Gynecologists have been debating the optimal route for repair of pelvic organ prolapse throughout the last century. The minutes of a North of England Obstetrics & Gynaecological Society meeting in 1918 describe the debate over how an 18-year-old woman with procidentia should be treated. The treatment proposed was a vaginal repair and ventrofixation. William Blair Bell, professor of obstetrics and gynecology in Liverpool, founder of the RCOG, urged against ventrofixation. William Fletcher-Shaw, a leading gynecological surgeon, deprecated all abdominal operations for prolapse. William Fothergill, professor of obstetrics and gynecology in Manchester, who described the Manchester repair, was also not in favor of the abdominal approach to prolapse surgery. In 1921 he is quoted as saying “It is not to the credit of the profession that women should go home with their cervices still projecting at the vulval cleft after having undergone the risk, discomfort and expense of futile ventrofixations at the hands of those who have never attempted to learn vaginal surgery.”

Until 20 years ago, the additional morbidity of the abdominal approach to prolapse surgery through a laparotomy incision encouraged surgeons to employ a vaginal approach to prolapse repair whenever possible. The introduction of laparoscopic and robotic surgical techniques with decreased morbidity compared with open abdominal procedures has resulted in a lowered threshold for choice of the abdominal approach to repair of uterovaginal prolapse.

In this chapter we will discuss the factors that influence the approach a surgeon employs for the repair of pelvic organ prolapse. Little robust evidence for most practices exists and decisions regarding approach are mainly influenced by the opinion of leading surgeons of the era. In clinical practice the final decision on which approach is taken will often depend on a number of factors rather than a single one. Thus, the obese patient with a history of multiple complex abdominal surgeries and chronic obstructive airways disease is likely to be more suitable for the vaginal approach with regional analgesia, rather than an open or laparoscopic abdominal approach.

Type of Prolapse

Anterior or Posterior Vaginal Wall Prolapse

Prolapse of the anterior or posterior walls of the lower half of the vagina is clearly more easily approached surgically through the vaginal route. Prolapse of the anterior vaginal wall may be repaired by a paravaginal repair that can be performed vaginally or abdominally via an open or laparoscopic route. Although use of the paravaginal repair has been popular with some surgeons, there is little robust evidence to support its use instead of a standard fascial repair for the treatment of anterior vaginal wall prolapse. No randomized controlled trials (RCTs) compare standard anterior repair with either abdominal or vaginal paravaginal repair. The trocar-guided polypropylene mesh systems and inlays that are inserted vaginally are effectively paravaginal vaginal repairs, as many of the trocars are placed through the paravaginal tissues proximately and distally. Evidence from recently published RCTs indicates that a trocar-guided vaginal approach using mesh may be superior to traditional anterior colporrhaphy with regard to anatomic success.^1-3

A recent Cochrane review of the surgical treatment of prolapse concluded that standard anterior repair was associated with more anterior compartment failures on examination than repairs performed with polypropylene mesh using armed transobturator approaches (RR 3.55, 95% CI 2.29–5.51).⁴ The same review also concluded that blood loss with armed transobturator meshes was significantly higher than that with native tissue anterior repair.

Rectoceles can be treated transvaginally or transanally. There is debate regarding which approach is superior. Colorectal surgeons tend to favor the transanal approach; the evidence suggests that for posterior vaginal wall prolapse, the vaginal approach was associated with a lower rate of recurrent prolapse than the transanal approach (RR 0.24, 95% CI 0.09–0.64), although there was a higher blood loss and postoperative narcotic use.⁴

Many surgeons believe that failure of traditional vaginal approaches to resolve either anterior or posterior prolapse may result from failure to address the descent of the vaginal vault, and that the key to the treatment of vaginal prolapse is suspension of the apex. Strong evidence to support or refute this theory is lacking.

Uterine Prolapse

Literature suggests conservation or removal of the uterus for uterine prolapse has been dictated as much by fashion and peer influence as by evidence of benefit. During the first half of the last century, uterine conservation was popular. The Manchester repair included cervical amputation and shortening of the cardinal ligaments as a repair for uterovaginal prolapse. During the last half century gynecologists have generally elected to perform a vaginal hysterectomy (VH) when uterine prolapse is present.

In recent years there has been a dramatic reduction in the rate of hysterectomy for menstrual dysfunction and interest has increased in the use of surgeries that conserve the uterus. Future desire for pregnancy may influence the decision of whether or not to remove the uterus; in addition, the risk of future cervical or uterine pathology needs to be considered.

Uterine conserving prolapse surgeries can be performed abdominally or vaginally. In 1993, van Lindert et al. described a sacrohysteropexy; many of the current hysteropexy surgeries appear to be a variation on that description.⁵ Sacrohysteropexy techniques involve attaching type I polypropylene mesh to the anterior surface of the cervix and passing it through an avascular area of the broad ligament approximately 1 cm above the level of the cervicouterine junction.

A single small randomized trial compared open abdominal sacrohysteropexy and VH with repair in 41 patients in each arm.⁶ The reoperation rate, either performed or planned, was 22% in the patients who underwent abdominal surgery and only 5% in those who underwent vaginal surgery. The authors concluded that VH with anterior and/or posterior colporraphy is preferable to abdominal sacrocolpopexy with preservation of the uterus. Several case series of both open and laparoscopic sacrohysteropexy have been published that have reported excellent results with sacrohysteropexy, although the numbers of women treated are typically very small (3–34 subjects) and retrospective chart reviews are known to be associated with higher success rates than prospective trials. Failure rates in these case series range from 0% to 22%.⁷

Recently two case series of laparoscopic sacrohysteropexies have been published. Rosenblatt et al. reported a 100% anatomic and subjective cure at 12 months.⁸ Price et al. reported 51 cases and only one recurrence following sacrohysteropexy but follow-up was conducted at ten weeks after surgery.⁹ The level of evidence for use of open or laparoscopic sacrohysteropexy to treat uterine prolapse is very poor and further studies are required.

Three retrospective case control studies have compared VH with uterine-sparing sacrospinous hysteropexy (USSH).^10-12 The numbers of women treated in all three series were small. No significant difference between USSH and VH in terms of objective or subjective cure rates was found. Both the operating time and blood loss were less for USSH compared with those for VH. A single underpowered RCT compared USSH with VH. The recovery period for USSH was shorter compared with that for VH and USSH was associated with a slightly higher number of apical recurrences with 11% of women undergoing USSH requiring further prolapse surgery compared with 7% in the VH group. The study concluded that USSH was associated with a shorter recovery time and more recurrent apical prolapse but no difference in functional outcomes and quality of life.¹³