Enterocele and Massive Vaginal Eversion Treatment & Management

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. Interestingly, an observational study of 90 women seeking nonsurgical management of symptomatic prolapse demonstrated that after 3 months of pessary use, genital hiatus size decreased significantly.^[23]

A cross-sectional study found that older patients were 10% more likely to choose a pessary rather than surgery and those patients who had previously undergone surgery for prolapse were 77% more likely to choose surgery over pessary. Similarly, the greater the degree of prolapse, the more likely patients were to choose surgery over pessary or expectant management.^[24] 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 therapy, and adequacy of perineal body did not predict failure of initial fitting.^{[25, 26]}

Some studies demonstrate that the rate of pessary continuation varies from 41-64% and the reasons for discontinuation are usually associated with inconvenience or inadequate relief of symptoms (40%), difficulty in removal (23%), pessary fell out (6%), and inability to urinate (5%).^[27]

Evaluation of the vaginal mucosa to assess estrogen status is necessary and vital 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.^[28]

Since ancient time, hundreds of pessaries have been described. At present, however, fewer than 20 pessary types are available and used for prolapse. A recent survey among AUGS members demonstrated that 78% of physicians tailored their choice of pessary to the specific pelvic support defect. Most of the responders generally favored a space-occupying rather than supportive pessary.^[28]

The supportive pessaries are defined as those that derive their support by a spring mechanism (ring, Gehrung, lever-type pessary) and are thought to be supported by the symphysis pubis. The space-filling pessaries are defined as supported by the creation of suction between the pessary and vaginal wall (eg, cube) or by providing a diameter larger than the genital hiatus (donut, InflatoBall, Shaatz) or by both mechanisms (Gellhorn).

Patients who choose pessary as a 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.

Vaginal pessaries remain a useful alternative in many patients, especially in the patients who are not good surgical candidates or patients who do not desire surgery. The authors of this article believe that all patients with symptomatic prolapse should at least be offered a trial of pessary prior to considering surgery.

Reconstructive 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. This article 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 they can be obliterative procedures that eliminate prolapse at the expense of potential coital function.

Preoperative bowel preparation can be considered but the recent gynecology and colorectal surgery literature suggest it is not necessary and may increase risks. If a bowel preparation is used, a combination of magnesium citrate and a Fleet enema on the night prior to surgery. The use of volume agents such as GoLYTELY is discouraged because a large amount of residual fluid in the bowel usually occurs, which may interfere with the surgery and potentiate contamination of the operative site. A first-generation cephalosporin is administered as a preoperative antibiotic prior to the time of the first incision. Deep vein thrombosis (DVT) prophylaxis should be instituted in all patients undergoing surgery for pelvic organ prolapse.

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 (re-establishing its continuity with the rectovaginal fascia), with appropriately high uterosacral ligament attachment. Specifically in cases of uterovaginal prolapse, the use of permanent sutures is preferred for the uterosacral ligament suturing. If the uterosacral ligaments are of insignificant strength, one may consider an abdominal sacral colpopexy or sacrospinous ligament fixation, depending on the approach.

Culdoplasty

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.

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 associated pelvic floor defects may be performed vaginally and may include anterior colporrhaphy, paravaginal repair, posterior colporrhaphy, and/or perineorrhaphy as required.

Vaginal approaches

Traditional vaginal approaches to reconstruction of the vaginal vault (following prior hysterectomy) include sacrospinous ligament fixation (unilateral or bilateral), bilateral iliococcygeus fascia suspension, or thigh 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 are considered obliterative procedures.

Sacrospinous ligament fixation may be approached by a posterior dissection or an anterior approach.^[29] The traditional posterior approach is described here.

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.

Two sutures are used, with at least 1 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 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 (see image below). This does not result in lateral deviation of the proximal vagina or in the posterior displacement observed with sacrospinous ligament fixation. High 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 and above 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 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 with intravenous indigo-carmine dye.

Le Fort colpocleisis

Le Fort partial colpocleisis involves retention of the uterus, and, therefore, should be preceded by dilatation and curettage (D&C). 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. Some authors prefer plication of the bladder neck (eg, Kelly plication) at this stage, even if no demonstrable or occult stress incontinence has been demonstrated preoperatively. The authors prefer the use of a midurethral sling procedure.

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 mucosa-lined tunnels are created. The entire vaginal mucosa 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.

Mesh-based kits

Recently, various minimally invasive, trocar-based transvaginal mesh kits have become popular in the management of vaginal vault prolapse.

For posterior compartment prolapse, a permanent mesh is introduced through an incision just lateral to the anus. A trocar is used to place the mesh and secure it near the level of the ischial spine. The trocar is placed through the buttock incision and guided pararectally through the ischiorectal fossa with the assistance of a finger dissecting from the apex of vagina towards the ischial spine. The ends of the mesh are secured at the apex and brought out through the 2 incisions lateral to the anus. The mesh, in effect, serves as artificial uterosacral ligaments to provide level I support for the vagina.

For anterior compartment support, these kits require placement of a mesh through a transobturator approach where 2 passes per side are done; one at the anteromedial aspect of the obturator foramen that exits close to the level of the urethrovesical junction and the other at the lateroposterior portion of the obturator foramen, which exits near the ischial spine at the arcus tendineus fascia pelvis.

The use of meshes in vaginal reconstructive surgery continues to be controversial. Few studies show a sufficient high level of evidence. Prior published studies could not demonstrate a significant advantage of meshes. Furthermore, vaginally placed meshes previously demonstrated a high erosion rate (>10%).^[30] Despite this, industry-driven, pelvic organ prolapse surgery with meshes is progressively increasing. Recent publications report better results and lower erosion rates (0-6.9%) that approach those of laparoscopic or open sacrocolpopexy (3-5%). Several studies suggest that transvaginal implantation of polypropylene mesh is an effective and safe technique for the correction of anterior prolapse. Synthetic meshes are used less frequently for posterior prolapse repair as traditional repair with native tissue yields good results.

The most recent results on synthetic meshes for total prolapse repair are encouraging.^[31] The improved mesh designs and prosthetic kits are important developments and might reduce the risk for complications. Before transvaginal meshes can be accepted as routine surgery, long-term controlled studies will have to confirm the effectiveness and safety of new meshes and include more functional data on sexuality and quality of life.^[32]

On July 13, 2011, the US Food and Drug Administration (FDA) issued a statement that serious complications are not rare with the use of surgical mesh in transvaginal repair of pelvic organ prolapse. The FDA reviewed the literature from 1996-2011 to evaluate safety and effectiveness and found surgical mesh in the transvaginal repair of pelvic organ prolapse does not improve symptoms or quality of life more than nonmesh repair. The review found that the most common complication was erosion of the mesh through the vagina, which can take multiple surgeries to repair and can be debilitating in some women. Mesh contraction was also reported, which causes vaginal shortening, tightening, and pain.

The FDA’s update states, “Both mesh erosion and mesh contraction may lead to severe pelvic pain, painful sexual intercourse or an inability to engage in sexual intercourse. Also, men may experience irritation and pain to the penis during sexual intercourse when the mesh is exposed in mesh erosion.” The FDA is continuing to review the literature regarding surgical mesh in the treatment of stress urinary incontinence and will issue a report at a later date. See the full update regarding surgical mesh in pelvic organ prolapse here: FDA Safety Communication: Update on Serious Complications Associated with Transvaginal Placement of Surgical Mesh for Pelvic Organ Prolapse.

It is important to emphasize that this FDA update and the concerns it highlights does not affect polypropylene mesh used in midurethral slings used for the treatment of stress urinary incontinence. Similarly, it does not pertain to the use of polypropylene mesh in sacral colpopexy, since it is placed through an intraperitoneal rather than a transvaginal approach. Another aspect that is not covered by the FDA update is the use of biological grafts in the reinforcement of transvaginal repairs.

In the authors' experience, much of the pain encountered following mesh kit prolapse surgery can be attributed to the novel pathways that these kits use to place and position the mesh, ie, the mesh arms. Since the mesh controversy remains a dynamic issue with conclusions that may change with time and deliberation, the authors would like readers to consider the possibility that mesh itself may not be the most responsible culprit. Other issues that may be of primary importance include the amount of mesh used (a dose-dependent phenomenon), the surgical techniques used in its placement, and the level of training of those doing the particular surgery in question.

Abdominal approaches

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 mesh, such as Mersilene or Prolene. 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 S3 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.

Various degrees of reperitonealization are used to avoid subsequent adhesions and/or entrapment of the bowel to or around 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 midsacral 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.^[33]

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 also been reported via the laparoscopic approach. 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.

A further development recently gaining recognition is the robot-assisted laparoscopic approach. The advantages of robotic surgery include improved visualization of the operative field with increased dexterity allowing more precise movements.^[34]

Robot-assisted laparoscopic sacrocolpopexy (RALS) is a new surgical management option for pelvic organ prolapse that secures the apex of vagina or cervical stump to the sacral promontory in a manner identical to an abdominal sacral colpopexy as described above. In addition to an umbilical camera port, 4 laparoscopic ports are placed, 3 for the surgical robot and 1 for the assistant. Prolene mesh is then attached to the sacral promontory and to the vaginal apex or cervical stump using nonabsorbable sutures. Reperitonealization of the mesh is desirable, but not always performed. Data suggests that this novel technique combines the advantages of open sacrocolpopexy with decreased hospital stay, less blood loss, low complication and conversion rates, and high patient satisfaction.^{[35, 36]}

Although the short-term outcomes of RALS are promising and encouraging, greater follow-up and numbers are needed to further establish the proper role of this procedure.^[37]

The authors strongly recommend following all reconstructive surgical procedures with administration of intravenous indigo-carmine dye and performance of 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.

For excellent patient education resources, visit eMedicine's Women's Health Center. Also, see eMedicine's patient education article Prolapsed Uterus.

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 perhaps more affected by the patient's preoperative voiding function 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; however, 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. Rarely, an oral taper-dose steroid is needed.

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.

Sacrospinous ligament fixation was reviewed by Sze and Karram.^[38] 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 less than 10%, as reported by multiple studies. Destructive operations, such as the Le Fort procedure, also have a success rate of over 90%.

Benson et al reported the first randomized comparison between abdominal and vaginal approaches to pelvic floor defects.^[39] 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.^[40] 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. These 2 studies have conflicting outcomes. Thus, further studies are needed before any definitive conclusions can be made.

Although initial success rates for the minimally invasive vaginal kits were reported in excess of 90%, recent reports have been lower. Jordaan et al had an overall success rate of 71% in all patients with prolapse and a 75% success rate in those presenting with only utero/vault prolapse.^[41] Mattox et al found a success rate of only 37% in elderly women.^[42] Long-term outcomes are still lacking.

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.

Newer trocar-based kits may present potential improvement in correction of impaired endogenous tissue; however, they invariably require implanting large amounts of mesh. Their long-term use, efficacy, and safety remain to be determined. An increasing number of women require surgical intervention for mesh-related complications based on limited data quality and short follow-up.^[43] The surgeon managing these complex problems of the pelvic floor should be proficient in a variety of procedures and approaches so that the patient may be fitted with the surgery that is the most appropriate for her specific set of problems.

Hysterectomy remains a common procedure during vaginal reconstructive pelvic surgery. Some authors propose uterine preservation, especially with implication of synthetic mesh kits.^[43] At present, no well-designed, prospective, randomized studies prove the superiority of hysterectomy or uterine preservation.^[44]