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Approach to Apical Prolapse Repair

Mary South, MD

VAGINAL Approach to Apical Repair

The use of robotic abdominal sacrocolpopexy for elective repair of pelvic organ prolapse should be approached with caution. Today’s trend in surgery is to accomplish the best results using the most minimally invasive method. Although robotic surgery is minimally invasive in the sense that it does not involve traditional laparotomy, the most minimally invasive approach to prolapse is still the vaginal approach. All benefits cited for the robotic approach also apply to the vaginal approach, but the vaginal approach also requires no abdominal incision, shorter operating time, and less expense.

The use of a vaginal versus abdominal approach for prolapse repair was evaluated in a recent Cochrane review.5 Its conclusion was that compared with abdominal sacrocolpopexy, sacrospinous ligament suspension was associated with a higher rate of recurrent vault prolapse and dyspareunia, although morbidity was higher with the abdominal approach. A randomized controlled trial was performed by Benson et al comparing abdominal sacrocolpopexy and sacrospinous ligament suspension, and is often cited when arguing against a vaginal approach for apical prolapse repair.6 However, this study has some limitations, and sacrospinous ligament fixation is not the only vaginal approach for prolapse repair.

In contrast to the high rate of recurrent prolapse found in a retrospective analysis of subjects who underwent sacrospinous ligament fixation, the use of uterosacral ligament suspension for apical prolapse repair has been shown to have satisfaction rates as high as 90%.7-9 In one series of 72 patients with a mean follow-up of 5 years, recurrent prolapse rates ranged from 5.5% to 15% in any compartment, with only a 3% rate of recurrent apical prolapse.10 Only 2 of the 72 subjects developed Stage II or greater recurrent prolapse. Sexual function was also assessed in subjects who were sexually active, of whom 94% (29/34) were noted to be satisfied with their sexual activity.

As with sacrocolpopexy, uterosacral ligament suspension has some potential for complications. Neural pain has been reported in 2 separate case series after uterosacral ligament suspension.11,12 Flynn et al reviewed 182 charts of subjects who underwent uterosacral ligament suspension and found 7 cases of pain that was felt to be associated with the uterosacral stitch placement.12 Clinically, this presents as pain and numbness in an S2-S4 distribution. The pain was resolved with either removal of the suspension suture or prolonged medical therapy. More seriously, Ridgeway et al described small bowel obstruction in 3 patients following vaginal hysterectomy with uterosacral suspension.13

Prior hysterectomy does not preclude the use of uterosacral ligament suspension for repair.9 The vaginal cuff can be entered and the pubocervical and rectovaginal fascia dissected until the peritoneum is entered. The uterosacral sutures can then be placed, anterior or posterior colporrhaphy performed as needed, and the cuff closed before tying down the suspensory sutures.

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DISCUSSION

Two questions emerge from this discussion. First, when planning to repair vaginal vault prolapse, should a vaginal or abdominal approach be selected? Second, if an abdominal approach is chosen, is robotic sacrocolpopexy equal to the open abdominal approach in terms of success, durability, and complications? The answers to these questions remain to be clarified, and must be investigated further with prospective, long-term studies. However, there are some basic guidelines that can help the practitioner to decide which method to employ when proceeding with repair.

A uterosacral ligament suspension is a reasonable approach to use in a patient who has primary prolapse, regardless of whether that patient has had a prior hysterectomy. If the patient has recurrent prolapse or the prolapse is severe (Stage III or IV with a large amount of redundant vaginal epithelium), sacrocolpopexy may be technically easier than vaginal repair—depending on the surgeon’s experience. In this situation, the mesh can be attached to more points along the vaginal wall than if uterosacral sutures are used, providing more even distribution and support to the distended vaginal epithelium.

Although some experts cite young age at the time of repair and daily heavy lifting as reasons to choose sacrocolpopexy over vaginal repair, there are opposing arguments as well. Mesh erosion can occur years after placement and, theoretically, a younger woman may have a higher likelihood of mesh erosion over the duration of her lifetime given her longer exposure. In addition, recent studies have suggested that heavy lifting may not be as much of a contributor to prolapse as chronic constipation and chronic cough.14 Finally, a vaginal approach may produce less scar tissue and fewer adhesions compared with an abdominal approach, making any future abdominal surgeries less difficult and potentially less risky.

If an abdominal repair is chosen after taking all these points into consideration, the next step is to weigh the laparoscopic against the robotic approach. Many advocates of the robotic approach contend that long-term durability must be similar to that of the open abdominal approach with fewer complications, but this may not necessarily be true. Although the preliminary reports cited here are encouraging, it is prudent to remain cautious until long-term data are available to confirm these assumptions. In contrast to the abdominal approach, the robotic approach requires that patients remain in steep Trendelenburg position for several hours and postoperative pain at the assistant port site can be significant, both of which could contribute to potential pulmonary complications. Finally, any surgeon attempting a robotic approach must first be comfortable with this technology. The absence of tactile feedback, the force generated by the robotic arms, and the disorientation that can occur with inexperienced operators while manipulating an arm that is active while it is out of view could all lead to intraoperative damage to nerves, vessels, and organs—particularly bowel.

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CONCLUSION

The author’s recommendation is that the choice of procedure for apical prolapse repair should be based on the surgeon’s experience and on a thorough, comparative risk/benefit review with the patient. Robotic-assisted techniques are the least invasive and have undisputed benefits, but long-term prospective studies evaluating their use are needed.

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Mary South, MD, is Adjunct Assistant Professor, Division of Urogynecology and Pelvic Reconstructive Surgery, Department of Obstetrics and Gynecology, University of Cincinnati College of Medicine, Cincinnati, OH.

References

1. Geller EJ, Siddiqui NY, Wu JM, Visco AG. Short-term outcomes of robotic sacrocolpopexy compared with abdominal sacrocolpopexy. Obstet Gynecol. 2008;112(6):1201–1206.
2. Patel MS, Sullivan DO, Tulikangas P. A Comparison of Costs for Abdominal, Laparoscopic and Robot-Assisted Sacral Colpopexy. American Urogynecological Society 29th Annual Scientific Meeting, Chicago, IL: Lippincott Williams & Wilkins; 2008. www.augs.org/Portals/0/Abstracts.pdf. Accessed January 2009.
3. Shveiky DS, Kudish B, Iglesia CB. Robotic versus vaginal colpopexy for apical prolapse: a case-control study. American Urogynecological Society 29th Annual Scientific Meeting, Chicago, IL: Lippincott Williams & Wilkins; 2008. www.augs.org/Portals/0/Abstracts.pdf. Accessed January 2009.
4. US Food and Drug Administration. FDA Public Health Notification: Serious Complications Associated with Transvaginal Placement of Surgical Mesh in Repair of Pelvic Organ Prolapse and Stress Urinary Incontinence. www.fda.gov/cdrh/safety/102008-surgicalmesh.html. Accessed January 2009.
5. Maher C, Baessler K, Glazener CM, Adams EJ, Hagen S. Surgical management of pelvic organ prolapse in women. Cochrane Database Syst Rev. 2004;3:CD004014.
6. Benson JT, Lucente V, McClellan E. Vaginal versus abdominal reconstructive surgery for the treatment of pelvic support defects: a prospective randomized study with long-term outcome evaluation. Am J Obstet Gynecol. 1996; 175(6):1421–1422.
7. Colombo M, Milani R. Sacrospinous ligament fixation and modified McCall culdoplasty during vaginal hysterectomy for advanced uterovaginal prolapse. Am J Obstet Gynecol. 1998;179(1):13–20.
8. Barber MD, Visco AG, Weidner AC, Amundsen CL, Bump RC. Bilateral uterosacral ligament vaginal vault suspension with site-specific endopelvic fascia defect repair for treatment of pelvic organ prolapse. Am J Obstet Gynecol. 2000;183(6):1402–1410.
9. Karram M, Goldwasser S, Kleeman S, Steele A, Vassallo B, Walsh P. High uterosacral vaginal vault suspension with fascial reconstruction for vaginal repair of enterocele and vaginal vault prolapse. Am J Obstet Gynecol. 2001;185(6): 1339–1342.
10. Silva WA, Pauls RN, Segal JL, Rooney CM, Kleeman SD, Karram MM. Uterosacral ligament vault suspension: five-year outcomes. Obstet Gynecol. 2006;108(2): 255–263.
11. Lowenstein L, Dooley Y, Kenton K, Mueller E, Brubaker L. Neural pain after uterosacral ligament vaginal suspension. Int Urogynecol J Pelvic Floor Dysfunct. 2007; 18(1): 109–110.
12. Flynn MK, Weidner AC, Amundsen CL. Sensory nerve injury after uterosacral ligament suspension. Am J Obstet Gynecol. 2006;195(6):1869–1872.
13. Ridgeway B, Barber MD, Walters MD, Paraiso MF. Small bowel obstruction after vaginal vault suspension: a series of three cases. Int Urogynecol J Pelvic Floor Dysfunct. 2007; 18(10):1237–1241.
14. Mouritsen L, Hulbaek M, Brostro/m S, Bogstad J. Vaginal pressure during daily activities before and after vaginal repair. Int Urogynecol J Pelvic Floor Dysfunct. 2007; 18(8):943–948.

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