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Abstract

Pelvic organ prolapse is a common medical condition that affects the quality of life of many women. Approximately 50% of parous women have pelvic organ prolapse and the lifetime risk for surgical intervention is 6.7% at the age of 80 years. In the USA, the number of women at risk for symptomatic prolapse is increasing, which is consistent with the recent increase in the overall number of prolapse and incontinence procedures being performed. Although prolapse is usually multicompartmental and isolated defects are rare, the apical compartment deserves special attention because apical support is integral to a durable prolapse repair. Since many women may initially present to their primary care physicians, all members of the medical community should have a basic understanding of the diagnosis and treatment for apical prolapse.

Keywords

apical prolapse colpocleisis hysteropexy mesh robotic-assisted laparoscopy sacrocolpopexy sacrospinous ligament fixation uterine preservation uterine prolapse vault prolapse

The objectives of this review are to:

Provide pertinent information on the pathophysiology and diagnosis of apical prolapse;

Discuss the advantages and disadvantages of the surgical options currently available;

Offer a general guideline to assist in choosing a surgical option;

Discuss the ongoing challenges and recent developments surrounding apical prolapse repair.

Etiology & risk factors

Pelvic organ prolapse (POP) is multifactorial. In patients who are genetically predisposed, a combination of aging, pregnancy and delivery, hormonal menopause and chronically high intra-abdominal pressures lead to this condition. Bump and Norton divided these risk factors into four categories:

Predisposing factors are genetics, race and gender;

Inciting factors are pregnancy and delivery, surgery (e.g., hysterectomy for prolapse), myopathy and neuropathy;

Promoting factors are obesity, smoking, pulmonary disease, constipation and recreational or occupational activities that cause chronic increases in intra-abdominal pressure;

Decompensating factors are aging, menopause, debilitation and medications [1].

Although childbirth has been considered as a major risk factor, the categories of risk factors mentioned above illustrate the multifactorial nature of this condition and shows that childbirth is not entirely responsible for prolapse. In a review of 1350 women with term deliveries, vaginal delivery was not associated with severe prolapse (POP-Quantification [POP-Q] stages III and IV), but was associated with an increase in mild prolapse (POP-Q stage II) compared with nulliparous women [2]. Further studies have demonstrated that the impact of delivery method on prolapse is most pronounced in the years immediately following delivery, with the difference becoming less pronounced with increasing time since delivery [3]. Given that routine elective cesarean section is associated with increased maternal and fetal risks, it is not recommended as a means to prevent prolapse [4].

The risk factors noted above lead to myopathy, neuropathy and fascial elongation and detachment. Damage to the neuromuscular and fascial components of the pelvis contributes to the gradual onset of symptomatic prolapse. Pelvic prolapse can be divided according to the affected compartment – apical (near the cervix or cuff), anterior (wall between urethra and vagina) and posterior (wall between vagina and rectum). DeLancey described three different levels of uterovaginal support [5]. Level I support, which includes the uterosacral-cardinal ligament complex, supports the cervix and the upper one-third of the vagina [5]. Level II supports the bladder, rectum and proximal vagina, while level III includes the perineal body and perineal membrane. Apical prolapse is due to loss of level I support, which causes the cervix to move anteriorly and the uterus to shift posteriorly until the uterus assumes a vertical axis. This position allows uterine prolapse to occur [6].

Presentation & diagnosis

Women with apical prolapse may present with complaints of pelvic heaviness, vaginal bulge symptoms, lower urinary tract symptoms, bowel dysfunction, dyspareunia and bleeding from the excoriated vaginal epithelium. Apical prolapse is usually diagnosed on physical examination by the presence of uterine or vault descent on pelvic examination. Descent of the cervix or the vaginal apex (after hysterectomy) is assessed by palpating the cervical os or hysterectomy scar and asking the patient to valsalva. Prolapse severity can be reported using the POP-Q. The degree of prolapse should be reported for all three compartments. Other critical measurements taken during the pelvic examination include the total vaginal length, genital hiatus and perineal body. The site and extent of support defects, attenuated tissues and areas of fibromuscular discontinuity are identified so that appropriate reconstruction with full thickness vaginal mucosa can be factored into the repair [7].

In certain cases, radiographic imaging can contribute to the diagnosis and treatment planning for apical prolapse. After a hysterectomy, apical prolapse can be due to an enterocele, high rectocele or sigmoidocele. Radiographic imaging, such as a pelvic MRI, can accurately identify the contents of the ‘herniating’ vaginal vault and assist in surgical planning. Pelvic MRI can also identify pelvic abnormalities, including ovarian cysts, pelvic masses, hydroureterosis, and ovarian and uterine masses. Abnormal findings on MRI may require further work-up before an elective procedure for prolapse is planned.

Conservative treatment options for apical prolapse

The fact that 50% of parous women have POP, but only 6.7% require surgical intervention in their lifetime demonstrates that not all cases of prolapse requires surgery [8,9]. Before discussing surgical options for symptomatic apical prolapse, a physician should consider the nonoperative treatment options. This is especially true when dealing with elderly patients or poor operative candidates. One should also consider nonsurgical options for women who still want to maintain fertility. The main option for nonsurgical treatment of vaginal prolapse is the pessary. In addition to relieving urge incontinence, difficulty voiding and sensation of pelvic heaviness and vaginal bulge, pessary use of longer than 1 year may also improve prolapse stage [10,11].

Factors that favor successful ring pessary use include anterior and/or apical defect, adequate vaginal capacity, narrow pubic arch and good pelvic floor strength. Two commonly used pessaries include the flexible ring pessary and the Gelhorn pessary [12]. The ring pessary is more common for anterior and apical defects, a Gelhorn for large high-grade prolapse and a donut pessary for posterior defects [12]. Women who are managed with a pessary may be offered vaginal estrogen and should be monitored for signs of erosion [12].

Surgical options for apical prolapse repair

Although some women find symptomatic relief with pessaries, many elect for surgical repair. In the USA, there has been a recent increase in the overall number of prolapse and incontinence procedures being performed [13]. Surgical options for apical prolapse can be categorized as: restorative versus compensatory versus obliterative; abdominal versus vaginal versus laparoscopic/robotic approach; native tissue repair versus graft augmented; and uterine sparing or not. Table 1 categorizes the most common surgical techniques according to the above criteria. A brief description of each procedure as well as recent data on outcomes and complications will be provided.

Table 1.

Surgical options for apical prolapse repair.

Surgical option	Approach	Native vs graft	Restorative vs compensatory	Uterine sparing
Sacrospinous ligament suspension	Vaginal	Native	Restorative	No
Uterosacral ligament suspension, McCall's culdoplasty	Vaginal	Native	Restorative	No
Manchester procedure	Vaginal	Native	Restorative	No, involves cervical amputation
Vaginal sacrospinous hysteropexy, abdominal uterosacral suspension	Vaginal or abdominal	Native	Restorative	Yes
Abdominal sacrospinous hysteropexy	Abdominal	Graft	Compensatory	No
Abdominal sacrocolpopexy	Abdominal/laparoscopic/robotic	Graft	Compensatory	No
Vaginal mesh kit	Vaginal	Graft	Compensatory	Yes/no
Colpocleisis	Vaginal	Native	Obliterative	Yes/no

Transvaginal, native-tissue suspension, nonuterine sparing (sacrospinous ligament fixation, McCall's culdoplasty, uterosacral ligament fixation & Manchester procedure)

This group of surgeries is considered the traditional vaginal repair. The uterosacral ligament fixation (USLS), sacrospinous ligament fixation (SSLS), McCall's culdoplasty and the Manchester procedure all restore apical vaginal support by resuspending the apex to the uterosacral or sacrospinous ligaments. They are either performed concomitantly with a vaginal hysterectomy if the uterus and cervix are in situ, or in posthysterectomy patients. The uterus is not preserved. Of these, the USLS and the SSLS are the most widely used procedures to repair apical prolapse.

Sacrospinous ligament fixation As implied by the name, this procedure restores apical support by suspending the apex to the sacrospinous ligament. This procedure is commonly performed in a unilateral fashion on the right side. Delayed absorbable sutures are placed in the sacrospinous ligament, 1–2 cm medial to the ischial spine in order to avoid injuring vascular and nerve structures. The sutures are then attached to the vaginal vault in order to suspend it without undue tension or laxity [7].

Uterosacral ligament fixation

The McCall's culdoplasty and the USLS are the two main variations of the USLS. The McCall's culdoplasty involves placing one to three ‘inside’ intraperitoneal sutures from one uterosacral ligament to the other, while incorporating the peritoneum of the culdesac to obliterate it and prevent enterocele formation. A series of ‘outside’ sutures are also placed to anchor the distal ligament pedicles to the vaginal vault [14]. In the high USLS technique, one to three nonabsorbable sutures are placed in the middle-third of the uterosacral ligament bilaterally, and then passed through the proximal edge of pubocervical and rectovaginal fasciae. This recreates the pericervical ring and level 1 support [15].

Manchester procedure

The Manchester procedure was first described in 1888. It involves a combined anterior and posterior colporrhaphy with or without cervical amputation. During this procedure, the parametria is sutured to the front of the cervix and the lower uterine segment. The ligaments are shortened, which elevates the cervix. The Manchester procedure is associated with several major problems, such as recurring prolpase in 20% of patients in the first few months of pregnancy, a decrease in fertility and pregnancy wastage of up to 50% due to cervical stenosis [16]. Thus, in the modern setting, the Manchester procedure is rarely performed and reserved for those few patients with cervical elongation who wish to retain the uterus.

Cure rates & complications

This group of traditional vaginal surgeries has a high-cure rate. A meta-analysis focused on the McCall's culdoplasty and USLS procedures found that at a follow-up of 12–84 months, they had a 98% success rate for restoring apical support. Furthermore, 82–100% of the patients reported relief of prolapse symptoms [17].

A randomized study comparing SSLS to the abdominal sacrocolpopexy (ASC) found that they had similar rates of subjective and objective success at 2-year follow-up and that the SSLS was less expensive and required less operating room time and recovery time [18].

Although the cure rate is high, recurrence is a major concern of native tissue repairs since the tissue may be atrophic and weakened. A study by Colombo et al. found that hysterectomy with SSLS for the treatment of uterovaginal prolapse carried a 27% risk of recurrence and a hysterectomy with modified McCall's procedure had a recurrence rate of 15% [19]. Similarly, a systematic review by Diwadkar et al. found that traditional vaginal surgeries (USLS, SSLS, iliococcygeus fascial suspension and McCall's culdoplasty) had the highest reoperation rate for prolapse recurrence (3.9%) [20].

The complication rate for these traditional repairs is estimated to be 15%, with urinary tract infection, bleeding and dyspareunia as the most commonly reported issues. The majority of complications are classified as Dindo I or II in the Dindo–Clavien classification system, which means that they can be managed medically or with a procedure in the clinic [21]. This contributes to the low total reoperation rate. In Diwadkar's systematic review, this group of surgeries had the lowest total reoperation rate (5.8%) when reoperation for recurrence and complications are taken into account [20].

One complication that may require reoperation is ureteral obstruction, which can occur during a USLS. This can be avoided by placing sutures in the inferomedial aspect of the uterosacral ligament, at the level of the ischial spine, and performing cystoscopy after the suspension [22]. A complication that is unique to the Manchester procedure is hematometra due to cervical stenosis, which required treatment with cervical dilatations in up to 11% of women [23].

Restorative, native-tissue suspension, uterine-sparing (vaginal sacrospinous hysteropexy, abdominal uterosacral suspension & abdominal sacrospinous hysteropexy)

Unlike the suture suspension procedures described above, these procedures allow for preservation of the uterus. Therefore, they are suitable options for women who would like to maintain the cervix and uterus for future fertility, sexual function or self identity. With that being said, fertility rates after hysteropexy have not been firmly established. A hysteropexy can be performed via a vaginal approach (vaginal sacrospinous hysteropexy [VSH]) or an abdominal approach (abdominal sacrospinous hysteropexy [ASH] and abdominal uterosacral suspension [AUSS]). During the VSH, the midline of the cervix is attached to the right sacrospinous ligament, approximately 2 cm medial to the ischial spine. During the ASH, the cervix is suspended to the sacrospinous ligament, whereas the AUSS involves attachment to the middle-third of the uterosacral ligament.

A review of the literature reported an 85–100% apical anatomic cure rate for VSH (follow-up range 4–72 months), 91–95% rate for ASH and an 88% success rate at 1-year follow-up for AUSS [24,25]. However, other studies have raised questions regarding the durability of the repair. In a randomized study, women with stage 2–4 uterine descent were randomized to undergo a vaginal hysterectomy or a VSH. At 1-year follow-up, the VSH group had a 21% rate of recurrent apical prolapse (stage 2 or higher) versus 3% in the hysterectomy group [26]. Furthermore, repeat surgery for recurrent prolapse (any compartment) was performed in 11% of the VSH group versus 7% in the hysterectomy group [26]. Notably, all women with preoperative stage 4 uterine prolapse who underwent VSH had recurrence by 1-year follow-up [26]. These data suggest that the VSH is not a durable option for stage 3–4 prolapse.

However, one should note that there is little correlation between anatomic and symptomatic cure. The same randomized study by Dietz et al. showed no difference in quality of life or urogenital symptoms between the hysterectomy and the VSH groups, although they had different anatomic outcomes and recurrence rates [26]. Likewise, when compared with an ASC, the ASH had a low rate of anatomic cure (39 vs 63%), but similar rate of subjective cure (83 vs 100%) [27].

Besides recurrence, complications from this group of procedures include lower urinary tract symptoms (up to 37%), persistent buttock pain (3–27%), and ureteral injury [24].

Abdominal approach, compensatory repair (includes abdominal & laparoscopic/robotic sacrocolpopexy)

Some surgeons consider the sacrocolpopexy to be the gold standard for apical prolapse repair in terms of its anatomic outcomes. The recent updated Cochrane review on surgical management of POP found that when compared with vaginal sacrospinous colpopexy, the ASC has a lower rate of recurrence (relative risk: 0.23; 95% CI: 0.07–0.77) and less postoperative dyspareunia (relative risk: 0.39; 95% CI: 0.18–0.86) [28]. However, the ASC was associated with longer operating time (weight mean difference: 21 min; 95% CI: 12–30) and higher cost (weight mean difference: US$1334; 95% CI: 1027–1641) [28].

There are minimally invasive approaches to the ASC, as it can be performed through pure laparoscopy or robotic-assisted laparoscopy. Some believe that the robot lowers the learning curve for laparoscopic ASC and has allowed more surgeons to offer minimally invasive surgery; however, this may be the case only for novice laparoscopists. A recent randomized controlled trial comparing laparoscopic and robotic ASC found that robotic surgery was associated with longer operating times, more postoperative pain, and higher costs [29]. One should note that all the surgeries in this study were performed by two experienced laparoscopists, who had also performed at least ten robotic ASCs prior to the study. Therefore, the results of this study may not be reflective of surgeons with less laparoscopy experience.

The ASC can be performed with the uterus in place or concomitantly with a total or supracervical hysterectomy. When performed with a supracervical hysterectomy, the cervical remnant is secured to the sacral promontory instead of the vaginal cuff. Some contend that when compared with a total hysterectomy, a concomitant supracervical hysterectomy at the time of ASC is associated with a decreased risk of injury to adjacent organs and mesh-related complications, such as infection and extrusion [30]. Other purported benefits include preservation of sexual, urinary and bowel function [31]. However, a Cochrane review and professional committee opinion on supracervical hysterectomy do not advocate this due to lack of data demonstrating preserved sexual and urinary function [31,32]. Furthermore, this procedure is associated with the risk of bleeding from the cervical stump and pelvic pain.

Although the benefits of the supracervical hysterectomy in regards to sexual, urinary, and bowel function has not been firmly established, a recent study by Benson et al. does suggest it delivers similar anatomic outcomes [30]. They compared their initial experience with the supracervical robotic-assisted laparoscopic sacrocolpopexy (SRALS) to the robotic-assisted laparoscopic sacrocolpopexy (RALS) in posthysterectomy patients. At a mean follow-up of 20.7 months for the SRALS and 38.4 months for the RALS, only one RALS patient had an apical recurrence [30]. The supracervical hysterectomy component increased the mean operative time from 194 min (RALS in posthysterectomy patients) to 284 min (SRALS) [30]. They concluded that SRALS is an effective repair method for apical vaginal defects in patients with significant POP who had not undergone a previous hysterectomy [30].

Regardless of the approach, the key aspect of the sacrocolpopexy is the suspension of the apex to the anterior longtitudinal ligament, at the level of the sacrum. Most surgeons use a Y-shaped piece of mesh to suspend the apex (cuff or cervix), but native tissue can also be utilized.

One of the main advantages of the sacrocolpopexy is the preservation of total vaginal length, which is important to women who are sexually active. It also has a high success rate and offers a durable repair. A systematic review reported a 78–100% rate of anatomic cure for all compartments and another study reported a 2.3% reoperation rate for recurrence [20,33]. The laparoscopic approach reduces morbidity, but still offers high levels of satisfaction and objective cure rates (77%) and low reoperation rate (5%) [34].

The mean complication rate for open ASC is higher than that of traditional vaginal repair and vaginal mesh kits, which are 17.1, 15.5 and 14.5%, respectively. Most of these complications are classified as Dindo I or II, and include pain (2.3%), mesh erosion (2.2%), visceral injury (1.7%) and wound issues (1.5%) [20].

Transvaginal graft-augmented repair (transvaginal mesh kits)

In the last several decades, mesh kits for prolapse repairs have gained popularity. Surgeries utilizing the mesh kits can be performed with or without uterine preservation. The cervix/cuff is suspended to the sacrospinous ligament using mesh. Mesh kits were touted to improve the durability of repairs, with anatomic cure of 82–86% at 1-year follow-up [35]. A recent meta-analysis also reported a low reoperation rate for recurrence (1.3%) [20].

However, a recent randomized study with a longer follow-up of 2 years came to a different conclusion. During this study, women were randomized to undergo repair using a transvaginal mesh kit or laparoscopic ASC. The laparoscopic ASC group had higher rates of satisfaction and objective cure (77 vs 43%), a longer total vaginal length (8.83 vs 7.81 cm), and a better reoperation rate (5 vs 22%) [34]. Since the ASC in this study was performed laparoscopically, the morbidities associated with the traditional approach were mitigated. These findings question the purported benefits of mesh kits.

Furthermore, recent studies have also demonstrated that mesh is associated with a higher incidence of complications, and these complications tend to be of higher severity. Unlike the complications associated with procedures using native tissue, mesh complications often require reoperation [20]. In Diwadkar's meta-analysis comparing traditional vaginal repair, the ASC and transvaginal mesh kits for apical prolapse repair, the mesh group had the highest total reoperation rate (8.5%), although it also had the shortest follow-up [20]. The high total reoperation rate was due to the higher grade of complications (most were Dindo IIIb), which required surgical treatment. The most common complication was mesh erosion and infections (5.8%) and this group also had the highest risk of dyspareunia (2.2%) [20]. Concern surrounding mesh complications spurred a US FDA investigation and subsequent warnings regarding the use of mesh for POP repair were released recently. This issue is discussed later in the article.

Obliterative (colpocleisis)

Although most patients are amendable to one of the four surgical options described above, colpocleisis may be the best option for certain patients. Colpocleisis is an obliterative process where the anterior and posterior vaginal walls are denuded, and the exposed fascia is imbricated in a sequential fashion until the entire vaginal vault is closed and obliterated. The Le Fort partial colpocleisis is a modification where the uterus is left in situ and two lateral channels are created to allow for drainage [35]. This procedure is usually combined with an aggressive perineorraphy to provide perineal support.

Since the vaginal cavity is closed by bringing the anterior and posterior walls together, this option is only appropriate for women who do not want to maintain coital ability. Traditionally, colpocleisis has been reserved for frail, elderly patients with advanced apical prolapse thought to be poor candidates for extensive vaginal reconstruction. However, increasing numbers of older, but otherwise healthy women are opting for this procedure for its high success and quick recovery [36]. Overall patient satisfaction with this obliterative procedure is greater than 90% and regret over losing coital ability is low at 0–12.9% [36]. The risk for significant postoperative complications (e.g., postoperative cardiac, thromboembolic, pulmonary and cerebrovascular events) is 5%, which may be attributed to the older age and frail condition of the patients [37]. The risk of minor surgical complications is 15 % and surgical mortality is approximately one in 400 cases [37]. Women who are considering a colpocleisis should have an evaluation of the endometrial cavity and be up to date on Pap screening since the uterine cavity cannot be sampled after colpocleisis [36]. Recurrent apical prolapse after colpocleisis is uncommon and can be addressed with repeat colpocleisis or perineorraphy if bothersome [36].

Individualized approach to choosing a surgical option

As noted above, most surgical options for apical prolapse repair are associated with good subjective outcomes even if the anatomy differ. Therefore, when choosing a surgical option, one should consider the patient's individual needs and desires, as certain approaches are preferred for certain situations. For patients who are elderly or have poor general health, one should consider the surgeries via vaginal approach since they are less morbid and require less recovery time. A patient with severe prolapse symptoms who also has severe comorbidities should consider a colplocliesis if sexual activity is not a concern.

Patients who have had recurrent prolapse after a prior transvaginal repair should also consider a compensatory repair such as the ASC, since these are generally more durable than the restorative options [7].

A sexually active patient will need to maintain total vaginal length. The ASC preserves an adequate total vaginal length, but changes the normal axis of the vagina. If an USLS or SSLS is performed, one should ensure that the sutures are placed deep enough from the introitus in order to maintain adequate vaginal length. The risk of dyspareunia can narrow surgical options for sexually active women. Surgeries requiring mesh, such as mesh kits and the ASC, have higher rates of dyspareunia. Furthermore, meshaugmented repairs are associated with significant rates of exposure/extrusion, and may not be the optimal choice for women who are sexually active. The ASC carries a 2.2% risk of mesh extrusion/erosion requiring reoperation, while the risk with mesh kits is 5.8% [20].

Women who want to maintain fertility should consider nonsurgical treatment with a pessary until she no longer wants to bear children. If she cannot tolerate a pessary or the pessary does not provide adequate support, a hysteropexy is a uterine-sparing option (VSH, ASH or AUSS).

Some women may want to preserve the uterus for reason other than fertility, such as sexual and orgasmic function, maintenance of pelvic anatomy integrity and body image. They should be counseled that although studies have shown that uterine preservation does reduce intraoperative blood loss, operating times, hospital stays and mesh erosion, the advantages of uterine preservation on quality of life remains a current topic of discussion [16].

Certain findings on a physical exam may guide the surgeon towards one surgical approach or another. A patient who has a foreshortened vagina from prior surgery should not undergo a SSLS if the vaginal cuff cannot reach the sacrospinous ligament. In this case a uterosacral ligament suspension or an abdominal suspension may be preferred [7]. In a patient who has severe stage 4 prolapse, a high USLS remains an option if the cardinal and uterosacral ligament pedicles are several centimeters below the hymen, but are palpable on tension. However, if there is extensive elongation of the pedicles, or it is difficult to appreciate their course and attachment to the pelvic sidewall, then a SSLS is preferred [7].

Current controversies regarding apical prolapse repair

In order to address the recurrence rates associated with traditional vaginal repairs and the morbidity of an open incision for an ASC, mesh kits and robotic-assisted laparoscopic ASC were introduced and quickly adopted. However, there remains a paucity of definitive data regarding the cure rates, complications profile and cost–effectiveness of these newer options and their roles in the treatment of apical prolapse remain a subject of discussion. One major question is whether mesh kits truly improve durability of repair, and if this benefit is worth the increased risk of complications. Another concern is whether the benefits of robotic-assisted laparoscopic ASC justify a significant increase in cost. This section will address these prevailing questions.

Mesh-augmented surgery

The recurrence rate associated with traditional vaginal repair led to the advent of mesh-augmented repairs, which are supposed to increase durability. However, a recent double-blind randomized controlled trial comparing women who underwent vaginal surgery for multi-compartment prolapse using mesh versus those without mesh found that at 12 months both groups had similar rates of recurrence, satisfaction, and improvement in their quality of life [38]. However, 15.6% of the mesh group had mesh exposure, and three out of the five patients required a reoperation to address the exposure [38]. Reports such as these question whether mesh-augmented repairs truly improve anatomic outcomes, and if so, are they worth the risk of mesh-related complications? Since these complications often lead to additional surgeries, the total reoperation rate for mesh-kit repairs of apical prolapse (8.5%) is higher than for traditional vaginal repairs and ASC [20].

An increased awareness of mesh-related complications spurred a recent FDA investigation that included a search of the Manufacturer and User Device Experience database as well as a literature review. A search of the FDA's Manufacturer and User Device Experience database from the last 3 years (1 January 2008–31 December 2010), identified 2874 medical device reports for urogynecologic surgical meshes. Of these, 1503 were associated with POP repairs. The FDA literature review concluded there is no evidence to support mesh augmentation in vaginal repair of the posterior or apical compartments and, although it provides superior anatomic outcomes for the anterior compartment, there is no difference in subjective outcomes compared with traditional repair [101]. One may still consider this an option for patients with severe apical prolapse or history of recurrence, but only after a thorough discussion regarding the increased risk of mesh complications and pain.

Robotic-assisted laparoscopic surgery

Robotic-assisted laparoscopy has revitalized interest in abdominal prolapse repairs, such as the sacrocolpopexy and sacrohysteropexy. Prior to laparoscopy, these surgeries required an open abdominal incision, which meant a higher blood loss, longer recovery time and wound complications. Pure laparoscopy minimized the morbidity of the ASC and ASH, but technical difficulty and a high learning curve limited these procedures to high-volume laparoscopic surgeons. The robot enabled surgeons with less advanced laparoscopic skills to perform minimally invasive ASC and ASH, but with significant added expense. Studies comparing the two minimally invasive approaches have consistently demonstrated laparoscopy incurs fewer costs, less operative time and less postoperative pain compared with the robotic-assisted approach, but with comparable results at 1 year [29].

The role of any abdominal repair, whether laparoscopic or open, is limited by the fact that it mainly addresses apical prolapse. Concomitant anterior or posterior compartment prolapse or stress incontinence usually requires additional surgery via a vaginal approach. Since most vaginal prolapse is multicompartmental and isolated apical prolapse is rare, some surgeons believe that abdominal prolapse surgeries (including robotic-assisted ASC/ASH) provide optimal and efficient treatment for only a small subset of patients [39].

Conclusion

POP is a prevalent issue and many women will seek surgical repair in their lifetime. Adequate support of the apex is integral to a durable repair. Conventional surgeries vary widely in anatomic outcomes, but most offer similar rates of subjective cure [20]. Mesh kits were developed to address the low anatomic cure rate of traditional vaginal surgery, but they are associated with higher complication rates, total reoperations rates and cost [20,34]. Furthermore, recent studies question whether mesh-augmented repairs truly improve anatomic outcomes [38]. The robot allows more surgeons to perform minimally invasive ASC, but at a significant cost [29]. The recent FDA notifications regarding mesh complications, the changing economy, and a paradigm shift from anatomic to symptomatic cure makes the future of these new options uncertain.

Future perspective

The field of female pelvic medicine and reconstructive surgery is undergoing a paradigm shift in terms of its outlook on outcomes. Traditionally, surgical success was measured by anatomic outcomes, which is generally considered a POP-Q stage of 0–1. However, in a recent study, 92% of the women reported subjective cure, even though only 50% had anatomic support proximal to the hymen [40]. They also found that the absence of vaginal bulge symptoms postoperatively had a significant relationship with a patient's assessment of overall improvement, while anatomic success alone does not [40]. This demonstrates the discrepancy between anatomic and symptomatic cure and suggests that our subspecialty may need to reassess its definition of ‘success’. If prolapse surgery is mostly elective and driven by quality of life, should we not align our definition of ‘success’ with the objective of our surgery?

The main theoretical advantage of mesh was improvement of recurrence rates and anatomic outcomes. However, the randomized controlled trial by Sokol et al. did not find superior objective or subjective outcomes in the mesh group. On the other hand, the mesh group did have a higher reoperation due to mesh exposure [38]. If this study is reflective of the authors' clinical experience, then the role of transvaginal mesh for prolapse repair will likely wane. The diminishing role of mesh is already being witnessed with the recent FDA statement that “transvaginal apical or posterior repair with mesh does not appear to provide any added benefit compared with traditional surgery without mesh” [101].

Executive summary

Backgorund

Although prolapse is usually multicompartmental and isolated defects are rare, the apical compartment deserves special attention because apical support is integral to a durable prolapse repair.

Etiology & risk factors

Pelvic organ prolapse is multifactorial and risk factors including aging, pregnancy and delivery, hormonal menopause and chronically high intra-abdominal pressures contribute to this condition.

Childbirth is not entirely responsible for prolapse and different modes of delivery (vaginal vs cesarean section) ultimately carry similar risks of prolapse.

Presentation & diagnosis

Physical examination needs to evaluate prolapse of all three compartments, total vaginal length, genital hiatus, perineal body and stress urinary incontinence.

Pelvic MRI can accurately identify the contents of the ‘herniating’ vaginal vault and pelvic abnormalities, such as ovarian cysts, pelvic masses, hydroureterosis and ovarian and uterine masses.

Conservative treatment options for apical prolapse

Pessary treatment should be offered to women with symptomatic apical prolapse, especially if they want to avoid hysterectomy or have significant comorbidities.

Surgical options for apical prolapse repair

Traditional vaginal apical repairs have high subjective outcomes and the most favorable complication and total reoperation rates.

Abdominal sacrocolpopexy (ASC) offers high anatomic and symptomatic success rates and maintains adequate total vaginal length, but is associated with higher surgical morbidity and rate of complications.

Hysteropexy allows for uterine preservation, but is associated with higher rates of anatomic recurrence.

Mesh kits are associated with higher risks of mesh complications, pain and reoperation, and it is uncertain if they provide true anatomic benefit.

Women with significant comorbidities should consider nonoperative management with a pessary, or less invasive surgical options such as the traditional transvaginal repair or a colpocleisis.

An individualized approach to choosing a surgical option

Although their anatomic success rates may vary, the subjective outcomes for most surgical options are similar. Surgical planning should be individualized to the patient's need and desires.

The advantages of uterine preservation in regards to sexual, urinary and bowel function has not been firmly established. Similarly, rates of successful pregnancy after hysteropexy are not well defined.

Current controversies regarding apical prolapse repair

The US FDA literature review concluded that there is no evidence to support mesh augmentation in vaginal repair of the posterior or apical compartments, and although it provides superior anatomic outcomes for the anterior compartment, there is no difference in subjective outcomes compared with traditional repair.

Minimally invasive approaches to the ASC afford similar anatomic outcomes with less blood loss and shorter hospital stay when compared with open ASC. However, it is unclear if robotic surgery brings any added benefits when compared with laparoscopic ASC, and whether these benefits substantiate the added cost.

Footnotes

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

No writing assistance was utilized in the production of this manuscript.

References

Papers of special note have been highlighted as:

of interest

of considerable interest

Bump

Norton

. Epidemiology and natural history of pelvic floor dysfunction. Obstet. Gynecol. Clin. North Am. 25, 723–746 (1998).

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Hobbs

. Relation between vaginal birth and pelvic organ prolapse. Acta Obstet. Gynecol. Scand. 88(2), 200–203 (2009).

Hannah

Whyte

Hannah

Maternal outcomes at 2 years after planned cesarean section versus planned vaginal birth for breech presentation at term: the international randomized term breech trial. Am. J. Obstet. Gynecol. 191(3), 917–927 (2004).

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Surgical Options for Apical Prolapse Repair

Abstract

Keywords

Etiology & risk factors

Presentation & diagnosis

Conservative treatment options for apical prolapse

Surgical options for apical prolapse repair

Transvaginal, native-tissue suspension, nonuterine sparing (sacrospinous ligament fixation, McCall's culdoplasty, uterosacral ligament fixation & Manchester procedure)

Uterosacral ligament fixation

Manchester procedure

Cure rates & complications

Restorative, native-tissue suspension, uterine-sparing (vaginal sacrospinous hysteropexy, abdominal uterosacral suspension & abdominal sacrospinous hysteropexy)

Abdominal approach, compensatory repair (includes abdominal & laparoscopic/robotic sacrocolpopexy)

Transvaginal graft-augmented repair (transvaginal mesh kits)

Obliterative (colpocleisis)

Individualized approach to choosing a surgical option

Current controversies regarding apical prolapse repair

Mesh-augmented surgery

Robotic-assisted laparoscopic surgery

Conclusion

Future perspective

Footnotes

References