Pelvic organ prolapse: Which operation for which patient?
The stream of new technologies seems never-ending. That’s part of the problem.
IN THIS ARTICLE
The more numerous the choices of surgical techniques for pelvic organ prolapse, the less agreement there is on which operation is best. Further complicating the picture is the industry’s push to consider augmentation with synthetic or biologic materials on an almost routine basis.
Few scientific comparisons of the various approaches have been performed, however. To help shed some light on surgical decision-making, we convened an expert panel to review published data and explore our experience with selected procedures.
What to consider before choosing a procedure
- A woman’s desires regarding sexual activity are a critical piece of information, just as are her general health and history of pelvic surgery.
- It also helps to know which symptoms of her prolapse and related pelvic floor disorders she finds most bothersome.
KARRAM: When a woman with symptomatic pelvic organ prolapse desires surgical correction, what factors do you explore before deciding which procedure to use?
BRUBAKER: I make an effort to determine the woman’s readiness to undergo surgery and her expectations for it, as well as any concomitant pelvic floor or medical/surgical conditions.
Other important factors that I consider include her pelvic surgical history—specifically, whether she has undergone earlier continence and/or prolapse repairs—and the presence of any materials in the proposed surgical site, especially foreign bodies that may limit dissection planes or have eroded into pelvic viscera.
I also consider her desire (or lack of it) for sexual activity, and her preferred route of surgical access.
Patient’s lifestyle should sway surgical decision
PARAISO: I take into account her age and stage of prolapse; vaginal length; innervation of the pelvic floor; hormonal status; desire for uterine preservation and coitus; symptoms of sexual, urinary, or bowel dysfunction; and any comorbidities that influence her eligibility for anesthesia or chronically increase intra-abdominal pressure. Connective tissue disorders are also important, as are any coexisting medical conditions that impede healing.
Lifestyle has an impact, too, especially if she regularly performs heavy manual labor.
After assessing the patient’s history and performing an examination, I target the prolapse and functional symptoms and correlating anatomic defects that exacerbate her quality of life. I tailor her surgical therapy in order to correct her symptoms and minimize compensatory defects and de novo dysfunction.
Ask her to prioritize her complaints
SHULL: I have the patient list her complaints in order of their severity and impact on her lifestyle.
Next, I complete a detailed pelvic exam, including use of a mirror to demonstrate the findings to her. If appropriate, I test bladder or bowel function.
At that point, we discuss what I think are appropriate options, although in some situations I may not be able to treat all her complaints with equal success.
KARRAM: I think prioritizing the patient’s complaints is a good idea. My foremost aim is to determine what the woman is most bothered by. If it is prolapse symptoms such as pressure and tissue protrusion, with no functional derangements, I try to ensure that my surgical repair provides durable support but does not create de novo derangements such as stress incontinence. So, for example, I try to determine whether she has preexisting stress incontinence that is masked by the prolapse.
Correlation between prolapse and dysfunction can be weak
Obviously, if the patient has many functional derangements associated with the prolapse symptoms, the preoperative consultation becomes much more complicated. Although the complexity may not change my surgical approach, I think it is important for the patient to understand that the correlation between anatomic descent and the functional derangement may not be very good.
OUR EXPERT PANELISTS
- Moderator Mickey Karram, MD, Director of Urogynecology, Good Samaritan Hospital, Cincinnati, and Professor of Obstetrics and Gynecology, University of Cincinnati.
- Linda Brubaker, MD, MS, Assistant Dean of Clinical and Translational Research, and Professor and Director, Division of Female Pelvic Medicine and Reconstructive Pelvic Surgery, Departments of Obstetrics & Gynecology and Urology, Loyola University Health System, Chicago.
- Marie Fidela Paraiso, MD, Co-Director of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology and the Urological Institute, The Cleveland Clinic, Cleveland, Ohio.
- Bob L. Shull, MD, Vice Chairman, Department of Obstetrics and Gynecology, and Chief, Section of Female Pelvic Medicine and Pelvic Reconstructive Surgery, Scott & White Health Care System, Temple, Tex.
As previously mentioned, I make a point to ask about sexual function. If the woman is elderly and has no intention of being sexually active again, I may consider a very tight or obliterative repair because these are much less invasive than conventional repairs.
Is one surgical route superior?
- There is no consensus among experts as to the preferred route of surgery for advanced pelvic organ prolapse.
KARRAM: Numerous vaginal, abdominal, and laparoscopic procedures have been described. Which route do you prefer?
BRUBAKER: I don’t prefer any laparoscopic procedures, but I am flexible about vaginal or abdominal approaches.
Among vaginal procedures, I prefer uterosacral suspension at the time of hysterectomy, or the Michigan modification of sacrospinous ligament suspension when the patient has already undergone hysterectomy.
As for abdominal procedures, I prefer sacrocolpopexy with Mersilene mesh.
In my hands, these reconstructive procedures give predictable results that allow me to appropriately counsel patients preoperatively.
KARRAM: Why do you dislike the laparoscopic approach?
BRUBAKER: It is not a matter of “dislike,” but a matter of getting the most reliable result for my patient. When scientific evidence from well-done clinical trials demonstrates the equivalency of laparoscopic procedures, I fully anticipate incorporating them into my practice. Similarly, the novel use of the robot may be useful in reconstructive pelvic surgery.
Laparoscopic repair can produce good results in the right hands
PARAISO: I prefer the laparoscopic and vaginal routes. In fact, I have converted most abdominal procedures to laparoscopic access. I have nearly 10 years of experience with laparoscopic sacrocolpopexy, with excellent success.
My colleagues and I did a cohort study that showed equal cure rates for this procedure, compared with open sacrocolpopexy.1 I also have had great success with the vaginal route when performing uterosacral vaginal vault suspensions.
Patients are referred to me or seek me out specifically for minimally invasive procedures, so the majority of operations I perform are laparoscopic procedures with or without vaginal procedures, or vaginal procedures alone.
Vaginal approach is possible in high percentage of cases
SHULL: I probably perform 98% of reconstructive cases transvaginally. If the woman has urinary incontinence as well as prolapse, I usually perform a midurethral sling procedure along with the repair.
KARRAM: I do roughly 90% of prolapse repairs transvaginally. For the last 6 to 8 years, my colleagues and I have utilized a high uterosacral vaginal vault suspension to support the vaginal cuff. We do so in conjunction with a modified internal McCall-type procedure to obliterate the cul-de-sac. We also do site-specific anterior and posterior colporrhaphy as needed, and a synthetic midurethral sling if the patient has stress incontinence.
In very young patients (under 35 years of age) or those who have substantial recurrent prolapse or a prolapsed foreshortened vagina, we consider abdominal sacrocolpopexy with synthetic mesh as our primary operation. In such cases, we commonly perform retropubic repair for incontinence and paravaginal defects, as well as posterior repair and perineorrhaphy.
I have very little experience with laparoscopic prolapse repairs.
Abdominal sacrocolpopexy is anatomically superior
KARRAM: Dr. Brubaker, you just chaired a consensus panel on pelvic organ prolapse for the International Consultation on Incontinence. This panel reviewed all the published literature on the topic. What conclusions did it reach about the various surgical procedures for pelvic organ prolapse?
BRUBAKER: The “big picture” findings were that abdominal sacrocolpopexy is anatomically superior to the other procedures, but carries a higher rate of short-term morbidity than transvaginal procedures. Since that panel, a review on sacrocolpopexy by Nygaard et al2 highlighted the strengths, weaknesses, and uncertainties of this procedure.
We found no indications for routine use of ancillary materials when performing primary transvaginal repairs.
- The best procedure depends on the patient’s health, type and extent of prolapse, and sexual activity. Surgical history also is key.
KARRAM: Let’s say a 60-year-old woman with advanced, symptomatic, primary pelvic organ prolapse presents to you for surgical treatment. The findings include posthysterectomy vaginal vault prolapse with a large cystocele, large rectocele, and an enterocele. What operation would you perform?
SHULL: I would probably elect a transvaginal approach using the uterosacral ligaments to suspend the cuff and reapproximate the connective tissue of the anterior and posterior compartments. My colleagues and I described this technique.3
PARAISO: If the patient is physically and sexually active and willing to undergo synthetic graft implantation, I would perform laparoscopic sacrocolpopexy, especially if previous transvaginal apical suspension has failed, if she has a foreshortened vagina, or if she has denervation of her pelvic floor.
Check for defecatory dysfunction
If it is necessary for her to manually digitate her vagina or splint her perineum to defecate, I would perform a rectocele repair and perineorrhaphy.
If she is not a candidate for laparoscopic or abdominal surgery because of a history of multiple procedures for inflammatory bowel disease or severe adhesions, has not had a previous transvaginal apical suspension, and has intact pelvic floor innervation, I would perform either uterosacral vaginal vault suspension or sacrospinous ligament suspension with concomitant anterior and posterior repair.
I would consider offering this patient a tension-free vaginal mesh “kit” procedure (with synthetic mesh) if she:
- has failed previous vaginal procedures,
- has multiple comorbidities,
- is not a candidate for laparoscopic or abdominal surgery,
- desires to remain sexually active, and
- is willing to use and has no contraindications to intravaginal estrogen therapy.
If she does not wish to remain sexually active and is not a good operative candidate, I would offer colpectomy and colpocleisis with perineorrhaphy.
Which circumstances pose special challenges?
- Apical suspension is a critical factor in success and durability of the surgery.
KARRAM: Which segment of the pelvic floor do you find most challenging when correcting advanced pelvic organ prolapse?
SHULL: My colleagues and I have reported our experience with several techniques of vaginal repair for prolapse, including sacrospinous ligament suspension, iliococcygeus fascial suspension, and uterosacral ligament suspension. When we analyzed specific sites in the vagina, the anterior compartment always had the greatest percentage of persistent or recurrent loss of support.
Our best success has been with uterosacral ligament suspension.
Vaginal apex is key to success
PARAISO: I also find the anterior segment challenging. However, if I am able to suspend the vaginal apex well, management of the anterior vaginal wall is less challenging. The anterior wall fails because treatment of high transverse cystoceles and anterior enteroceles (less commonly seen) depends on the apical suspension. Many of these defects go untreated because they are often not detected.
BRUBAKER: I agree with Dr. Paraiso. If you get the apex up solidly, you’re usually home free.
KARRAM: Yes. If one can get good, high, durable support to the apex, the other segments of the pelvic floor are much more likely to endure.
- Despite claims to the contrary, reoperation rates are low for most conventional repairs.
- Surgeons may be tempted to adopt graft augmentation techniques to keep up with “Dr. Jones.”
KARRAM: As you know, there has been a recent push to consider augmenting most pelvic organ prolapse repairs with either biologic or synthetic mesh. This approach is based on a perception that conventional repairs without augmentation inevitably will fail. Do you agree with this perception?