Jelovsek 22/12/08 11:33 Page 75
Surgical Procedures for Pelvic Organ Prolapse
component of a durable surgical repair for women with advanced future fertility because the mesh configuration may not allow adequate growth
prolapse.
1,11,12
The Surgery for Pelvic Organ Prolapse Committee of the of the cervix and lower uterine segment.
Third International Consultation on Incontinence noted that: “the apex is
the keystone of pelvic organ support… the best surgical correction of The vaginal sacrospinous ligament suspension is another common approach
the anterior and posterior walls is doomed to failure unless the apex is that transvaginally attaches the upper vagina or cervix to the ligament
adequately supported.”
11
between the ischial spine and the sacrum. Success rates of sacrospinous
ligament suspension range from 63 to 97%. Although in randomized trials
Two common approaches for correcting apical prolapse include the this procedure has fewer complications and quicker recovery than sacral
abdominal sacral colpopexy and the vaginal sacrospinous ligament colpopexy, it is not without serious complications. Surgeons should use
suspension. The sacral colpopexy suspends the upper vagina from the sacral selective attention when dissecting the pararectal space to identify the
promontory using polypropylene mesh via an abdominal approach. Sacral coccygeus–sacrospinous ligament as excessive dissection may lead to
hemorrhage from the inferior gluteal, hypogastric venous plexus, and
internal pudendal vessels. Careful placement of sutures into the ligament is
also advised. We recommend the use of the Capio Device (Boston Scientific
Two common approaches for correcting Corp, Natick, Massachusetts) or the downward needle pass technique
apical prolapse include the abdominal
described by Miyazaki.
24
sacral colpopexy and the vaginal Three randomized controlled trials have compared the abdominal sacral
sacrospinous ligament suspension.
colpopexy with the vaginal sacrospinous suspension,
10,13,14
and a Cochrane
review has concluded that the abdominal sacral colpopexy was associated
with lower recurrent prolapse but a longer operating time, longer length of
admission, greater morbidity, and higher cost than the vaginal sacrospinous
colpopexy is a good procedure for patients who have other indications for ligament suspension, with overall objective cure rates of around 90%.
15
abdominal surgery. Key features are the use of permanent polypropylene Other transvaginal apical suspension procedures include: iliococcygeus
mesh; using multiple sutured attachments to the anterior and posterior wall ligament fixation, in which the vaginal apex is attached to the iliococcygeal
of the vagina; and attaching the opposite end of the mesh to the upper fascia just below the ischial spine;
25
high uterosacral ligament suspension, in
third of the sacral promontory to avoid life-threatening hemorrhage from which two or three sutures are passed through the proximal and lower
presacral venous bleeding. middle portions of the uterosacral ligament complex and passed through
the new vaginal apex;
26
and the modified McCall culdoplasty, in which the
The laparoscopic approach to sacral colpopexy appears to be as successful vaginal apex is sutured to posterior vaginal wall, cul-de-sac peritoneum,
as the open approach with a slightly longer operating time but significantly distal uterosacral ligaments, and tissue lateral and posterior to the upper
reduced blood loss and hospitalization time.
16
The more recent robotic vagina and rectum.
27
Uterosacral ligament suspension is commonly
approach to sacral colpopexy attempts to minimize this longer operating performed in the US and has estimated success rate of between 85 and
time by allowing surgeons who are unable to laparoscopically suture to 90%. Silva et al. looked at five-year outcomes from uterosacral ligament
begin using a minimally invasive approach to sacral colpopexy. Although
hysterectomy is often performed concomitantly at the time of sacral
colpopexy, there appears to be an increased risk for post-operative mesh
The laparoscopic approach to sacral
erosion into the vagina.
10,13,17–19
This risk is slightly above the approximate 3%
erosion rate when hysterectomy is not performed.
20
Surgeons should
colpopexy appears to be as successful as
counsel patients about this increased risk as it usually requires partial or
the open approach with a slightly longer
complete removal. When possible, care should be taken to meticulously
close the vaginal cuff in two layers, avoid suturing mesh over the suture line,
operating time but significantly reduced
and ensure sterile technique.
blood loss and hospitalization time.
There are alternatives to hysterectomy at the time of abdominal prolapse repair,
including a subtotal hysterectomy and sacral hysterocolpopexy, where the suspension, showing a success rate of 85% with only 3% having recurrent
cervical stump (for subtotal hysterectomy) or cervix and upper vagina are prolapse of the vaginal apex.
28
The most commonly reported complication
suspended by mesh attachment to the sacrum. Recent studies have reported of this procedure is ureteral obstruction, which occurs in approximately
excellent results with laparoscopic-sutured hysteropexy and sacrospinous 5.9% of cases. Intra-operative identification of this temporary obstruction
hysteropexy. No prospective randomized trials have been performed.
21–23
It has using cystoscopy and intravenous indigo carmine reduces the true injury
been our practice to perform these procedures in patients who prefer to rate to less than 1%.
29
maintain future fertility or request uterine preservation. We have recently
modified the sacral hysterocolpopexy by adding an anterior mesh strap that is Anterior Vaginal Wall Prolapse
sewn to the anterior cervix and upper vagina with two arms that are tunneled Anterior colporrhaphy is a surgical technique to repair anterior vaginal prolapse
through the broad ligament bilaterally and attached to the sacrum over the that involves the central plication of vaginal muscularis and adventitia overlying
posterior mesh strap. This modification is not offered to patients who desire the bladder. Success rates range from 80–100% in case series to only 40–60%
US OBSTETRICS & GYNECOLOGY 75
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