Management of apical pelvic organ prolapse - Beyond the Abstract

In our review article we describe various techniques to surgically repair apical prolapse. These include vaginal, abdominal, and minimally invasive techniques using traditional laparoscopy or robotics, as well as prolapse repairs with augmentation of mesh material. The decision on which route and technique to utilize is based on several factors.

These include the surgeon’s training and experience, the age and medical comorbidities of the patient, the severity of the prolapse, the risk of complications and the patient’s willingness to accept risks, and overall goals of the surgery.[1]

There is continued controversy on the benefits of robotic sacrocolpopexy versus laparoscopic sacrocolpopexy for apical prolapse. In our review article, we mentioned two randomized controlled trials that compared these techniques and found equal efficiency but longer operating times and more pain in the robotic groups. Recently, a meta-analysis by De Gouveia De Sa M et al reviewed nine studies, which included 1,157 subjects. They found no difference in anatomical outcomes, quality of life measures, mortality, or length of hospital stay. They did identify increased pain and longer operating times in the robotic groups. There were fewer complications in the robotics group but they cautioned that this might not be accurate, given the inclusion of non-randomized trials in their review. Based on this new review, we still support the use of both robotics and laparoscopic surgery to aid
surgeons in minimally invasive sacrocolpopexies given that not all surgeons are adequately training to perform complex laparoscopy. [2]

Another option for apical prolapse repair that was not mentioned in the review article is hysteropexy. Uterine preservation surgery is becoming increasingly popular with patients and should be considered as an option for patients with uterine prolapse who desire uterine preservation. Two studies have evaluated patient preference for hysterectomy for treatment of pelvic organ prolapse. Frick et al found that 60% of women would have preferred uterine sparing surgery if given the option, and Korbly et al found 36% of women would have preferred uterine preservation.[3,4] Techniques for hysteropexy include uterosacral suspension, either transvaginally, abdominally, or laparoscopically, sacrospinous ligament fixation, and sacrohysteropexy, either transvaginally, abdominally, or laparoscopically. Romanzi et al compared vaginal hysterectomy (n=100) to uterosacral hysteropexy (n=100) and found similar objective outcomes at 1.5 years.[5] A meta-analysis in 2013 demonstrated equal efficacy between vaginal hysterectomy and sacrospinous hysteropexy.[6] Vaginal mesh kits can also be utilized for hysteropexy usually utilizing the sacrospinous ligaments, however, these should be used by surgeons with experience due to their higher complication rates. The most evidence available is supporting sacrohysteropexy. However, there is variability in the technique, dissection, and mesh placement. A prospective study compared (n=72) open hysterectomy with sacrocolpopexy to open sacrohysteropexy and found no anatomical differences at 51 weeks. However, they did find significantly lower mesh exposure rates in the sacrohysteropexy group.[7] Given that many women would like the option to keep their uteri, surgeons should become familiar with these techniques and try to provide them as an alternative to hysterectomy with prolapse repair. There remains a lack of data, however, on the effect of uterine suspension on later pregnancy.

We emphasize that there is no “one size fits all” approach to prolapse. Treatment needs to be individualized based on the patient’s needs and wishes as well as the expertise of the surgeon. The ideal surgical repair will reduce risk yet provide the most durable procedure a patient can tolerate.

Written By:

Alexandriah N Alas1, Jennifer T Anger2

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1. Hill AJ, Barber MD (2015) Apical prolapse repair: weighing the risks and benefits. Curr Opin Obstet Gynecol 27 (5):373-379. doi:10.1097/GCO.0000000000000203
2. De Gouveia De Sa M, Claydon LS, Whitlow B et al. (2015) Robotic versus laparoscopic sacrocolpopexy for treatment of prolapse of the apical segment of the vagina: a systematic review and meta-analysis. Int Urogynecol J. doi:10.1007/s00192-015-2763-0
3. Frick AC, Barber MD, Paraiso MF et al. (2013) Attitudes toward hysterectomy in women undergoing evaluation for uterovaginal prolapse. Female Pelvic Med Reconstr Surg 19 (2):103-109. doi:10.1097/SPV.0b013e31827d8667
4. Korbly NB, Kassis NC, Good MM et al. (2013) Patient preferences for uterine
preservation and hysterectomy in women with pelvic organ prolapse. Am J Obstet Gynecol 209 (5):470 e471-476. doi:10.1016/j.ajog.2013.08.003
5. Romanzi LJ, Tyagi R (2012) Hysteropexy compared to hysterectomy for uterine prolapse surgery: does durability differ? Int Urogynecol J 23 (5):625-631. doi:10.1007/s00192-011-1635-5
6. Gutman R, Maher C (2013) Uterine-preserving POP surgery. Int Urogynecol J 24 (11):1803-1813. doi:10.1007/s00192-013-2171-2
7. Costantini E, Porena M, Lazzeri M et al. (2013) Changes in female sexual function after pelvic organ prolapse repair: role of hysterectomy. Int Urogynecol J 24 (9):1481-1487. doi:10.1007/s00192-012-2041-3