Enterocele and Massive Vaginal Eversion 

Updated: May 11, 2016
Author: Rony A Adam, MD; Chief Editor: Kris Strohbehn, MD 

Overview

Background

Massive vaginal vault prolapse is a devastating condition with discomfort, genitourinary and defecatory abnormalities as the primary consequences. Pelvic organ prolapse is prevalent and associated with significant health–related quality of life and economic impact.[1] References to prolapse of the womb were first made in ancient Egypt, dating back to 1550 BC. Vaginal vault prolapse refers to significant descent of the vaginal apex following a hysterectomy (see the image below) while uterovaginal prolapse denotes apical prolapse of the cervix, uterus and proximal vagina.

Enterocele and massive vaginal eversion. Posthyste Enterocele and massive vaginal eversion. Posthysterectomy vaginal vault prolapse.

These apical failures are often accompanied by anterior and or posterior vaginal compartment prolapse with or without enterocele. Although this obviously is not a new condition, apical prolapse is thought to be increasingly common as life expectancy increases. According to population projections from the U.S. Census Bureau from 2010 to 2050 and published age-specific prevalence estimates for bothersome, symptomatic pelvic floor disorders and pelvic organ prolapse, the number of women with uterovaginal prolapse is expected gradually to increase from 3.3 to 4.9 million from 2010 to 2050.[2]

Whereas complete vaginal eversion is obvious, lesser degrees of prolapse and the presence of enterocele are more difficult to discern and require careful evaluation of all anterior, posterior, and apical compartment defects. Also, associated functional abnormalities, whether concurrent or potential, must be properly explored, evaluated, and discussed with the patient.

Problem

A uniform definition of what constitutes apical prolapse or any pelvic organ prolapse does not exist. The International Urogynecological Association and International Continence Society define pelvic organ prolapse as the descent of one or more of the anterior vaginal wall, posterior vaginal wall, the uterus (cervix), or the apex of vagina (vaginal vault or cuff scar after hysterectomy).[3] Indeed, a degree of uterine/vaginal descensus is present in many, if not most, women who are multiparous. Not all patients with prolapse are symptomatic, and the degree of prolapse often does not correlate with the degree of symptoms reported by the patient. Furthermore, pelvic floor- related symptoms do not predict the anatomic location of the prolapse especially in women with mild to moderate prolapse.[4] A systematic and comprehensive description of pelvic organ prolapse is useful to help document and communicate the severity of the problem, to establish treatment guidelines, and to improve the quality of research to standardizing definitions.

The pelvic organ prolapse quantification (POP-Q) system was developed to address deficiencies in measuring and reporting the extent of prolapse. Specific sites are defined separately on the anterior, posterior, and apical vaginal compartments and are measured with respect to a fixed reference point, the hymen. These measurements can then be categorized into an ordinal staging system ranging from 0-4.

  • Stage 0 denotes no prolapse (the apex can descend as far as 2 cm relative to the total vaginal length).

  • Stage 1 means that the most distal portion of the prolapse descends to a point more than 1 cm above the hymen.

  • Stage 2 denotes that the maximal extent of the prolapse is within 1 cm of the hymen (outside or inside the vagina).

  • Stage 3 means that the prolapse extends more than 1 cm beyond the hymen but no more than within 2 cm of the total vaginal length.

  • Stage 4 denotes complete eversion, which is defined as extending to within 2 cm of the total vaginal length.

    The POP-Q staging system has been validated and demonstrates good interobserver and intraobserver reliability. Although POP-Q staging adequately addresses the extent of prolapse, assumptions about which organ is behind the visualized bulge should be made with caution and should be made only after a complete evaluation.

    Regarding enterocele, the definition is somewhat more difficult. Previous texts have defined enterocele as a hernia in which peritoneum and abdominal contents displace the vagina and is palpable within the cul-de-sac, as evaluated during a rectovaginal examination in the erect position.  Patients with such findings may have a deep cul-de-sac and thus represent a normal variant.  A more anatomic definition was proposed by Richardson, who suggested that enterocele occurs when endopelvic fascia does not intervene between the peritoneum and vagina (see image below).[5]  The differences in these approaches have not been completely resolved as data does not support the endopelvic fascial defects proposed.

Enterocele and massive vaginal eversion. Large api Enterocele and massive vaginal eversion. Large apical endopelvic fascial defect representing an enterocele demonstrated by the transabdominal route. Note the proximal cervicovaginal and rectovaginal fascia separate from the peritoneum.

 

 

Epidemiology

Frequency and Prevalence

Pelvic organ prolapse (POP) when defined by symptoms has prevalence of 3-6% and up to 50% when based upon vaginal examination. Moreover, the prevalence of surgical correction of the prolapse varies widely from 6 to 18% with incidence of POP surgery from 1.5 to 1.8 per 1,000 women years and peaks in women aged 60-69.[6] Swift reported on the frequency of different stages of pelvic organ prolapse in a routine gynecologic clinic population based upon the POP-Q staging system. Most women had stage 1 or stage 2 prolapse (43.3% and 47.7%, respectively), few women had stage 0 or stage 3 prolapse (6.4% and 2.6%, respectively), and none had stage 4 pelvic organ prolapse.[7] Samuelsson et al report a prevalence of 30.8% for any prolapse, using the Baden-Walker halfway system, in a study of the general population in Sweden. Vaginal vault prolapse is thought to occur postoperatively in 0.5% of hysterectomy cases, whether they are performed vaginally or abdominally.[8] In a population-based Dutch study the prevalence of pelvic organ prolapse based on POP-Q staging were: stage 0 = 25.0%; stage I = 36.5%; stage II = 33%, stage III = 5.0%; stage IV = 0.5%.[9]

Etiology

Current evidence support a multifactorial etiology of POP. Swift reported that significant trends for increasing prolapse were found with advancing age, parity, postmenopausal status, previous hysterectomy, and prior corrective surgery for prolapse.[7]  Multivariate analysis in a study performed by Samuelsson et al revealed independent statistical associations with age, parity, maximal birth weight, and pelvic floor muscle strength.[8]  Such associations were not found regarding weight or hysterectomy status. Some epidemiologic evidence contradicts the opinion that female pelvic organ prolapse worsens with age.[8] Furthermore, Sze et al demonstrated that vaginal birth is not associated with POPQ stages III and IV prolapse, but it is associated with an increase in POPQ stage II defect.[10]

It is well recognized that POP runs in the families, giving credence to a hereditary contribution to the phenotype with some evidence that loci on chromosomes 10q and 17q may contribute to the etiology of prolapse.[11, 12, 13, 14] Racial differences have been reported for pelvic organ prolapse, although is not yet clear whether the differences are biological or sociocultural. Whitcomb et al showed that compared with African-American women, Latina and white women had four to five times higher risk of symptomatic prolapse, and white women had 1.4-fold higher risk of objective prolapse  at or beyond the hymen.[1] More recently, data obtained from African American and Hispanic women who were enrolled in the Women’s Health Initiative Hormone Therapy with available genotyping data from Women’s Health Initiative-SHARe, suggests that common germ-line variations may contribute to increased risk of POP among African Americans and Hispanics; however, further research with larger minority sample sizes is necessary to confirm this finding.[15]

Pathophysiology

As discussed, genetic factors may play a significant role in development of uterovaginal prolapse. Current basic science research suggests a molecular etiology of pelvic organ prolapse. Some studies demonstrate an increased rate of apoptosis and significant depletion of mitochondrial DNA in uterosacral ligaments in women with uterovaginal eversion.[16, 17]

The precise etiology of pelvic organ prolapse remains elusive. Additional theories include diminished sacral nerve function and/or defects in collagen. The pelvic floor is a unique and complex system constructed of skeletal and striated muscles, support and suspensory ligaments, fascial layers and an intricate neural network. When this system is damaged, pelvic floor failure may occur and pelvic organ prolapse ensues.[18]

DeLancey describes the anatomy of vaginal vault prolapse in terms of 3 levels of support (see image below).[19]

Enterocele and massive vaginal eversion. Levels of Enterocele and massive vaginal eversion. Levels of support as described by DeLancey (1992). Note that level I refers to apical (or uterovaginal) support.

See the list below:

  • Level I refers to the support of the upper vagina and cervix or the vaginal cuff (in a woman who has undergone total hysterectomy) by the cardinal-uterosacral ligament complex.

  • Level II denotes the lateral support of the mid vagina to the arcus tendineus fascia pelvis (white line).

  • Level III is represented by the fusion of tissue along the base of the urethra and the distal rectovaginal septum to the perineal body.

The conditions of enterocele and vaginal eversion represent failures of level I support, although other compartments may be affected. Uterovaginal prolapse does not denote intrinsic uterine disease and, therefore, may not necessarily require a hysterectomy in all cases. It should be noted, however, that no evidence proves or disproves the benefit of hysterectomy at the time of apical suspension.

Apical prolapse occurs because of tearing (or attenuation) of the cardinal-uterosacral ligament complex. This results in failure to support the upper vagina and/or uterus over the pelvic diaphragm, which should be in a near-horizontal plane in a woman in the erect position. Level I support is considered primary in maintaining adequate overall pelvic support.

Richardson describes an enterocele in anatomic terms, as a break in the integrity of endopelvic fascia at the vaginal apex (see image below).[20]

Enterocele and massive vaginal eversion. Normal po Enterocele and massive vaginal eversion. Normal posthysterectomy vaginal vault. Note the presence of continuity of the endopelvic fascia at the vaginal apex, resulting from the fusion of cervicovaginal and rectovaginal fascia, and their fusion with the uterosacral ligament portion of endopelvic fascia.

Normally, posthysterectomy enterocele is precluded by the apposition of pubocervical and rectovaginal fascia (collectively termed endopelvic fascia) at the apex. Anterior, apical, and posterior enteroceles have been described based upon the location of the fascial defect and the location of the ensuing herniation of bowel.

Apical enterocele is the most common enterocele and is primarily associated with post-hysterectomy vaginal vault prolapse. Apical enterocele may present with or without vaginal vault prolapse (see images below).

Enterocele and massive vaginal eversion. Early ent Enterocele and massive vaginal eversion. Early enterocele with no vault prolapse. Note contact of peritoneal contents with vaginal mucosa, with no intervening endopelvic fascia.
Enterocele and massive vaginal eversion. Progressi Enterocele and massive vaginal eversion. Progressive enterocele now demonstrating true vaginal vault prolapse.
Enterocele and massive vaginal eversion. Massive e Enterocele and massive vaginal eversion. Massive enterocele with total vaginal vault prolapse.

Anterior enteroceles are rare and may occur following sacrospinous ligament fixation, when the proximal vagina is displaced posteriorly, creating a potential space in the anterior compartment. Because they present as a protrusion of the anterior vaginal wall, they may be the true etiology of some cystoceles. In women with an intact uterus, posterior enteroceles have been described. These are due to tearing of the proximal rectovaginal fascia from its attachment to the cardinal-uterosacral ligament complex, which results in descent of the peritoneal contents down the posterior aspect of the vagina (see image below). 

Enterocele and massive vaginal eversion. Posterior Enterocele and massive vaginal eversion. Posterior enterocele in a patient with a uterus. Note that peritoneal contents have dissected between the vaginal mucosa and rectovaginal fascia through a proximal defect.

Posterior enterocele is usually accompanied by significant uterovaginal prolapse and prolapse of other compartments as well.[20]

Histologic studies by Tulikangas et al failed to find breaks in the fibromuscular layer in women who underwent surgical correction for enterocele compared with controls (women who did not have pelvic organ prolapse).[21] Admittedly, the authors' findings did not correlate with their subjective clinical findings of thinning of the vaginal wall in enteroceles. Hsu et al similarly found a lack of difference in vaginal wall thickness on MRI studies of patients with prolapse and their normal controls.[22] The numbers in these studies, however, were small and further investigation is needed before this controversy is fully resolved.  Nonetheless the authors believe that considering this theory in the context of surgical correction has merit and aids in properly managing these conditions.

Presentation

Patients may present with an obvious vaginal bulge that is visualized or felt by the patient. Conversely, the patient may report a vague sense of pelvic heaviness or a sensation that something is about to fall out. The bulging is often noted to be worse toward the end of the day, as compared with when the patient first wakes up, or when the patient is straining at defecation or urination. When vaginal epithelium remains exteriorized, it undergoes cornification and, often, ulceration, which can result in significant pain, vaginal bleeding, discharge and infection.

Functional difficulties may be encountered during coitus. Defecation may be difficult; associated constipation is very common. Incomplete bladder emptying also is common, and, in severe cases, complete obstruction may occur. Voiding dysfunction may result in frequent urinary tract infections and, occasionally, overflow incontinence. Due to kinking of the urethra, occult (potential) stress incontinence and even intrinsic sphincter deficiency may be present. A history of stress incontinence that spontaneously improved and/or resolved as the prolapse progressively worsened is especially concerning for the presence of occult stress incontinence. In a cross-sectional study urinary urge incontinence was associated with anterior wall prolapse, while stress urinary incontinence was strongly linked to posterior wall prolapse.[4] Advanced pelvic prolapse may result in ureteral kinking with the potential for hydroureter, hydronephrosis in 30% of cases.[23]

A detailed history is required to evaluate the patient. Information regarding any functional problems that may be caused by the prolapse should be ascertained. Essential to the preoperative evaluation and surgical decision-making is the review of any prior pelvic surgery, including obtaining operative reports, especially if surgery was performed for prior pelvic floor dysfunction. It is imperative to evaluate and stabilize the patient’s general health to assess for and mitigate against any increased surgical risks

A commitment to surgically treat all associated and relevant pelvic floor defects requires a careful and comprehensive urogynecologic examination. A diligent search for all pelvic support defects and repair of these defects increases the likelihood of overall surgical success and patient satisfaction. The apical, anterior, and posterior compartments are evaluated separately, with and without straining and/or coughing in the supine position and again in the erect position if needed, preferably with an empty bladder. A standardized examination should be performed and documented. The POP-Q exam is helpful for quantifying the extent of prolapse and accurate follow-up. Carefully evaluate the rectovaginal septum for integrity, strength, and thickness along its entire length. Look for any signs of enterocele, such as bowel peristalsis, along the posterior vagina or near the apex. Look for any obvious pubocervical/rectovaginal detachments at the periphery of an apical bulge. Evaluate the cul-de-sac in the supine and standing positions, with and without Valsalva maneuvers.

Indications

Treatment of pelvic organ prolapse is indicated if it is symptomatic or is causing associated morbidity. Asymptomatic prolapse, with minor degrees of protrusion that cause no other problems, must be discussed with the patient but does not necessarily require treatment.  In the older population, even extensive prolapse may be asymptomatic from the patient's point of view, but questioning her family or caregiver may reveal troublesome symptoms, and further evaluation may reveal significant resultant morbidity.

Offer conservative management to these patients as the initial management option. Conservative management may include observation with mild degrees of asymptomatic prolapse or a pessary fitting. Surgical management may be considered in appropriate candidates if conservative therapies fail or are declined by the patient.

Relevant Anatomy

The cardinal-uterosacral ligaments are localized thickenings of the endopelvic fascia that invest the pelvic organs. The same endopelvic fascia that is anterior to the vagina is called pubocervical; posteriorly, it is termed rectovaginal fascia or Denonvilliers fascia. Laterally, the endopelvic fascia attaches the vagina to the arcus tendineus fascia pelvis to provide lateral support to the mid-vaginal compartment, whereas the distal rectovaginal fascia attaches laterally to the aponeurosis of levator ani.[24]

The integrity of the vaginal apex following hysterectomy depends on the fusion of the pubocervical fascia with the rectovaginal fascia. Surgically, the uterosacral ligaments lie medial to the ureters in the pelvis. The proximal uterosacral ligament fans out and attaches to the lateral aspect of the sacrum. MRI studies show slight variations in the attachment of the uterosacral ligament, although most overlay the sacrospinous ligament/coccygeus muscle. The proximal vagina usually points into the hollow of the sacrum towards S3 and S4 and maintains a near-horizontal plane when the woman stands erect.

Although the term fascia is frequently used to denote the surgically significant layer used for pelvic reconstruction, histologically, it is a fibromuscular layer with varying amounts of smooth muscle, collagen, and elastin that is located deep to the epithelium.

Contraindications

Pessary use is contraindicated in the presence of vaginal ulceration and breakdown or in the presence of an active vaginal infection. Severe vaginal atrophy is best treated prior to starting pessary use, in the absence of contraindications for estrogen use.

The medical evaluation of a patient for surgical repair is a topic that is too broad for this article. However, one should tailor the proposed operation to the specific defects noted preoperatively, taking into consideration the patient's overall health and prior surgical history. The chosen approach, whether vaginal, abdominal, laparoscopic, or robotically-assisted should be selected with careful consideration of these patient-related points, in addition to the surgeon's level of skill and available local resources. Appropriate consultations and referrals during the preoperative evaluation can ensure the highest degree of success and safety.

 

Workup

Laboratory Studies

See the list below:

  • Standard preoperative laboratory evaluation should be performed to screen for anemia, metabolic abnormalities, and clotting problems. Surgical procedures for the repair of massive prolapse frequently involve elderly patients, and the operations are often prolonged, involving Trendelenburg position with legs elevated in stirrups. Pay special attention to the effects on patients with cardiac or pulmonary conditions, and appropriate tests such as ECG, CBC, and clotting studies are important. Prophylactic anticoagulant therapy should be considered in all patients.

  • A urinalysis and culture are routinely sent to rule out infection and/or hematuria.

  • If the prolapse is extensive, BUN and creatinine may be elevated because of obstruction and should therefore be evaluated.

Imaging Studies

See the list below:

  • Imaging studies have traditionally included intravenous pyelogram (IVP) for cases of severe prolapse to rule out hydronephrosis. A renal ultrasound is now the preferred technique if needed for this indication.

  • Controversy exists regarding the utility of other imaging studies. These may include dynamic cystoproctography, magnetic resonance imaging (MRI), 3D and 4D transperineal ultrasound, and even peritoneography (ie, the injection of radiographic dye into the peritoneal cavity).[25] These studies may be reserved for difficult and inconclusive cases, especially for the diagnosis of enterocele and sigmoidocele but are not routinely necessary.

Diagnostic Procedures

See the list below:

  • Although controversial, multichannel urodynamic studies with prolapse reduction may be used to further evaluate the preoperative patient with significant prolapse.

    • These studies often include initial uroflowmetry (with the prolapse not reduced) followed by insertion of a pessary, or other methods to reduce the prolapse (speculum, proctoswabs etc) , performance of complex cystometry, and a pressure-voiding study with or without electromyography (EMG). Although uroflowmetry is ideal, measuring the patient's voided volume and a subsequent postvoid residual by ultrasound or catheterization should suffice for the vast majority of cases. Postvoid residual volumes less than 50-100 mL are considered normal range, if the patient voids at least 200 mL.[26]

    • With the prolapse reduced and pessary placement checked so it is not obstructing the urethra, complex cystometry with provocative maneuvers is used to assess for occult stress incontinence.

    • When initial uroflowmetry is combined with a pressure-voiding study, information regarding the potential for postoperative obstructed voiding is obtained and may influence the choice of procedures.

  • Several diagnostic procedures are available for the assessment of anal incontinence, which often coexists with prolapse and urinary incontinence and is beyond the scope of this manuscript.

 

Treatment

Medical Therapy

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).[27]

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%).[30]

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.[31]

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.[32]

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.[32] 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.

Surgical Therapy

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 Details

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.[33]

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.

Intraoperative Details

When including hysterectomy as a treatment modality for uterovaginal prolapse, preservation, restoration, and strengthening of pelvic support is of primary importance.[34] 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

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

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).

Enterocele and massive vaginal eversion. Sacrospin Enterocele and massive vaginal eversion. Sacrospinous ligament fixation. The right sacrospinous ligament is being penetrated using the Nichols-Veronikis ligature carrier.

Take care to avoid injury to the inferior gluteal artery, pudendal neurovascular bundle, and the sciatic nerve (see image below).

Enterocele and massive vaginal eversion. The anato Enterocele and massive vaginal eversion. The anatomy surrounding the right ischial spine.

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).

Enterocele and massive vaginal eversion. Note the Enterocele and massive vaginal eversion. Note the pudendal neurovascular bundle at the lateral aspect of the sacrospinous ligament. Also note the proper penetration of the suture into the body of the coccygeus muscle.

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.

Enterocele and massive vaginal eversion. Following Enterocele and massive vaginal eversion. Following penetration of the sacrospinous ligament, the permanent suture (on the left) is attached to the posterior vagina by a figure-eight stitch, incorporating rectovaginal fascia but not penetrating the mucosa. Once this stitch is tied, a pulley has been created whereby the vagina can be drawn up to the ligament by pulling on the free suture and then tied down. The delayed absorbable suture is driven through-and-through and is tied on the vagina.

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).

Enterocele and massive vaginal eversion. Depiction Enterocele and massive vaginal eversion. Depiction of completed fascial reconstruction with uterosacral reattachment in the sagittal view. Note that the vaginal apex has been restored to its normal anatomic location and is directed to the hollow of the sacrum.

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).

Enterocele and massive vaginal eversion. Le Fort c Enterocele and massive vaginal eversion. Le Fort colpocleisis begins with dissection and excision of a rectangular patch of mucosa on both the anterior and posterior vagina. Gradual inversion of the vaginal tube is accomplished by interrupted sutures that approximate anterior to posterior. Reapproximation of the lateral vaginal mucosal edges serves to maintain the tunnels on either side of the repair. From Thompson JD. Surgical correction of defects in pelvic support. In: Rock JR, Thompson JD, eds. TeLinde's Operative Gynecology. 8th ed. Philadelphia, Pa: Lippincott-Raven; 1997.

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.

Mesh-based kits

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

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.

Enterocele and massive vaginal eversion. Transabdo Enterocele and massive vaginal eversion. Transabdominal repair of the large enterocele noted in Image 2. Note interrupted permanent sutures used for repair.

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.

Enterocele and massive vaginal eversion. Mesh conf Enterocele and massive vaginal eversion. Mesh configuration for abdominal sacral colpopexy. The crux of the Y is formed by permanent sutures with the knots tied down on the side that faces the sacrum, not the vagina.

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).

Enterocele and massive vaginal eversion. Note the Enterocele and massive vaginal eversion. Note the anatomy of the lower presacral space. Take care to adequately mobilize the sigmoid colon and ensure the safety of the right ureter. Identification of the middle sacral vessels is important to avoid hemorrhage.
Enterocele and massive vaginal eversion. Note adeq Enterocele and massive vaginal eversion. Note adequate bites taken into the anterior sacral fascia at sacral level 3 (S3). Take care not to attach the mesh too high (towards the sacral promontory) so that the normal vaginal axis is maintained. Also, take care to avoid excess tension on the vagina.
Enterocele and massive vaginal eversion. Note the Enterocele and massive vaginal eversion. Note the axis of the vagina and the attachment of the mesh to the sacrum at sacral level 3 (S3).

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.[35]

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).

Enterocele and massive vaginal eversion. Bilateral Enterocele and massive vaginal eversion. Bilateral uterosacral reattachment has been performed laparoscopically with a permanent suture in a patient who desired retention of the uterus.

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.[36] 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.[39]

Postoperative Details

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.

Follow-up

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 eMedicineHealth's Women's Health Center. Also, see eMedicineHealth's patient education article Prolapsed Uterus.

Complications

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.[40] 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.[41] 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.[42] 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.[43] 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.[44] 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.[45]

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.[46]

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.[47]

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.[48] 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.[49]