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Advances in Urogynecology


Vaginal Repair of Pelvic Organ Prolapse: Advantages and Patient Selection

Dorothy Kammerer-Doak, MD; Cindi Lewis, MD

Pelvic organ prolapse and stress urinary incontinence are common disorders affecting at least 30% of adult women.1 Women have a risk of 11% for undergoing at least one surgical correction for pelvic floor dysfunction (assuming a lifetime expectancy of 79 years), with almost 30% of procedures performed for recurrent prolapse and/or incontinence.2 The approach for pelvic reconstructive surgery may be either vaginal or abdominal. This article focuses on the selection of the surgical approach and the advantages of the vaginal route in the repair of these disorders.

There are two randomized, prospective studies comparing vaginal sacrospinous ligament fixation with abdominal sacral colpopexy for the correction of vaginal vault prolapse, with conflicting results.3,4 Mean follow-up was at least 2 years. Patients in both groups underwent anti-incontinence procedures as appropriate, and women in the abdominal group underwent vaginal anterior or posterior colporrhaphy, if indicated. In the first study, outcome was classified as "unsatisfactory" if the vaginal apex descended more than 50% of its length, the posterior or anterior vaginal wall protruded beyond the hymen, or if the patient had symptoms of prolapse.3 This trial noted a significantly higher number of unsatisfactory results for the vaginal approach (33%) compared with the abdominal route (16%). The relative risk (RR) of an optimal outcome with abdominal sacral colpopexy was 2.03 (95% confidence interval [CI] 1.22-9.83), and the RR of an unsatisfactory result with vaginal sacrospinous ligament fixation was 2.11 (95% CI 0.90-4.94). No differences were noted in complications or hospital stay between the two routes. In the second trial, no differences were reported in either subjective or objective success rates between the two surgical approaches (94% and 76%, respectively, for abdominal sacral colpopexy versus 91% and 69% for vaginal sacrospinous ligament fixation, P > .05). Additionally, the vaginal route was associated with shorter operative time, quicker return to activities of daily living, and lower overall costs.4

A third randomized trial also compared the vaginal and abdominal routes for repair of uterovaginal prolapse and incontinence.5 Using quality of life and symptoms as evaluated by the Urogenital Distress Inventory as the primary outcome and need for further prolapse surgery as a secondary outcome, there were similar anatomic outcomes for the two groups. However, there were increased symptoms of prolapse, overactive bladder, obstructive micturition, and increased repeat prolapse surgery with abdominal sacral colpopexy. It was concluded that vaginal repair was superior to abdominal repair, but the women in the abdominal group did not undergo hysterectomy or repair of cystocele or rectocele other than colpopexy. By contrast, women in the vaginal group all underwent hysterectomy, with suspension of the vaginal apex to the uterosacral ligaments, as well as anterior and posterior colporrhaphy if indicated.

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SURGICAL PROCEDURES

The vaginal approach to pelvic reconstruction has the advantage of access to all three segments of prolapse, the anterior and posterior vagina and the apex, as well as the ability to perform procedures for stress urinary incontinence that commonly coexists with prolapse, via the same approach. Perineorrhaphy and posterior colporrhaphy are most easily accomplished with a vaginal approach.

Cystocele traditionally is repaired vaginally via anterior colporrhaphy, with failure rates of up to 40%.6 Three different techniques of anterior colporrhaphy were compared in a randomized, prospective trial: standard plication, standard plication reinforced with polyglactin 910 mesh, and ultralateral dissection and plication. There were no differences in "cure," defined as cystocele less than or equal to stage I, among the three techniques with median follow-up of 23.3 months. Anatomic cure was noted in 30% of subjects undergoing standard plication, 42% undergoing standard plication plus polyglactin 910 mesh, and 46% undergoing ultralateral dissection and plication. A second type of surgical procedure to correct cystocele, in which the lateral vaginal fornices are reapproximated to the arcus tendineus fascia pelvis (paravaginal defect repair), is commonly performed through an abdominal incision, but can also be performed vaginally (Figures 1, 2).7 Utilizing the vaginal approach for paravaginal defect repair, success—defined as no prolapse of the lateral sulci—is reported in 98%, with a mean follow-up of 1 year.7

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 Figure 1. Vaginal paravaginal defect repair

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 Figure 2. Abdominal paravaginal defect repair demonstrating suture placement with vaginal finger elevating paravaginal defect

Vaginal repair of uterine or vaginal vault prolapse requires resuspension of the vaginal apex to ligamentous or connective tissue supports in the pelvis.8 The two most common structures used to resuspend the prolapsed vaginal apex are the uterosacral and sacrospinous ligaments (Figure 3). Many pelvic floor surgeons prefer the uterosacral to the sacrospinous vaginal vault suspension because of better restoration of normal vaginal axis anatomy and decreased recurrent anterior vaginal wall prolapse.8,9 A retrospective, case-control comparison of these two techniques noted significantly higher cystocele recurrence, as well as operative time and blood loss with sacrospinous compared with uterosacral ligament suspension at 4 to 9 years follow-up (P ≤ .04).10

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 Figure 3. Vaginal vault fixation sites8

With uterosacral vaginal vault suspension, three sutures are placed through each uterosacral ligament near the level of the ischial spine following vaginal hysterectomy, or opening of the vaginal cuff in posthysterectomy vaginal vault prolapse. Following anterior and posterior repair, if needed, each uterosacral suture is then brought through the most proximal/superior pubocervical fascia anteriorly, and the other free end through the rectovaginal septum (Figure 4). Two large, retrospective series noted 90% subjective success (ie, absence of complaint of vaginal prolapse and no repeat surgery for recurrent prolapse), and 87% objective cure.8,11 Follow-up in these studies was limited, with a mean of about 1 to 2 years. However, long-term results have been reported using the Mayo culdoplasty, a type of vaginal apex suspension utilizing the uterosacral ligaments.12 With the Mayo culdoplasty, the uterosacral ligaments are used to suspend the posterior vaginal wall, and the cul-de-sac is obliterated when the uterosacral ligaments are tied together in the midline (Figure 5). The median follow-up was 8.8 years, with information available regarding recurrent prolapse in about 75% of the original cohort. Symptoms of prolapse (bulging) were reported by 11.5%, and need for subsequent surgical repair for recurrent prolapse by 5.2%. Satisfaction with the surgical repair was expressed by 82%.12

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 Figure 4. Uterosacral vaginal vault suspension9

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 Figure 5. Modified Mayo-McCall culdoplasty

Stress urinary incontinence commonly coexists with prolapse, and can be repaired vaginally with sling procedures. Traditionally, sling procedures were reserved for complicated and recurrent stress urinary incontinence, and were associated with increased morbidity compared with retropubic urethropexy.13 However, modifications to the sling, such as tension-free vaginal tape placed at the midurethra with minimal tension, yield similar success and morbidity to the Burch retro-pubic urethropexy.14

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Route Selection

Proponents of the abdominal approach for repair of pelvic organ prolapse contend that the literature supports greater durability of the repair. But is this true? And is that the only consideration when discussing surgery with a patient and obtaining informed consent? More than 40 different procedures have been described for the treatment of vaginal prolapse,8 including 20 variations on surgical repair for anterior vaginal prolapse alone.15 Defects in vaginal support of the anterior, apical, and posterior compartments are rarely isolated,16 and it is important to understand the dynamic interrelation of these compartments when attempting to reconstruct the pelvic floor. This also makes it difficult to design a study to evaluate and compare specific procedures for treating prolapse.

Selection of the route for prolapse repair should be evidence-based, but there are only three randomized trials comparing vaginal and abdominal procedures. As previously noted, two of these studies suggest that either route yields similar results.3-5 No significant differences were reported in complications, estimated blood loss, postoperative hemoglobin level, length of hospital stay, or sexual activity. The operative time and cost was significantly less for the vaginal procedure, with a faster return to activities of daily living.4,5 No differences were noted between the vaginal and abdominal groups when comparing quality of life and incontinence scores utilizing validated instruments before and after surgery.5

The patient's individual surgical risk must also be considered, especially in the older population who is more likely to have pelvic floor disorders. In a population-based study, 22% of women undergoing prolapse procedures had comorbid conditions17—and this calculation did not include obesity, an increasingly significant comorbid condition. Data are sparse comparing complications and effects of medical comorbidities between the abdominal and vaginal approaches to prolapse repair. To date, the best proxies available are the studies comparing these issues in subjects undergoing vaginal or abdominal hysterectomy, and the surgical literature reporting risk factors with laparotomy.

There are three randomized trials, two comparing vaginal and abdominal hysterectomy18,19 and one comparing abdominal, vaginal, and laparoscopically assisted vaginal hysterectomy.20 All three found that vaginal hysterectomy had decreased postoperative pain, shorter hospital stays, and no significant difference in overall postoperative complications except for febrile morbidity, which was greater with abdominal hysterectomy. Faster recovery of bowel function, decreased time to return to normal activities (including fitness to return to work),18,20 and decreased operative time18,19 were also reported for vaginal hysterectomy. Although the outcomes from the hysterectomy data cannot be directly applied to the comparison of abdominal and vaginal routes for prolapse repairs, it does seem reasonable to consider the differences in patient recovery when an abdominal incision is avoided.

Complications

Obesity has become an epidemic, with a 61% increase between 1991 and 200021; according to data from the US Centers for Disease Control and Prevention, there are 23 million obese women in the United States.22 Obesity is clearly linked to diabetes and cardiovascular disease,23 and is reported as a risk factor for prolapse as well.24-26 But is obesity an independent risk factor for perioperative and postoperative complications? Vaginal surgery is often preferred for obese patients based on the premise that vaginal surgery results in less morbidity, but recent gynecologic and general surgery literature does not necessarily support this. Adjusting antibiotic dosing in the obese patient has been shown to significantly reduce surgical-site infection.27 However, no overall association was found between body mass index and serious complications in a large, retrospective review comparing 444 vaginal and 503 abdominal hysterectomies, but the study was not designed to compare morbidity of vaginal versus abdominal hysterectomy in obese subjects.28 In an elective general surgery population, obesity was not found to be a risk factor for serious postoperative complications using multivariate analysis,29 and studies have found no difference in complication rates after vaginal hysterectomy in obese versus nonobese patients.30 However, there are greater risks of complications with abdominal hysterectomy in obese women, including a 5-fold greater risk of wound infection.31,32 Intraoperative and immediate postoperative subcutaneous oxygen saturation is significantly less in obese patients,33 and this may contribute considerably to the increase in surgical-site infections seen in this group. Obesity and its cohort, diabetes, are also associated with incisional hernias at 1, 3, and 5 years after surgery.34 Thus, a vaginal approach to reconstructive surgery in obese patients and/or those with diabetes may help to avoid wound complications, including infection and hernias.

Optimizing postoperative pulmonary function is thought to be important for decreasing the risk of atelectasis and postoperative pneumonia. Abdominal incisions are associated with decreased pulmonary function. In the general surgery literature, studies of both open and laparoscopic cholecystectomy and bowel surgery noted that avoiding an abdominal incision better preserved pulmonary function, and postoperative pneumonia was reduced.35,36 While there are no comparisons of vaginal and abdominal gynecologic surgeries, pulmonary impairment was significantly less after laparoscopic compared with abdominal hysterectomy.37 Randomized trials are clearly needed to determine if there is a pulmonary benefit to performing vaginal surgery, especially in those patients with risk factors for pulmonary disease.

Disruption of the incision is an important postoperative complication of any surgical procedure. The spectrum of abdominal incision breakdown ranges from superficial wound separation to fascial dehiscence. The incidence of serious wound disruption has remained stable over the last 60 years, despite changes in suture material, antibiotic prophylaxis and surgical techniques.38 Abdominal superficial wound separation occurs in approximately 5% of cases,38 and gynecologic surgery carries an increased risk of infection due to the involvement of the genitourinary tract (class II clean-contaminated wound). Fascial dehiscence, a more serious complication from an abdominal incision, confers mortality of 24%, and is reported to occur in 1.2% of cases.38,39 In comparison, a review of all hysterectomies and pelvic repairs performed at the Mayo Clinic from 1970 through 2001 found a 0.032% rate of vaginal evisceration (12 patients).40

Sexual Function

Sexual function is an important quality-of-life consideration for the patient undergoing pelvic reconstructive surgery. One of the arguments for performing an abdominal procedure is that it maintains the vaginal length necessary for normal vaginal intercourse. Measurement of vaginal length and caliber in 37 sexually active subjects following vaginal and abdominal repair of stage IV prolapse found no difference in impact on sexual function between the two routes, but the abdominal approach was associated with a greater vaginal length.41 Following vaginal surgery for prolapse and incontinence, sexual function and satisfaction were not found to correlate with objective changes in vaginal anatomy.42 Posterior colporrhaphy and Burch colposuspension—and not the method for suspending the vaginal apex—were associated with dyspareunia.42 After bilateral uterosacral ligament suspension and site-specific vaginal reconstruction, total vaginal length decreased by 0.75 cm on average, with 88% having a vaginal length of 7 cm or greater.43 This same study described 29 patients with vaginal correction of stage III or IV prolapse, and found their sexual satisfaction remained high and symptoms of dyspareunia were unchanged from baseline at 6 months after surgery.43 From a sexual function perspective, abdominal vaginal suspension should be performed on patients who have a foreshortened vagina at baseline and who desire to maintain vaginal sexual activity.

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CONCLUSION

Two recent randomized trials that compared the vaginal with the abdominal route for the repair of pelvic organ prolapse report equal success between both approaches, increased operative times and costs, and slower return to activities of daily living with the abdominal procedures.4,5 The risks of pulmonary complications and time to return of normal bowel function are decreased, and the risk of wound complications are avoided with the vaginal route.4,5, 35-37 A significant advantage to the vaginal repair of pelvic organ prolapse is the ability to treat defects of support in the anterior, apical, and posterior compartments, as well as perform anti-incontinence procedures via a unified approach. However, the abdominal route is preferred in women with a foreshortened vagina who wish to maintain sexual function because vaginal depth is best preserved with abdominal procedures (Table).

View this table

 Table. Vaginal Repair of Pelvic Organ Prolapse


Dorothy Kammerer-Doak, MD, is associate clinical professor, Department of Obstetrics and Gynecology, University of New Mexico; and urogynecologist, Lovelace Health Systems, Albuquerque, NM; and Cindi Lewis, MD, is urogynecology fellow, University of New Mexico, Albuquerque.


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