Surgical Management of Pelvic Organ Prolapse
Kate V. Meriwether
PELVIC ORGAN PROLAPSE PATIENT BURDEN AND RELEVANT OUTCOME MEASURES
Pelvic organ prolapse (POP) has profound impacts on women’s quality of life. Qualitative work in this field holds important revelations about how women are affected by this disorder.1 Shame and silence surround POP, which creates an enormous emotional burden.2,3 This problem is compounded by the fact that women often do not know about treatment options, including surgery.1 Goals important to patients following surgery include relief of bulge symptoms and sense of restoration of normal anatomy, closely followed by desire to maintain or restore sexual function.4,5 Given this context, it is of no surprise that at least 12.6% of women undergo POP surgery in their lifetime,6,7 and that measuring the success of these surgeries is paramount, albeit varied.
Historically, success in POP surgery was measured by restoration of normal vaginal anatomy, and this was the way surgeons weighed the benefit of one surgery versus another. For years, the patient experience was not fully integrated into outcome measures for POP surgery. Fortunately, a shift has been occurring in the field that emphasizes the importance of patientcentered outcome measures, and compound measures that integrate both anatomic restoration and the patient’s experience of POP-related symptoms are advocated.1,8,9,10,11 In other words, surgeons in the field should evaluate if certain surgeries cause relief of symptoms relevant to patients and have a positive impact on patients’ lives (Table 42.1).
Validated patient-centered outcomes that are commonly used to assess POP symptoms or their impact on the patient include the Pelvic Floor Distress Inventory (PFDI), the Pelvic Floor Impact Questionnaire (PFIQ), and the Pelvic Organ Prolapse/Urinary Incontinence Sexual Function Questionnaire (PISQ).11,15,16,17,18 Other frequently used relevant outcomes includes recurrence of symptoms of prolapse after surgery and the prevalence of reoperation for recurrent prolapse or complications of the original surgery. For objective outcomes, high-quality studies often use an objective measure of vaginal anatomical failure as defined by the Pelvic Organ Prolapse Quantification (POP-Q) exam. Common examples of definitions of anatomical failure include any stage 2 or greater prolapse, prolapse beyond the hymen, or apical prolapse as measured by a vaginal apex more than one-third or one-half down its total vaginal length (Fig. 42.1).1,8,9,10,11,19
Anatomic success is measured by the different portions of the vagina, or compartments, including the apical, posterior, anterior, and distal/perineal compartments, and the different surgeries intended to address different compartments (Fig. 42.2).20 For example, surgeries that address the apical compartment include sacrocolpopexy/sacrocervicopexy/sacrohysteropexy, uterosacral ligament suspension/uterosacral ligament hysteropexy, sacrospinous ligament fixation/sacrospinous ligament hysteropexy, sacrospinous ligament fixation with graft, anterior abdominal wall hysteropexy, iliococcygeal fixation, colpocleisis, and the Manchester procedure. Surgeries that address the anterior compartment include anterior vaginal repair, paravaginal repair, and anterior vaginal repair with graft. Similarly, surgeries that address the posterior compartment include posterior vaginal repair, posterior vaginal repair with graft, and levator plication. The distal or perineal compartment is addressed specifically by perineal repair.20
CURRENT DECISIONS IN SELECTING A PROCEDURE
In the current surgical climate, patients and surgeons are faced with several important decisions when selecting a procedure. For the most part, these decisions should be based on a combination of the patient’s desires and goals as well as the surgeon’s familiarity and experience with a procedure.
The first of these decisions is one to determine if the patient desires insertive vaginal intercourse in the future. This lack of desire for insertive vaginal intercourse
makes women possible candidates for an obliterative procedure. Usually, this entails a colpocleisis, where opposing vaginal walls are de-epithelialized and sutured to one another, shortening the vaginal length substantially,21 as opposed to a reconstructive procedure, such as a vaginal apical suspension.22,23,24,25,26,27,28,29 Of note, women consider body image, sexuality, and their sense of self when considering this decision, and even women who do not wish to engage in vaginal insertive intercourse may desire to avoid colpocleisis for a variety of reasons. It is also important to note that insertive vaginal intercourse is only a possible part of sexual activity, so the patient’s range of sexual expression should be considered prior to arriving at a shared decision to perform colpocleisis. The minimal risk of recurrence after colpocleisis, as well as the minimally invasive approach,30 should be weighed against the patient’s certainty that she is amenable to this obliterative procedure.
makes women possible candidates for an obliterative procedure. Usually, this entails a colpocleisis, where opposing vaginal walls are de-epithelialized and sutured to one another, shortening the vaginal length substantially,21 as opposed to a reconstructive procedure, such as a vaginal apical suspension.22,23,24,25,26,27,28,29 Of note, women consider body image, sexuality, and their sense of self when considering this decision, and even women who do not wish to engage in vaginal insertive intercourse may desire to avoid colpocleisis for a variety of reasons. It is also important to note that insertive vaginal intercourse is only a possible part of sexual activity, so the patient’s range of sexual expression should be considered prior to arriving at a shared decision to perform colpocleisis. The minimal risk of recurrence after colpocleisis, as well as the minimally invasive approach,30 should be weighed against the patient’s certainty that she is amenable to this obliterative procedure.
TABLE 42.1 Common Outcomes Used to Define Success in Pelvic Organ Prolapse Surgery | ||||||||||||||||||||||||||||||||||||
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 FIGURE 42.1 Common examples of objective anatomic failure after prolapse surgery. |
 FIGURE 42.2 Types of prolapse procedures by compartment they repair or address.20 |
The second important decision to be made by the patient in consultation with her surgeon is uterine preservation versus a concomitant hysterectomy during the chosen POP surgery. Clearly, this decision applies only to women with a uterus still in place (no former hysterectomy). Uterine preservation surgeries are gaining popularity among women and physicians as women consider fertility desires, menopause timing, body image, and a sense of self while making this decision.31,32 Uterine preservation shortens operating room time, reduces blood loss, and decreases mesh exposure risk in procedures involving permanent mesh grafts.33,34 Contraindications to these surgeries include relatively elevated risk of cervical, uterine, or ovarian cancer; inability to comply with adequate pelvic cancer screening; genetic cancer syndromes that increase pelvic cancer risk; and current or suspected uterine or adnexal pathology.35
The next important decision faced by women involves use of a graft in their reconstruction versus a surgery using the patient’s natural tissue. Graft reconstruction is more durable and when involving the apical/anterior compartment results in more cephalad vaginal anatomy,36 but the reoperation rate for POP recurrence and subjective relief of POP symptoms is similar between natural tissue and graft-augmented procedures.37,38,39,40 There is recent evidence that overall reoperation for graft-related POP surgery may be greater than natural tissue ligament surgery, even accounting for more POP recurrence, due to the large number of surgeries for graft-related complications.41,42 Regarding biologic grafts for POP repair, it has been demonstrated that these do not improve the postoperative recurrence rate or symptoms following repair of prolapse and can have complication rates as high as those of synthetic grafts.36,43 There are recent restrictions placed by the U.S. Food and Drug Administration (FDA) on the type and indication for which grafts can be placed
in the pelvis.44 International organizations, such as the National Institute for Health and Care Excellence, recommend that women having procedures with permanent graft should be appropriately counseled and informed and registered in a registry database to properly track outcomes.45 Women should have specific counseling about the type of graft being used and the route of administration of that graft prior to making a decision about graft-related surgery.
in the pelvis.44 International organizations, such as the National Institute for Health and Care Excellence, recommend that women having procedures with permanent graft should be appropriately counseled and informed and registered in a registry database to properly track outcomes.45 Women should have specific counseling about the type of graft being used and the route of administration of that graft prior to making a decision about graft-related surgery.
Once the decision is made whether to use or not to use graft in the repair of POP, the surgeon also must decide on the route of surgery. In general, surgeons can operate laparoscopically/robotically, vaginally, or through an open abdominal incision in the repair of POP, and the choice of certain procedures (such as sacrocolpopexy) may dictate the most optimal route. Certain comorbidities held by the patient, such as an enlarged uterus that is to be removed concurrently or suspected concurrent uterine or adnexal malignancy, may entice the patient or surgeon to choose an open abdominal route or, in the case of an experienced laparoscopic surgeon, a laparoscopic or robotic route. For some surgeons, the need to remove the adnexa concurrently for malignancy risk reduction may also entice them to approach the surgery abdominally or laparoscopically/robotically. Patient comorbidities that make abdominal or laparoscopic surgery too risky, such as pulmonary compromise or heart conditions, may argue for the vaginal route to avoid Trendelenburg positioning, abdominal distension, or longer operating room times. It should be noted that laparoscopic or robotic routes are associated with less blood loss, recovery time, and pain than open abdominal procedures despite longer operating room times.46 Regardless of the route deemed most appropriate for the patient, the surgeon should have expertise in the route chosen, the patient should have the health and lack of comorbidities to undergo that route of surgery, and the surgery should address the components of the vagina that are prolapsed.47
Another key decisional step in POP surgery is to decide whether to perform a concurrent stress urinary incontinence (SUI) procedure at the time of POP surgery. Women undergoing POP surgery, especially those with preexisting SUI symptoms, are at higher risk for SUI following prolapse correction if they do not undergo an anti-incontinence procedure at the time of their POP surgery.48,49 There are many different practice patterns on concurrent SUI surgery, including performing universal concurrent SUI surgery, always doing stress incontinence surgery as an interval procedure, or basing the decision on preoperative testing including reduction cough stress testing and/or urodynamic studies. Evidence does not demonstrate any of these approaches to be superior but does indicate that women without preoperative SUI symptoms prior to POP surgery or with a negative workup for stress incontinence get less benefit from concurrent stress incontinence surgery than those who do have SUI symptoms.49,50 Surgeons must weigh the risks of the stress incontinence surgery itself, including the increased operating room time and the risks of urinary retention, urinary tract infections, and de novo urgency symptoms, against the benefit to the individual patient.
SURGICAL OUTCOMES WITH INDIVIDUAL PROCEDURE TYPES (TABLE 42.2)
Graft-Augmented Apical Suspension Procedures: Sacrocolpopexy and Sacrohysteropexy
To many, a sacrocolpopexy is believed to be the “gold standard” of apical suspension procedures due to this procedure’s increased durability and its multicompartment repair of the vagina (Fig. 42.3).28,51 On the other hand, some debate this “gold standard” label, citing anatomic failure rates of 22% to 27% at 7 years in a large rigorous trial.28 It is important to note, however, that reoperation for POP was small, only 5%, in the same study in the same time frame.28 Another randomized controlled trial showed 100% success in a median follow-up of 42 months,52 indicating how change in follow-up time and the definition of success can dramatically affect the success rate of a procedure. Similar outcomes, with low reoperation rates but substantial anatomic recurrence, were discovered for sacrohysteropexy in a recent systematic review.34
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