. Additionally, synthetic mesh may become ingrown and difficult to remove. Complications may therefore be irreversible. Thus, the FDA urges clinicians to weigh the risks versus theoretical benefit of this practice. The American College of Obstetricians and Gynecologists (2011) and AUGS (2012) echo these concerns and recommend that vaginal synthetic mesh for the treatment of POP should be reserved for high-risk women in whom the benefits outweigh the risks.
Surgeons using mesh or grafts should be familiar with the different types and their characteristics. Biologic grafts may be autologous, allograft, or xenograft. Autologous grafts are harvested from another part of the patient’s body such as rectus abdominis fascia or thigh fascia lata. Morbidity is low but may include increased operative time, pain, hematoma, or weakened fascia at the harvest site. Allografts come from a human source other than the patient and include cadaveric fascia or cadaveric dermis. Xenografts are biologic tissue obtained from a source or species foreign to the patient such as porcine dermis, porcine small intestinal submucosa, or bovine pericardium. Biologic materials have varying biomechanical properties and, as noted earlier, are associated with high rates of prolapse recurrence. Thus, recommendations on the appropriate clinical situations for biologic material are limited.
Synthetic mesh is classified as types I through IV, based on pore size (Table 24-8) (Amid, 1997). Pore size is the most important property of synthetic mesh. Bacteria generally measure less than 1 μm, whereas granulocytes and macrophages are typically larger than 10 μm. Thus, a mesh with pore size <10 μm may allow bacterial but not macrophage infiltration and thereby predispose to infection. Accordingly, type I mesh has the lowest rate of infection compared with types II and III. Pore size is also the basis of tissue ingrowth, angiogenesis, flexibility, and strength. Pore sizes of 50 to 200 μm allow for superior tissue ingrowth and collagen infiltration. This again favors type I. Meshes are either monofilament or multifilament. Multifilament mesh has small intrafiber pores that can harbor bacteria, therefore, monofilament mesh is recommended. From these findings, consensus suggests that if synthetic mesh is used, type I monofilament is the best choice for reconstructive pelvic surgery.
TABLE 24-8Types of Surgical Mesh ||Download (.pdf) TABLE 24-8 Types of Surgical Mesh
| Type I: ||Macroporous. Pore size >75 μm (size required for infiltration by macrophages, fibroblasts, blood vessels in angiogenesis, and collagen fibers) |
| ||GyneMesh, Atrium, Marlex, Prolene |
| Type II: ||Microporous. Pore size <10 μm in at least 1 dimension |
| || Gore-Tex |
| Type III: ||Macroporous patch w/multifilaments or a microporous component |
| || Teflon, Mersilene, Surgipro, Mycro Mesh |
| Type IV: ||Submicronic. Pore size <1 μm. Often used in association with type I mesh for intraperitoneal adhesion prevention |
| || Silastic, Cellgard, Preclude |
Mesh or graft augmentation will undoubtedly persist due to the current poor cure rates with traditional transvaginal repairs. However, evidence to guide the surgeon and provide a patient with accurate safety and efficacy information is scant. Moreover, industry-driven, premature adoption of untested materials and procedures has historically led to unacceptable complications. For these reasons, randomized, prospective trials comparing traditional repairs with graft or mesh augmentation are needed.
Concomitant Prolapse and Incontinence Surgery
Prior to prolapse repairs, women should be evaluated for SUI (Chap. 23). Those with bothersome SUI symptoms are considered for concurrent antiincontinence surgery. However, in women without SUI symptoms, latent stress incontinence may be unmasked or SUI may develop de novo following prolapse repair. Therefore, preoperative urodynamic testing with the prolapse replaced is recommended. If SUI is demonstrated, these patients also are considered for a concurrent antiincontinence operation. This has been a difficult decision for patients and surgeons because a procedure with known risks is being performed for a problem that does not currently exist and may never develop.
The CARE (Colpopexy and Urinary Reduction Efforts) trial has helped clarify this problem (Brubaker, 2006). In this trial, women undergoing abdominal sacrocolpopexy for prolapse who did not exhibit symptoms of SUI were randomized to undergo concurrent Burch colposuspension or not. Preoperative urodynamic testing was performed, but surgeons were blinded to the results. Three months after surgery, 24 percent of women in the Burch group and 44 percent of women in the control group met one or more criteria for SUI. The incontinence was bothersome in 6 percent of the Burch group and 24 percent of the control group.
These data can be interpreted in several ways. It can be argued that all women undergoing sacrocolpopexy for stage 2 or greater anterior vaginal wall prolapse should undergo Burch colposuspension, as 44 percent will develop SUI symptoms. However, the opposing argument is that only 24 percent will develop bothersome incontinence symptoms, thus three quarters of women would be subjected to an unnecessary operation.
In a similar trial, the Outcomes Following Vaginal Prolapse Repair and Mid Urethral Sling (OPUS) trial, women undergoing vaginal surgery for POP who did not have SUI symptoms were randomly assigned to receive a midurethral sling or sham incision. Twelve months after surgery, 27 percent of women in the sling group and 43 percent of women in the sham group had incontinence (Wei, 2012).
Importantly, these studies provide high-quality evidence for a surgeon to share during patient counseling. The decision to perform a concurrent antiincontinence operation in women without SUI should be individualized and based on risks, benefits, and patient goals and expectations.