Enterocele and Massive Vaginal Eversion Treatment & Management
- Author: Rony A Adam, MD; Chief Editor: Kris Strohbehn, MD more...
Supporting the epithelial environment in the vagina with estrogen, if no contraindication exists, helps minor symptoms of vaginal irritation and discomfort. Estrogen assists the healing process if ulceration is present and prepares the vagina for subsequent pessary use. Short-term topical preparations are preferred because of their rapid effect and limited systemic absorption. The authors use conjugated equine estrogens or estradiol cream 2-3 times a week for at least 4-6 weeks until an effect can be noted.
Subsequent to, or in conjunction with, estrogen therapy (depending upon the severity of the prolapse), a pessary may be offered. The primary indication for fitting a pessary is the nonsurgical relief of symptoms associated with pelvic organ prolapse. In a long-term assessment of quality of life, Tenfelde et al report improved quality of life with the use of pessaries over a mean of 4½ years (range of 1-15).
A prospective study conducted by Wu et al identified younger age, higher parity, a history of pelvic surgery, and stress urinary incontinence as characteristics associated with initial failure of pessary fitting. Interestingly, the degree of pelvic organ prolapse, hormone replacement therapy, and adequacy of perineal body did not predict failure of initial fitting.[28, 29] Maintaining pessary rates varies from 41 to 64% and the reasons for discontinuation usually associated with inconvenience or inadequate relief of symptoms (40%), difficulty in removal (23%), pessary fell out (6%), and inability to urinate (5%).
Longitudinal data from the US Centers for Medicare and Medicaid Service over a 9 year period on 4,019 women with diagnosed pelvic organ prolapse, demonstrated a pessary continuation rate of 69% with 3% developed vesicovaginal or rectovaginal fistulas and 5% had a mechanical genitourinary device complication. Twelve percent of women underwent surgery for prolapse repair by 1 year, with 24% by 9 years.
Evaluation of vaginal epithelium to assess estrogen status is necessary and vital in order to prevent pessary-associated erosion and ulceration in atrophic vagina. Thus, the use of concurrent vaginal estrogen therapy is recommended in the absence of contraindications.
At present, fewer than twenty pessary types are available and used for prolapse. In a survey among AUGS members 78% of providers tailored their choice of pessary to the specific pelvic support defect. Most respondents generally favored a space-occupying rather than supportive pessary. Supportive pessaries are defined as those that involve a spring mechanism (ring, Gehrung, lever-type pessary) and thought to be supported by symphysis pubis. Space-occupying pessaries are defined as supported by the creation of suction between the pessary and vaginal wall (e.g. cube) or by providing a diameter larger than the genital hiatus (donut, InflatoBall, Shaatz) or by both mechanisms (Gellhorn).
Patients who choose pessary as treatment of their prolapse should be followed closely and should be examined at regular intervals. Common complications of long-term pessary use include vaginal discharge and bleeding, and mucosal erosion/abrasion. Serious complications of pessary use are usually seen in neglected patients and can include infections, fistulas, complete erosions, or incarcerations.
Surgery to repair enterocele and apical prolapse should address the underlying defect-specific pathophysiology of the patient's condition and should restore normal anatomy. This includes addressing all 3 levels of vaginal support as discussed previously (see Pathophysiology), with restoration of the normal vaginal axis and the integrity of the endopelvic fascia in all of its compartments. There are several options for the treatment of vaginal eversion. Changes and modifications have been made to original procedures, however, the paramount principles are still present and include the attachment of vaginal apex to level I support. Therefore this manuscript is limited to discussing these surgical principles as they relate to management of the failure of level I (apical) support.
Pelvic reconstructive procedures can be vaginal, abdominal, laparoscopic, robot-assisted or a combination of these. Surgical techniques can be reconstructive, with the aim of restoring anatomy and maintaining the potential for coitus, or can be obliterative that by definition eliminate prolapse at the expense of future coital function.
The goals of surgical treatment of vaginal eversion include but are not limited to improvement of quality of life, restoration of anatomy (with the exception of colpocleisis), and prevention of reoccurrence pf prolapse.
Preoperative bowel preparation was historically employed. However, a single-blind, randomized control trial of mechanical bowel preparation, conferred no benefit regarding surgeons' intraoperative assessment of the operative field. Furthermore, it noted decreased patient satisfaction, and increased abdominal symptoms in the postoperative period in patients who underwent bowel preparation before reconstructive vaginal prolapse surgery.
A first-generation cephalosporin is administered as a preoperative antibiotic prior to the time of the first incision. All reconstructive procedures begin with careful examination under anesthesia, and a Foley catheter is placed after the patient is appropriately prepped and draped. Some physicians advocate catheters with 30 ml balloons for better palpation of the bladder neck, although 10 ml balloons also seem to work well.
When including hysterectomy as a treatment modality for uterovaginal prolapse, preservation, restoration, and strengthening of pelvic support is of primary importance. Pay particular attention to reattachment of the cardinal-uterosacral ligament complex to the posterolateral vaginal apex, with a high uterosacral ligament attachment thus reestablishing its continuity with the rectovaginal fascia. The use of permanent sutures for the uterosacral ligament colpopexy has been traditionally advocated. Another option is to use prolonged delayed absorbable suture. If the uterosacral ligaments are of insignificant strength, one may consider a sacrospinous ligament fixation or abdominal sacral colpopexy instead.
Culdoplasty is performed per surgeon preference. The most commonly performed culdoplasties are the McCall, Moschcowitz, and Halban methods. Although not described in this article, the McCall culdoplasty approximates the uterosacral ligaments in the midline. The external McCall stitch also incorporates the posterior vaginal apex. The Moschcowitz culdoplasty closes the pelvic peritoneum with purse-string sutures that incorporate both anterior and posterior peritoneum along with the uterosacral ligaments. The Halban culdoplasty shortens each uterosacral ligament using a reefing stitch, with vertical purse-string sutures interposed between the uterosacral sutures. Other procedures exist but are generally variations of these procedures. Culdoplasty serves to close the posterior cul-de-sac and further direct the vaginal apex toward the hollow of the sacrum. It does not, however, address the underlying endopelvic fascial defects at the vaginal apex, as discussed previously and therefore have been abandoned by some.
Adequate closure of the cuff serves to reestablish continuity of the endopelvic fascia at the apex by reapproximating pubocervical fascia with rectovaginal fascia at the most proximal end. The combined effect of proper orientation of the upper vagina in a near-horizontal plane (in the erect position) and the reestablishment of endopelvic fascial integrity as described constitutes both the treatment and prevention of enterocele. All significant pelvic floor defects need to be addressed during this surgery to decrease the likelihood of recurrence. Repair of pelvic floor defects may be performed vaginally and may include anterior colporrhaphy, paravaginal repair, posterior colporrhaphy, rectovaginal septal reconstruction and/or perineorrhaphy as needed.
Vaginal approaches to reconstruction of the vaginal vault (following prior hysterectomy) include sacrospinous ligament fixation (unilateral or bilateral), bilateral iliococcygeus fascia suspension, or high uterosacral vaginal vault suspension. Each of these reconstructive procedures addresses level I (apical) support. Procedures such as the Le Fort partial colpocleisis or colpectomy with colpocleisis are useful in particular situations, but they are considered obliterative procedures.
Sacrospinous ligament fixation begins with incision of the posterior vagina in the midline or just lateral to the midline to the level of the vaginal apex. If an enterocele is encountered, it may be completely dissected and opened. The bowel contents are reduced, and the redundant peritoneum is excised. Alternatively, the sac may be left as is, since the most important part of the repair is the proper identification and reapproximation of the endopelvic fascial defect at the apex, preferably with permanent sutures. The rectovaginal space is then dissected laterally, and the rectal pillar is perforated to gain access to the pararectal space in a position overlying the ischial spine. The space is developed, the sacrospinous ligament within the coccygeus muscle is palpated, and the surrounding area is cleared off gently. Several instruments are available to penetrate the ligament for adequate suspension, including the Deschamps ligature carrier, the Miya Hook (CooperSurgical, Inc, Trumbull, Conn) the Nichols-Veronikis ligature carrier (BEI Medical Systems Company, Inc, Teterboro, NJ), the Capio device (Boston Scientific Corporation, Natick, Mass) (see image below), and the EndoStitch (U.S. Surgical, Norwalk, Conn).
Take care to avoid injury to the inferior gluteal artery, pudendal neurovascular bundle, and the sciatic nerve (see image below).
Avoid dissection superior to the coccygeus muscle and lateral to the ischial spine. Do not place retractors beyond the sacrospinous ligament and never pass the ligature carrier/needle posterior to the ligament because of risk of vascular injury of the inferior gluteal artery. The ligature carrier should pierce the ligament 1.5-2 finger breadths medial to the ischial spine, without encircling the coccygeus muscle (see image below).
Two sutures are used, with at least one that is permanent. They are sutured to the muscularis of the vagina, incorporating rectovaginal fascia but excluding vaginal mucosa because of the high incidence of granulation tissue at the site of the surgical knots of permanent suture. A second stitch can be delayed absorbable with both arms brought out through the vaginal epithelium (see image below). Avoid suture bridging when tying down these sutures.
Some physicians have advocated bilateral sacrospinous ligament fixation for a more durable repair. The authors prefer bilateral sacrospinous attachment in defect-directed repair and reconstruction of the rectovaginal septum when adequate uterosacral ligaments are not found. Exercise clinical judgment intraoperatively to determine whether this can be accomplished without undue tension. Consider the potential benefits in view of the potential increase in risk, both from intraoperative injury and the long-term effect on vaginal anatomy.
Uterosacral vaginal vault suspension with fascial reconstruction aims to restore normal level I anatomy and is almost always done bilaterally (see image below).
This does not result in lateral deviation of the proximal vagina or in the posterior displacement observed with sacrospinous ligament fixation. Uterosacral ligament reattachment may be performed vaginally by the transperitoneal approach as depicted below, but it can also be accomplished retroperitoneally without the need to open the enterocele sac. It may be used immediately following a vaginal hysterectomy or for posthysterectomy vaginal prolapse. Once the posterior vagina is opened, the enterocele sac is identified and excised, the peritoneal cavity is entered, and the uterosacral ligaments are identified distally and are gradually "walked up" toward the sacrum using Allis clamps. Identification may be aided by inserting a finger rectally and palpating the proximal rectovaginal fascia. The proximal aspect of the ligament at the level of the ischial spine is used for resuspension to exclude the defect that is responsible for the prolapse. Permanent sutures are used to grasp and hold each ligament separately; anterior compartment defects can be addressed at this stage.
The ligaments are sutured to the rectovaginal fascia laterally near the apex and also incorporated into the proximal lateral cervicovaginal fascia anteriorly without midline plication. The authors prefer at least 2 stitches in each uterosacral ligament with reapproximation of the pubocervical and rectovaginal fascia across the vaginal apex to correct or prevent enterocele. Posterior colpoperineorrhaphy may be performed as needed. Take care to ensure the integrity of the ureters by carefully palpating the uterosacral ligament, staying medial to the ureter, and liberally using cystoscopy and verifying adequate urine efflux.
Le Fort colpocleisis
Le Fort partial colpocleisis involves retention of the uterus, and, therefore, should be preceded by dilatation and curettage (D&C) or preoperative endometrial biopsy and is contraindicated in patients with postmenopausal bleeding. This procedure may be performed under local or regional anesthesia to accommodate a patient who is frail.
Rectangular strips of both anterior and posterior vagina are obtained, extending from 2 cm distal to the cervix to the level of the bladder neck anteriorly and similarly on the posterior vaginal wall. Sufficient vagina is left laterally to fashion bilateral canals for drainage (see image below).
Dissection should leave adequate endopelvic fascia anteriorly and posteriorly to retain strong tissue for reapproximation. Excellent hemostasis is required and achieved by electrocautery.
The anterior and posterior denuded vaginal walls are sutured with either an interrupted or continuous delayed absorbable suture in a progressive manner to invert the prolapsed vagina. The lateral mucosal edges are reapproximated so that lateral tunnels are formed throughout the length of the vagina on either side. If actual or occult incontinence has been demonstrated preoperatively, a tension-free vaginal tape (TVT) or transobturator tape (TOT) may be performed by adding a midline vaginal incision at this time and continuing as per routine for TVT or TOT.
For posthysterectomy vault prolapse, a colpectomy with colpocleisis is performed in a similar fashion, except that no epithelium-lined tunnels are created. The entire vaginal epithelium is dissected off in strips, and the vaginal endopelvic fascia is progressively inverted by concentric purse-string sutures of delayed absorbable material once meticulous hemostasis is achieved. The urethra and bladder neck are managed in the same way as described for a Le Fort procedure.
Whether performing a LeForte or a total colpocleisis, care must be exercised to not carry the anterior epithelial excision too far distal for fear of opening the bladder neck and urethra by the posterior displacement the anterior segment will undergo when the colpocleisis is complete. Severe postoperative urinary incontinence may result if this occurs.
Trocar-based vaginal kits have become popular in the management of vaginal vault prolapse in the beginning of this century and were advocated as safe and durable treatment option for vaginal prolapse. With the increase in adverse event reports related to these devices over the past several years, the FDA has reclassified transvaginal mesh used for treating pelvic organ prolapse or POP to indicate the risks associated with the product. The new requirements currently only pertain to transvaginal mesh used for transvaginal prolapse repair and does not include mesh used to treat stress urinary incontinence (SUI) and abdominal repair of POP. Thus, well-designed comparison studies need to determine their place and safety in the management of pelvic organ prolapse.
Abdominal approaches to vaginal vault suspension include sacral colpopexy or uterosacral reattachment with fascial reconstruction. The abdominal approach allows for concomitant abdominal procedures to be performed, including paravaginal repair, Burch colposuspension, or suburethral sling (depending upon associated pelvic floor defects, preoperative urodynamics, concomitant pelvic pathology, and medical history). Often, concurrent vaginal surgery is required to complete adequate reconstruction. In either technique, carefully exclude enterocele and repair the enterocele if found. When performing defect-specific repair, this is accomplished abdominally by incising the peritoneum at the vaginal cuff and identifying the endopelvic fascia. If a break is found, it is repaired with interrupted permanent sutures (see image below). Conversely, a traditional Moschcowitz or Halban procedure is recommended by some urogynecologists.
Abdominal sacral colpopexy may be performed with fascia but is most often performed with a permanent light polypropylene mesh. The authors prefer a Y configuration, with the distal end of the graft attached to the anterior and posterior aspects of the vaginal cuff and spacing allowed between the crux of the Y and the vaginal cuff (see image below). This potentially decreases the amount of mesh in contact with the vagina, which may be important in the prevention of subsequent erosion.
Each arm of the mesh is attached to the vagina with 4-5 interrupted stitches of permanent suture, taking care to incorporate endopelvic fascia in each bite. The proximal aspect of the mesh is attached to the anterior sacral fascia at the level of S2 with permanent suture (see images below).
Attachment of the mesh to the sacral promontory may minimize vascular and/or neurologic injuries, but it also results in an unnatural anteflexion of the vaginal apex. Some have felt that this predisposes the posterior compartment to development or recurrence of enteroceles. There is also concern of increased risk of spondylodiscitis if the promontory is chosen as the attachment site.
Reperitonealization is used to avoid subsequent entrapment of the bowel within the mesh. Formal culdoplasty, such as a traditional Moschcowitz or Halban procedure, has been advocated, although the authors have not found it necessary as long as the enterocele has been repaired as described and the vagina is attached to level S3 and not higher. Take care to avoid damage to the bladder and rectum during dissection, as well as the ureters, particularly on the right side. Cautiously proceed with the dissection in the presacral space and pay attention to avoid damage to the middle sacral vessels. Assure that there is no undue tension on the vagina with the mesh in place.
Data from the colpopexy and urinary reduction efforts (CARE) randomized trial evaluated the use of Burch colposuspension at the time of sacrocolpopexy in women who were stress continent. Patients who received a prophylactic Burch colposuspension were about half as likely to develop stress urinary incontinence after the surgery. No differences were noted in the development of postoperative urgency symptoms in the 2 groups.
High uterosacral reattachment is performed using the same principles discussed previously. Reconstruction of the continuity of endopelvic fascia is the cornerstone of therapy. The authors find a Moschcowitz or Halban culdoplasty unnecessary. Maintain an adequate hiatus between the sacrum and vagina after the sutures are tied by allowing 2 finger breadths to leave sufficient space for the sigmoid colon. Avoid upward tension on the vagina.
As discussed previously, the uterosacral vaginal vault suspension with fascial reconstruction may be performed vaginally or abdominally. Using the same principles, this procedure is amenable to the laparoscopic approach as well (see image below).
Similarly, sacral colpopexy has been reported via the laparoscopic approach with or without robotic assistance. These are useful surgical approaches if the surgeon takes care not to alter the operation in a way that would fundamentally change and weaken the reconstruction.
Purported advantages of robotic surgery include improved (3-dimensional) visualization of the operative field with increased dexterity allowing more precise movements. The surgical technique consists with placement of four laparoscopic ports, three for the surgical robot and one for the assistant in addition to a port for the camera. A prolene mesh is then attached to the sacrum and to the vaginal apex or cervical stump using nonabsorbable sutures. Peritonealization of the mesh desirable, but not always performed. Data suggests that this approach combines the advantages of open sacrocolpopexy with decreased hospital stay, less blood loss, low complication and conversion rates, and high rates of patient satisfaction.[37, 38]
When the robotic approach is compared to traditional (“straight stick”) laparoscopy, although it has similar outcomes, is noted to take longer and to be associated with significantly increased cost.
The authors strongly recommend following all reconstructive surgical procedures with evaluation of bilateral ureteral patency with cystoscopy. Intraoperative identification and immediate repair of ureteral injury is associated with reduced morbidity and an improved outcome.
Postoperatively, stool softeners have been suggested, although they are not mandatory unless a concomitant anal sphincteroplasty has been performed or the patient has a propensity for developing severe constipation. If stool softeners are indicated, administer them for 2 weeks.
Patients are usually seen in 4 weeks for vaginal reconstructive surgery or in 1 week and then 4-6 weeks following abdominal (or laparoscopic) surgery. For long-term follow-up, they are observed every 6-12 months, as needed.
Hemorrhage; operative site infection; and damage to the bowel, bladder, and ureters are the most common complications during reconstructive pelvic surgery, regardless of the route or method chosen. Dyspareunia also may develop, especially when posterior vaginal incisions are employed. Additional complications shared by all pelvic surgeries, such as thromboembolism, cardiac events, or pneumonias, require meticulous preoperative and postoperative management and adequate prevention strategies (see Preoperative Details and Postoperative Details). Of particular concern to the urogynecologist is the development of postoperative urinary retention and severe constipation, which are less affected by the actual vault suspension and more affected by the preoperative and postoperative management and concurrent surgical procedures.
Sacrospinous ligament fixation can result in severe hemorrhage from the inferior gluteal artery, internal pudendal vessels, or the hypogastric venous plexus. Damage to these structures is best avoided as delineated above (see Sacrospinous ligament fixation). In the event of such hemorrhage, initial packing is most beneficial, with individual and careful ligation using clips or suture. Hypogastric artery ligation is only helpful if the internal pudendal artery is hemorrhaging. The most common vessel injured is the inferior gluteal artery.
Another complication of sacrospinous ligament fixation is buttock pain on the side of fixation. This occurs in 15% of patients and usually resolves spontaneously by 6 weeks, requiring reassurance and nonsteroidal anti-inflammatory agents.
Other possible complications of sacrospinous ligament fixation include damage to the sciatic nerve, rectal injury, vaginal stenosis, and subsequent defects of anterior compartments. Damage to the sciatic nerve is possible and necessitates removal of the offending suture. Rectal injury may occur and is best avoided by adequate medial retraction of the rectum during the procedure. Vaginal stenosis may occur if excessive amounts of the vagina are removed during anterior and/or posterior colporrhaphy concurrent with sacrospinous ligament fixation. Because of the posterior displacement of the upper vagina, patients are prone to subsequent anterior compartment defects at a rate of approximately 8%.
Colpocleisis is a safe procedure and, in fact, is used in patients who otherwise may not be good surgical candidates for more extensive reconstruction. Immediate complications are rare but may include bleeding, infection, urinary retention, and urgency. Postoperative stress incontinence may occur in 10% of cases when the vesical neck and/or urethra are not adequately supported. To avoid this, if true occult or obvious SUI exists preoperatively, a TVT or TOT may be included in the procedure, or, if no incontinence is demonstrable, a suburethral Kelly plication may prevent future incontinence. Reported complications from the vaginal kits include infection, bleeding, and rectal lacerations. In addition, dyspareunia and mesh erosions may also occur. Long-term follow-up is still lacking for these kits.
Abdominal sacral colpopexy may result in life-threatening hemorrhage from the presacral venous plexus. Such bleeding may be particularly difficult to control because of extensive anastomosis, lack of venous valves, and retraction of the vessels into the sacral bone when they are completely severed. Because of the likelihood that packing with laparotomy packs may exacerbate bleeding upon their removal and further shearing of these delicate veins, careful application of pressure with a gloved finger is the initial maneuver to arrest such hemorrhaging. Bleeding may be stopped by clips, cautery, or suture; maintain keen awareness of the location of the iliac vessels, ureters, and rectum. If these measures are unsuccessful, sterile stainless steel or titanium thumbtacks may be used at the point of bleeding from a retracted presacral vessel. Bone wax has also been used successfully in the management of such bleeding.
Other early complications of abdominal sacral colpopexy include mesh infection, bowel obstruction, and ileus. Mesh erosion is a late complication and occurs in 3-7% of cases. Suspect the diagnosis of mesh infection in a patient following abdominal sacral colpopexy with mesh at any interval when the patient reports persistent vaginal discharge, bleeding, and/or dyspareunia.
Conservative measures using estrogen vaginal cream may be tried first, although results have been disappointing. Some physicians advocate an abdominal approach to remove the entire mesh. Dissection in this circumstance tends to be quite difficult because of scarring and should be attempted only if a more conservative vaginal approach has failed or is associated with postoperative infection. If possible, leaving the sacral attachment is prudent because of the potential for severe hemorrhage from the scarred presacral space. Vaginally excising the eroded mesh as deep as is safely accessible, undermining and freshening the edges of the involved vagina, and closing it primarily with delayed absorbable sutures generally is preferable. Recurrence of apical prolapse usually is not observed following mesh excision, although it may be related to close temporal proximity to the original surgery. Despite this, do not delay management of mesh erosion.
An emerging, significant but rare complication of sacral colpopexy is spondylodiscitis. This is thought to be due to infection of the disc, bone, periosteum or other surrounding spinal structures near the proximal attachment of the graft following sacral colpopexy. It has been postulated that placement of suture at the promontory corresponds to the L5-S1 disc. For that and other anatomical reasons, the authors suggest placing these proximal sutures lower down at around S2.
Outcome and Prognosis
Sacrospinous ligament fixation was reviewed by Sze and Karram. They report an overall failure rate of 19%, a reoperation rate for recurrent prolapse of 2.7%, and a reoperation rate for apical recurrence of 1.8%. Abdominal sacral colpopexy has an overall failure rate of 10-24% depending on the criteria used and length of follow-up. Indeed based on extended follow-up of the CARE trial 2-year cure rates may range from 19% if perfect anatomic support is the criteria, to 97% if the criteria is absence of subsequent treatment for POP. Similarly failure rates increased from years 2 to 7 following surgery. Destructive operations, such as the Le Fort procedure, tend to have a success rate of over 90%.
Benson et al reported the first randomized comparison between abdominal and vaginal approaches to pelvic floor defects. They reported a reoperation rate of 12% (5 of 42) for recurrent apical prolapse when performed vaginally and a reoperation rate of 2.6% (1 of 38) when performed abdominally. They report unsatisfactory results leading to reoperation in 33% of the vaginal group versus reoperation in 16% of the abdominal group, with a mean follow-up of 2.5 years (range of 1-5.5 y).
Maher et al also performed a randomized prospective trial comparing sacrospinous ligament fixation with abdominal sacral colpopexy in posthysterectomy vaginal vault prolapse. Follow-up averaged 2 years postsurgery and showed a subjective success rate of 94% in the abdominal group and 91% in the vaginal group with objective cure rates of 76% in the abdominal group and 69% in the vaginal group. These differences were not statistically significant. The abdominal approach showed longer operative times, slower return to normal activity, and increased costs compared with the vaginal approach.
The most recent Cochrane review to date (2013) determined effects of different surgeries used in the management of pelvic organ prolapse from fifty six randomized controlled trials (5954 women). They concluded that for upper vaginal prolapse (uterine or vault), abdominal sacral colpopexy was associated with a lower rate of (1) recurrent vault prolapse on examination and (2) painful intercourse than with vaginal sacrospinous colpopexy. These benefits must be balanced against a longer operating time, longer time to return to activities of daily living and increased cost of the abdominal approach. In single studies the sacral colpopexy had a higher success rate on examination and lower reoperation rates than high vaginal uterosacral suspension and transvaginal polypropylene mesh.
Future and Controversies
Few well-controlled comparative studies regarding the treatment of apical prolapse are available in the literature. The concept of defect-specific repair in female pelvic reconstructive surgery is one that has been embraced by many, but not all, urogynecologists and pelvic surgeons. Whether long-term outcomes are improved using this concept remains to be determined through well-designed studies with long-term follow-up.
The implications of minimally invasive approaches in the treatment of apical prolapse, specifically laparoscopic and robotic-assisted sacrocolpopexy, present potential improvements in correction of impaired native tissue. Recent systemic review and meta- analysis yielded estimated success rate for robotic sacrocolpopexy of 98.6% ( 95% CI, 97.0%-100%) with mesh exposure rate of only 4.1% (95%CI, 1.4%-6.9%), and rate of reoperation for mesh revision 1.7%. The rates of reoperation for recurrent apical and nonapical prolapse were 0.8% and 2.5% respectively.
There remains a debate if the uterus is a bystander in surgical management of prolapse in perimenopausal women, specifically in women of certain cultural beliefs. Some authors propose uterine preservation as another option for the surgical correction of uterovaginal prolapse. A contemporary randomized trial comparing mesh-based laparoscopic sacral hysteropexy with standard TVH with 1 year follow-up had 20% loss to follow-up and admittedly large technical differences between the operations. It showed no improvement in apical failures from uterine sparing surgery and revealed more reoperations for failures of non-apical compartments.
Practice patterns with respect to hysterectomy for prolapse are complex when the use of colpopexy and cystoscopy and rates of intraoperative complications are analyzed by surgeon volume. High volume surgeons had the lowest complication rates, were most likely to perform an apical suspension procedure as well as address the anterior and/or posterior compartments and to use intraoperative cystoscopy. This was noted despite noting that the high volume surgeons operated on patients with higher degrees of prolapse and those who had prior prolapse or anti-incontinence surgery. The finding that intermediate-volume surgeons have the highest rates of intraoperative complications suggests a nonlinear relationship between surgeon volume and complications and may be reflective of the likelihood of requesting further assistance. Moreover, High-volume surgeons were more likely than low-volume surgeons to perform a standardized preoperative pelvic examination, offer a pessary, and preoperatively evaluate for stress urinary incontinence.
Whitcomb EL, Rortveit G, Brown JS, Creasman JM, Thom DH, Van Den Eeden SK. Racial differences in pelvic organ prolapse. Obstet Gynecol. 2009 Dec. 114(6):1271-7. [Medline].
Wu JM, Hundley AF, Fulton RG, Myers ER. Forecasting the prevalence of pelvic floor disorders in U.S. Women: 2010 to 2050. Obstet Gynecol. 2009 Dec. 114(6):1278-83. [Medline].
Haylen BT, de Ridder D, Freeman RM, Swift SE, Berghmans B, Lee J. An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for female pelvic floor dysfunction. Neurourol Urodyn. 2010. 29(1):4-20. [Medline].
Miedel A, Tegerstedt G, Maehle-Schmidt M, Nyren O, Hammarstrom M. Symptoms and pelvic support defects in specific compartments. Obstet Gynecol. 2008 Oct. 112(4):851-8. [Medline].
Richardson AC, Lyon JB, Williams NL. A new look at pelvic relaxation. Am J Obstet Gynecol. 1976 Nov 1. 126(5):568-73.
Barber MD, Maher C. Epidemiology and outcome assessment of pelvic organ prolapse. Int Urogynecol J. 2013 Nov. 24 (11):1783-90. [Medline].
Swift SE. The distribution of pelvic organ support in a population of female subjects seen for routine gynecologic health care. Am J Obstet Gynecol. 2000 Aug. 183(2):277-85. [Medline].
Samuelsson EC, Victor FT, Tibblin G, Svardsudd KF. Signs of genital prolapse in a Swedish population of women 20 to 59 years of age and possible related factors. Am J Obstet Gynecol. 1999 Feb. 180(2 Pt 1):299-305. [Medline].
Slieker-ten Hove MC, Pool-Goudzwaard AL, Eijkemans MJ, Steegers-Theunissen RP, Burger CW, Vierhout ME. The prevalence of pelvic organ prolapse symptoms and signs and their relation with bladder and bowel disorders in a general female population. Int Urogynecol J Pelvic Floor Dysfunct. 2009 Sep. 20(9):1037-45. [Medline]. [Full Text].
Sze EH, Hobbs G. Relation between vaginal birth and pelvic organ prolapse. Acta Obstet Gynecol Scand. 2009. 88(2):200-3. [Medline].
Levin PJ, Visco AG, Shah SH, Fulton RG, Wu JM. Characterizing the phenotype of advanced pelvic organ prolapse. Female Pelvic Med Reconstr Surg. 2012 Sep-Oct. 18 (5):299-302. [Medline].
Campeau L, Gorbachinsky I, Badlani GH, Andersson KE. Pelvic floor disorders: linking genetic risk factors to biochemical changes. BJU Int. 2011 Oct. 108 (8):1240-7. [Medline].
Allen-Brady K, Cannon-Albright L, Farnham JM, Teerlink C, Vierhout ME, van Kempen LC, et al. Identification of six loci associated with pelvic organ prolapse using genome-wide association analysis. Obstet Gynecol. 2011 Dec. 118 (6):1345-53. [Medline].
Allen-Brady K, Norton PA, Farnham JM, Teerlink C, Cannon-Albright LA. Significant linkage evidence for a predisposition gene for pelvic floor disorders on chromosome 9q21. Am J Hum Genet. 2009 May. 84(5):678-82. [Medline]. [Full Text].
Giri A, Wu JM, Ward RM, Hartmann KE, Park AJ, North KE, et al. Genetic Determinants of Pelvic Organ Prolapse among African American and Hispanic Women in the Women's Health Initiative. PLoS One. 2015. 10 (11):e0141647. [Medline].
Sun MJ, Cheng WL, Wei YH, Kuo CL, Sun S, Tsai HD. Low copy number and high 4977 deletion of mitochondrial DNA in uterosacral ligaments are associated with pelvic organ prolapse progression. Int Urogynecol J Pelvic Floor Dysfunct. 2009 Jul. 20(7):867-72. [Medline].
Takacs P, Gualtieri M, Nassiri M, Candiotti K, Medina CA. Vaginal smooth muscle cell apoptosis is increased in women with pelvic organ prolapse. Int Urogynecol J Pelvic Floor Dysfunct. 2008 Nov. 19(11):1559-64. [Medline].
Elneil S. Complex pelvic floor failure and associated problems. Best Pract Res Clin Gastroenterol. 2009. 23(4):555-73. [Medline].
DeLancey JO. Anatomic aspects of vaginal eversion after hysterectomy. Am J Obstet Gynecol. 1992 Jun. 166(6 Pt 1):1717-24; discussion 1724-8. [Medline].
Richardson AC. The anatomic defects in rectocele and enterocele. J Pelvic Surg. 1995. 1(4):214-221.
Tulikangas PK, Walters MD, Brainard JA, Weber AM. Enterocele: is there a histologic defect?. Obstet Gynecol. 2001 Oct. 98(4):634-7. [Medline].
Hsu Y, Chen L, Delancey JO, Ashton-Miller JA. Vaginal thickness, cross-sectional area, and perimeter in women with and those without prolapse. Obstet Gynecol. 2005 May. 105(5 Pt 1):1012-7. [Medline].
Dancz CE, Walker D, Thomas D, Özel B. Prevalence of Hydronephrosis in Women With Advanced Pelvic Organ Prolapse. Urology. 2015 Aug. 86 (2):250-4. [Medline].
Leffler KS, Thompson JR, Cundiff GW, et al. Attachment of the rectovaginal septum to the pelvic sidewall. Am J Obstet Gynecol. 2001 Jul. 185(1):41-3. [Medline].
Majida M, Braekken IH, Umek W, Bo K, Saltyte Benth J, Ellstrom Engh M. Interobserver repeatability of three- and four-dimensional transperineal ultrasound assessment of pelvic floor muscle anatomy and function. Ultrasound Obstet Gynecol. 2009 May. 33(5):567-73. [Medline].
Thomas AZ, Giri SK, Cox AM, Creagh T. Long-term quality-of-life outcome after mesh sacrocolpopexy for vaginal vault prolapse. BJU Int. 2009 Dec. 104(11):1676-9. [Medline].
Tenfelde S, Tell D, Thomas TN, Kenton K. Quality of life in women who use pessaries for longer than 12 months. Female Pelvic Med Reconstr Surg. 2015 May-Jun. 21 (3):146-9. [Medline].
Wu V, Farrell SA, Baskett TF, Flowerdew G. A simplified protocol for pessary management. Obstet Gynecol. 1997 Dec. 90(6):990-4. [Medline].
Friedman S, Sandhu KS, Wang C, Mikhail MS, Banks E. Factors influencing long-term pessary use. Int Urogynecol J Pelvic Floor Dysfunct. 2010 Jan 9. [Medline].
Clemons JL, Aguilar VC, Sokol ER, Jackson ND, Myers DL. Patient characteristics that are associated with continued pessary use versus surgery after 1 year. Am J Obstet Gynecol. 2004 Jul. 191(1):159-64. [Medline].
Alperin M, Khan A, Dubina E, Tarnay C, Wu N, Pashos CL, et al. Patterns of pessary care and outcomes for medicare beneficiaries with pelvic organ prolapse. Female Pelvic Med Reconstr Surg. 2013 May-Jun. 19 (3):142-7. [Medline].
Cundiff GW, Weidner AC, Visco AG, Bump RC, Addison WA. A survey of pessary use by members of the American urogynecologic society. Obstet Gynecol. 2000 Jun. 95(6 Pt 1):931-5. [Medline].
Ballard AC, Parker-Autry CY, Markland AD, Varner RE, Huisingh C, Richter HE. Bowel preparation before vaginal prolapse surgery: a randomized controlled trial. Obstet Gynecol. 2014 Feb. 123 (2 Pt 1):232-8. [Medline].
Frick AC, Barber MD, Paraiso MF, Ridgeway B, Jelovsek JE, Walters MD. Attitudes toward hysterectomy in women undergoing evaluation for uterovaginal prolapse. Female Pelvic Med Reconstr Surg. 2013 Mar-Apr. 19(2):103-9. [Medline].
Brubaker L, Cundiff GW, Fine P, Nygaard I, Richter HE, Visco AG, et al. Abdominal sacrocolpopexy with Burch colposuspension to reduce urinary stress incontinence. N Engl J Med. 2006 Apr 13. 354 (15):1557-66. [Medline].
Chen CC, Falcone T. Robotic gynecologic surgery: past, present, and future. Clin Obstet Gynecol. 2009 Sep. 52(3):335-43. [Medline].
Elliott DS, Frank I, Dimarco DS, Chow GK. Gynecologic use of robotically assisted laparoscopy: Sacrocolpopexy for the treatment of high-grade vaginal vault prolapse. Am J Surg. 2004 Oct. 188(4A Suppl):52S-56S. [Medline].
Geller EJ, Siddiqui NY, Wu JM, Visco AG. Short-term outcomes of robotic sacrocolpopexy compared with abdominal sacrocolpopexy. Obstet Gynecol. 2008 Dec. 112(6):1201-6. [Medline].
Pan K, Zhang Y, Wang Y, Wang Y, Xu H. A systematic review and meta-analysis of conventional laparoscopic sacrocolpopexy versus robot-assisted laparoscopic sacrocolpopexy. Int J Gynaecol Obstet. 2016 Mar. 132 (3):284-91. [Medline].
Propst K, Tunitsky-Bitton E, Schimpf MO, Ridgeway B. Pyogenic spondylodiscitis associated with sacral colpopexy and rectopexy: report of two cases and evaluation of the literature. Int Urogynecol J. 2014 Jan. 25 (1):21-31. [Medline].
Sze EH, Karram MM. Transvaginal repair of vault prolapse: a review. Obstet Gynecol. 1997 Mar. 89(3):466-75. [Medline].
Nygaard I, Brubaker L, Zyczynski HM, Cundiff G, Richter H, Gantz M, et al. Long-term outcomes following abdominal sacrocolpopexy for pelvic organ prolapse. JAMA. 2013 May 15. 309 (19):2016-24. [Medline].
Benson JT, Lucente V, McClellan E. Vaginal versus abdominal reconstructive surgery for the treatment of pelvic support defects: a prospective randomized study with long-term outcome evaluation. Am J Obstet Gynecol. 1996 Dec. 175(6):1418-21; discussion 1421-2. [Medline].
Maher CF, Qatawneh AM, Dwyer PL, Carey MP, Cornish A, Schluter PJ. Abdominal sacral colpopexy or vaginal sacrospinous colpopexy for vaginal vault prolapse: a prospective randomized study. Am J Obstet Gynecol. 2004 Jan. 190(1):20-6. [Medline].
Maher C, Feiner B, Baessler K, Schmid C. Surgical management of pelvic organ prolapse in women. Cochrane Database Syst Rev. 2013 Apr 30. 4:CD004014. [Medline].
Hudson CO, Northington GM, Lyles RH, Karp DR. Outcomes of robotic sacrocolpopexy: a systematic review and meta-analysis. Female Pelvic Med Reconstr Surg. 2014 Sep-Oct. 20 (5):252-60. [Medline].
Rahmanou P, Price N, Jackson SR. Laparoscopic hysteropexy versus vaginal hysterectomy for the treatment of uterovaginal prolapse: a prospective randomized pilot study. Int Urogynecol J. 2015 Nov. 26 (11):1687-94. [Medline].
Morgan DM, Pulliam S, Adam RA, Swenson C, Guire K, Kamdar N, et al. Analysis of High-, Intermediate-, and Low-Volume Surgeons When Performing Hysterectomy for Uterovaginal Prolapse. Female Pelvic Med Reconstr Surg. 2016 Jan-Feb. 22 (1):43-50. [Medline].
Pulliam SJ, Morgan DM, Guaderrama N, Guire K, Adam RA. Differences in Patterns of Preoperative Assessment Between High, Intermediate, and Low Volume Surgeons When Performing Hysterectomy for Uterovaginal Prolapse. Female Pelvic Med Reconstr Surg. 2016 Jan-Feb. 22 (1):7-10. [Medline].
Dietz HP. Prolapse worsens with age, doesn't it?. Aust N Z J Obstet Gynaecol. 2008 Dec. 48(6):587-91. [Medline].
Wee WW, Wong HF, Lee LC, Han HC. Incidence of hydronephrosis in severe uterovaginal or vault prolapse. Singapore Med J. 2013 Mar. 54(3):160-2. [Medline].
Beverly CM, Walters MD, Weber AM, Piedmonte MR, Ballard LA. Prevalence of hydronephrosis in patients undergoing surgery for pelvic organ prolapse. Obstet Gynecol. 1997 Jul. 90(1):37-41. [Medline].
Jones K, Yang L, Lowder JL, Meyn L, Ellison R, Zyczynski HM. Effect of pessary use on genital hiatus measurements in women with pelvic organ prolapse. Obstet Gynecol. 2008 Sep. 112(3):630-6. [Medline].
Rock J, Jones III H. The nonsurgical management of pelvic organ prolapse: The use of vaginal pessaries. Tenth ed. Te Linde's Operative Gynecology. Lippincott Williams&Wilkins; 2008. p. 937.
Goldberg RP, Tomezsko JE, Winkler HA, Koduri S, Culligan PJ, Sand PK. Anterior or posterior sacrospinous vaginal vault suspension: long-term anatomic and functional evaluation. Obstet Gynecol. 2001 Aug. 98(2):199-204. [Medline].
Khandwala S. Transvaginal mesh surgery for pelvic organ prolapse: one-year outcome analysis. Female Pelvic Med Reconstr Surg. 2013 Mar-Apr. 19(2):84-9. [Medline].
Finamore PS, Echols KT, Hunter K, Goldstein HB, Holzberg AS, Vakili B. Risk factors for mesh erosion 3 months following vaginal reconstructive surgery using commercial kits vs. fashioned mesh-augmented vaginal repairs. Int Urogynecol J Pelvic Floor Dysfunct. 2010 Mar. 21(3):285-91. [Medline].
Feiner B, Gietelink L, Maher C. Anterior vaginal mesh sacrospinous hysteropexy and posterior fascial plication for anterior compartment dominated uterovaginal prolapse. Int Urogynecol J Pelvic Floor Dysfunct. 2010 Feb. 21(2):203-8. [Medline].
De Ridder D. Should we use meshes in the management of vaginal prolapse?. Curr Opin Urol. 2008/07. 18(4):377-82.
Brubaker L for the Pelvic Floor Disorders Network. Burch colposuspension at the time of sacrocolpopex in stress continent women reduces bothersome stress urinary symptoms: The CARE randomized trial. J of Pelvic Med and Surg. 2005. 11(S1):S5.
Kramer BA, Whelan CM, Powell TM, Schwartz BF. Robot-assisted laparoscopic sacrocolpopexy as management for pelvic organ prolapse. J Endourol. 2009 Apr. 23(4):655-8. [Medline].
Jordaan DJ, Prollius A, Cronje HS, Nel M. Posterior intravaginal slingplasty for vaginal prolapse. Int Urogynecol J Pelvic Floor Dysfunct. June/2006. 17(4):326-9. [Medline].
Mattox TF, Moore S, Stanford EJ, Mills BB. Posterior vaginal sling experience in elderly patients yields poor results. Am J Obset Gynecol. May/2006. 194(5):1462-6. [Medline].
Feiner B, Jelovsek JE, Maher C. Efficacy and safety of transvaginal mesh kits in the treatment of prolapse of the vaginal apex: a systematic review. BJOG. 2009 Jan. 116(1):15-24. [Medline].
Fatton B, Amblard J, Jacquetin B. [Is hysterectomy indicated during prolapsus treatment?]. Ann Urol (Paris). 2007 Jun. 41(3):91-109. [Medline].
Addison WA, Livengood CH, Sutton GP, Parker RT. Abdominal sacral colpopexy with Mersilene mesh in the retroperitoneal position in the management of posthysterectomy vaginal vault prolapse and enterocele. Am J Obstet Gynecol. 1985 Sep 15. 153(2):140-6. [Medline].
Barksdale PA, Elkins TE, Sanders CK, et al. An anatomic approach to pelvic hemorrhage during sacrospinous ligament fixation of the vaginal vault. Obstet Gynecol. 1998 May. 91(5 Pt 1):715-8. [Medline].
Borstad E, Rud T. The risk of developing urinary stress-incontinence after vaginal repair in continent women. A clinical and urodynamic follow-up study. Acta Obstet Gynecol Scand. 1989. 68(6):545-9. [Medline].
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 Jul. 175(1):10-7. [Medline].
DeLancey JO, Morley GW. Total colpocleisis for vaginal eversion. Am J Obstet Gynecol. 1997 Jun. 176(6):1228-32; discussion 1232-5. [Medline].
Emge LA, Durfee RB. Pelvic organ prolapse: four thousand years of treatment. Clin Obstet Gynecol. 1966 Dec. 9(4):997-1032. [Medline].
Farnsworth BN. Posterior intravaginal slingplasty (infracoccygeal sacropexy) for severe posthysterectomy vaginal vault prolapse--a preliminary report on efficacy and safety. Urogynecol J Pelvic Floor Dysfunct. 2002. 13(1):4-8. [Medline].
Goh V, Halligan S, Kaplan G, et al. Dynamic MR imaging of the pelvic floor in asymptomatic subjects. AJR Am J Roentgenol. 2000 Mar. 174(3):661-6. [Medline].
Halligan S, Bartram C, Hall C, Wingate J. Enterocele revealed by simultaneous evacuation proctography and peritoneography: does "defecation block" exist?. AJR Am J Roentgenol. 1996 Aug. 167(2):461-6. [Medline].
Hanson GE, Keettel WC. The Neugebauer-Le Fort operation. A review of 288 colpocleises. Obstet Gynecol. 1969 Sep. 34(3):352-7. [Medline].
Iglesia CB, Fenner DE, Brubaker L. The use of mesh in gynecologic surgery. Int Urogynecol J Pelvic Floor Dysfunct. 1997. 8(2):105-15. [Medline].
Jenkins VR. Uterosacral ligament fixation for vaginal vault suspension in uterine and vaginal vault prolapse. Am J Obstet Gynecol. 1997 Dec. 177(6):1337-43; discussion 1343-4. [Medline].
Miklos JR, Kohli N, Lucente V, Saye WB. Site-specific fascial defects in the diagnosis and surgical management of enterocele. Am J Obstet Gynecol. 1998 Dec. 179(6 Pt 1):1418-22; discussion 1822-3. [Medline].
Nguyen JK, Hall CD, Bhatia NN. Transvaginal bladder neck suspension to Cooper's ligament: a review of the literature. Int Urogynecol J Pelvic Floor Dysfunct. 2000. 11(5):320-4. [Medline].
Petros PE. Vault prolapse II: Restoration of dynamic vaginal supports by infracoccygeal sacropexy, an axial day-case vaginal procedure. Int Urogynecol J Pelvic Floor Dysfunct. 2001. 12(5):296-303. [Medline].
Pohl JF, Frattarelli JL. Bilateral transvaginal sacrospinous colpopexy: preliminary experience. Am J Obstet Gynecol. 1997 Dec. 177(6):1356-61; discussion 1361-2. [Medline].
Randall CL, Nichols DH. Surgical treatment of vaginal inversion. Obstet Gynecol. 1971 Sep. 38(3):327-32. [Medline].
Shull B. Clinical evaluation and physical examination of the incontinent woman. J Pelvic Surg. 2000. 6(6):334-343.
Timmons MC, Addison WA, Addison SB, Cavenar MG. Abdominal sacral colpopexy in 163 women with posthysterectomy vaginal vault prolapse and enterocele. Evolution of operative techniques. J Reprod Med. 1992 Apr. 37(4):323-7. [Medline].
Umek WH, Morgan DM, Ashton-Miller JA, DeLancey JO. Quantitative analysis of uterosacral ligament origin and insertion points by magnetic resonance imaging. Obstet Gynecol. 2004 Mar. 103(3):447-51. [Medline].
Welgoss JA, Vogt VY, McClellan EJ, Benson JT. Relationship between surgically induced neuropathy and outcome of pelvic organ prolapse surgery. Int Urogynecol J Pelvic Floor Dysfunct. 1999. 10(1):11-4. [Medline].
Minagawa T, Ogawa T, Ishizuka O, Nishizawa O. Impact of dynamic transrectal ultrasonography on pelvic organ prolapse. J Urol. 2015 Feb. 193(2):670-6. [Medline].
Cosma S, Menato G, Preti M, et al. Advanced utero-vaginal prolapse and vaginal vault suspension: synthetic mesh vs native tissue repair. Arch Gynecol Obstet. 2014 May. 289(5):1053-60. [Medline].
Attenberger UI, Morelli JN, Budjan J, et al. The value of dynamic magnetic resonance imaging in interdisciplinary treatment of pelvic floor dysfunction. Abdom Imaging. 2015 Oct. 40(7):2242-7. [Medline].