CURRENT
OPINION Apical prolapse repair: weighing the risks
and benefits
Audra Jolyn Hill and Matthew D. Barber
Purpose of review
This article reviews the current literature regarding surgical repair of vaginal apical prolapse and discusses
the risks and benefits of various surgical approaches.
Recent findings
Vaginal uterosacral ligament suspension has similar anatomic and subjective outcomes to sacrospinous
ligament fixation at 1 year. Native tissue vaginal repairs offer decreased morbidity compared with mesh-
augmented sacrocolpopexy; however, sacrocolpopexy has greater anatomic success. Minimally invasive
sacrocolpopexy appears to be equivalent to open abdominal sacrocolpopexy. Native tissue repairs and
transvaginal mesh kits support the vaginal apex with similar results; however, long-term follow-up is
needed. Robotic and laparoscopic sacrocolpopexy are equally effective in restoring the vaginal apex.
Summary
Surgical restoration of the vaginal apex can be accomplished via a variety of approaches and techniques.
When deciding on the proper surgical intervention, the surgeon must carefully calculate the risks and
benefits of each procedure while incorporating the patient’s individual medical and surgical risk factors.
Lastly, a discussion regarding the patient’s overall goals of care is paramount to the decision-making
process.
Keywords
apical prolapse, apical support, sacrocolpopexy, sacrospinous colpopexy, uterosacral colpopexy
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(Fig. 2). SSLF has been evaluated in numerous pro- 0–1) of 98.3% (CI 95.7, 100) for the apical segment
spective and retrospective cohort studies with [13].
reported anatomical success rates ranging from 64 Complications surrounding USLS include both
to 97% [4]. Patient satisfaction following SSLF bowel and urinary events. A retrospective review of
ranges from 80 to 90% [8–10]. In 2007, a systematic over 900 patients who underwent USLS identified an
review and meta-analysis by Morgan et al. [10] found overall adverse event rate of 31.2%, with 20.3%
an overall failure rate of any compartment to be being attributed to a postoperative urinary tract
28.8% [confidence interval (CI) 18.4, 36.3] with the infection. Rates of pulmonary and cardiac events
anterior compartment being the most likely site were 2.3%, whereas the rate of ileus and small bowel
of recurrence. This may be due to the deflection obstruction were less than 0.5%. The composite
of the vaginal axis posteriorly leaving the anterior recurrence rate was 14.4% (which included both
compartment more susceptible to a larger intra- anatomic and symptomatic-based criteria) with a
abdominal pressure burden. Postoperative compli- median follow-up time period of 6.9 (range, 0.2–
cations include buttock pain and neurovascular 93.8) months, with 55% of sites of recurrence occur-
injury. Buttock pain occurs in 3–15% of patients ring in the anterior compartment. Retreatment of
and typically resolves within 6 weeks following the prolapse was seen in 3.4% of patients and included
& & &&
surgical procedure [11 ,12 ]. Neurovascular injuries both surgical and pessary management [14 ].
are rare, but if they do occur, typically involve the In 2014, a comparison of surgical outcomes
pudendal, inferior gluteal, and/or sacral nerves between USLS and SSLF in women with uterine or
or vessels. posthysterectomy apical prolapse was reported by
the National Institute of Child Health and Human
&
Development Pelvic Floor Disorders Network [12 ].
UTEROSACRAL LIGAMENT SUSPENSION Success was defined as composite outcome measure-
USLS involves attachment of the vaginal apex to the ment and included the absence of the following:
proximal uterosacral ligaments via an intraperito- descent of the vaginal apex more than one third of
neal approach (Fig. 3 a and b). Multiple variations in the vaginal canal, anterior or posterior vaginal wall
the surgical procedure exist and usually surround beyond the hymen, bothersome vaginal bulge
the number and type of sutures (delayed absorbable symptoms as reported on the Pelvic Floor Distress
and/or permanent) used during the repair. Ana- Inventory and any form of retreatment for prolapse
tomic success rates range from 48 to 96% with a (surgery or pessary). A total of 374 patients were
mean reoperation rate for prolapse of 5.8% [4]. A included in this trial (188 USLS, 186 SSLF). At 2 years,
meta-analysis identified pooled rates of anatomical there was no statistical difference between the two
success (Pelvic Organ Prolapse Quantification stage groups for surgical success (USLS, 64.5% vs. SSLF,
63.1%) with an adjusted odds ratio of 1.1 (CI 0.7,
1.7). Additional outcomes measured at 2 years
included bothersome vaginal bulge symptoms
(18.0%), anterior or posterior prolapse beyond the
hymen (17.5%) and retreatment with surgery or
pessary (5.1%) with no differences between groups.
(a) Perioperative events were similar between the two
groups, with the most common event being bladder
perforation associated with retropubic midurethral
sling placement. Neurological pain requiring inter-
vention was higher in the SSLF group (12.4 vs. 6.9%,
P ¼ 0.0749), whereas the rate of intraoperative ure-
teral obstruction was noted in six (3.2%) patients
who underwent USLS compared with zero patients
&
in the SSLF group [12 ].
USLS may also be performed via abdominal
route through an open or laparoscopic approach.
A retrospective review comparing vaginal utero-
sacral suspension (96 patients) and laparaoscopic
uterosacral suspension (22 patients) was performed
(b)
by Rardin et al. [15] and found no significant differ-
ences in adverse events, subjective or anatomic out-
FIGURE 3. Uterosacral ligament suspension. comes.
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with laparoscopic sacrocolpopexy (LSC). A total of and report different cost variables, making overall
57 patients were randomized, and at 1 year, there comparisons difficult. In 2010, Judd et al. [35]
was no difference in patient satisfaction or rates of reported on the use of a decision analytical model
recurrent prolapse between the two interventions. for comparing LSC to R-LSC cost based on their own
Minimally invasive techniques for performing institutional data. Their model suggested R-LSC was
sacrocolpopexy include both traditional laparo- more expensive ($7353 vs. $5792) and the robotic
scopy and robotic approaches. Multiple retro- approach only became cost equivalent when the
spective and cohort studies have evaluated LSC operating room time was reduced to 149 min. Given
and robotic-assisted laparoscopic sacrocolpopexy the variability in the data, additional prospective
(R-LSC) in regards to both objective and subjective trials are needed comparing the various routes with
outcomes, durability of repair and overall feasibility similar cost variables and predefined outcomes (i.e.
&
[28 ]. operating room time).
Paraiso et al. [30] reported a randomized con- Complications following sacrocolpopexy can
trolled trial on 78 women with symptomatic vaginal occur with either an open or minimally invasive
vault prolapse who underwent LSC or R-LSC. approach. Adverse events associated with open ASC
Patients who underwent a R-LSC experienced a are similar to those associated with open abdominal
longer operative time (67 min mean difference, pelvic surgery, that is, wound complications,
P < 0.0001), increased postoperative pain up to haemorrhage, and damage to surrounding organs.
6 weeks following surgery and required a longer A multicenter retrospective review comparing out-
use of anti-inflammatory agents (20 vs. 11 days) comes of open vs. minimally invasive sacrocolpo-
compared with LSC. At 1 year, there was no differ- pexy was performed on over 1000 women. ASC was
ence between anatomic and quality-of-life measures found to have a higher overall rate of complications
between the two groups. Additionally, the cost of (20.0 vs. 12.7%, P ¼ 0.001). The minimally invasive
R-LSC was higher compared with LSC ($16 278 vs. group was found to have a shorter length of stay,
$14 342, P ¼ 0.008), which the authors attributed to decreased blood loss, but longer operative times
&&
longer operative room costs. compared with ASC [29 ]. When comparing ASC
In 2014, Anger et al. compared LSC and R-LSC in with R-LSC, the rates for intraoperative injury to
a randomized fashion for patients with sympto- pelvic organs, infection and thrombotic events are
&&
matic stage II POP. The focus of this study was to similar [25,26,31,36]. Unger et al. [37 ] performed a
compare overall cost and relevant outcomes follow- retrospective analysis comparing perioperative and
ing each surgical intervention. Patients who under- postoperative adverse events in 406 women who
went R-LSC had an average of 24.4 min increase in underwent either R-LSC or LSC. Rates of bladder
operative time (202 vs. 179 min, P ¼ 0.03); however, injury (3.3 vs. 0.4%, P ¼ 0.04) and estimated blood
the total surgical time was not statistically different loss more than 500 ml (2.5 vs. 0%, P ¼ 0.01) were
between the two groups (246 vs. 225 min, P ¼ 0.11). found to be higher in the robotic group compared
The authors attributed the increased operative time with traditional laparoscopy. Rates of mesh erosion,
in the R-LSC to docking of the robot. Pain with bowel obstruction, cardiac and pulmonary events
normal activities was elevated in the robotic were similar between the two groups with a median
patients 1 week following surgery (3.5 vs. 2.6), but follow-up time of 195 days (interquartile range
by 2 weeks, the pain levels were similar to patients 73.5–427 days). The overall conversion rate to an
who underwent laparoscopy. Adverse events (intra- open ASC was 1.9% and was performed due to
operatively or postoperatively) did not differ suboptimal visualization, bowel injury, adhesions,
between the two groups. Additionally, anatomic presacral bleed or pulmonary compromise. Mesh
outcomes and quality-of-life measures were similar exposure was identified in 2.7% of patients with
at 6-month follow-up. When evaluating the cost no difference between the two groups (R-LSC 3.3
vs. LSC 2.4%, P ¼ 0.62) [37 ].
&&
comparison between LSC and R-LSC, cost was bro-
ken down into day of surgery costs and total 6-week Sacrocolpopexy offers a durable repair of the
costs. Day of surgery costs and total 6-week costs vaginal apex, yet carries the increased risk of mesh
were initially higher in the R-LSC group; however, complications compared with native tissue repairs.
after removal of the initial purchase cost and main- In 2015, a systematic review conducted by Siddiqui
&&
tenance fees for the robot, the cost difference was no et al. [38 ] compared outcomes after mesh sacro-
&&
longer significant [24 ]. colpopexy with native tissue vaginal repairs. Mesh
A number of studies have been performed look- sacrocolpopexy was found to have a significantly
ing at the cost of robotic sacrocolpopexy compared greater likelihood of anatomic ‘success’ compared
with the open and/or laparoscopic approaches with native tissue vaginal repairs [pooled odds ratio
[34,35]. The majority are retrospective in nature 2.04 (CI 1.12, 3.72)]. The data were limited or
1040-872X Copyright ß 2015 Wolters Kluwer Health, Inc. All rights reserved. www.co-obgyn.com 377
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inconsistent regarding all-cause reoperation rates, & period and the need for intervention after sacrospinous ligament colpopexy.
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surgical approaches and perioperative behavioral therapy for apical vaginal
vaginal repair and mesh sacrocolpopexy, ileus or &
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&& organ prolapse: a systematic review and meta-analysis of comparative scopic and abdominal sacral colpopexy: objective outcome and perioperative
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sacrocolpopexy for pelvic organ prolapse. && minimally invasive abdominal sacrocolpopexy. Am J Obstet Gynecol 2014;
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24:377–384. 38. Siddiqui NY, Grimes CL, Casiano ER, et al. Mesh sacrocolpopexy compared
34. Elliott CS, Hsieh MH, Sokol ER, et al. Robot-assisted versus open sacro- && with native tissue vaginal repair: a systematic review and meta-analysis.
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