Pelvic Organ Prolapse in Women - Surgical Repair of Apical Prolapse (Uterine or Vaginal Vault Prolapse) PDF

05.05.
2015
Pelvicorganprolapseinwomen:Surgicalrepairofapicalprolapse(uterineorvaginalvaultprolapse)
OfficialreprintfromUpToDate
www.uptodate.com2015UpToDate
Author
SectionEditor
DeputyEditor
KimberlyKenton,MD,MS,FACOG,FACS
LindaBrubaker,MD,FACS,FACOG KristenEckler,MD,FACOG
Alltopicsareupdatedasnewevidencebecomesavailableandourpeerreviewprocessiscomplete.
Literaturereviewcurrentthrough:Apr2015.|Thistopiclastupdated:Jun16,2014.
INTRODUCTIONApicalprolapseisthedescentofuterus,cervix,orvaginalvault.Pelvicorganprolapse
(POP)affectsmillionsofwomenapproximately200,000inpatientsurgicalproceduresforprolapseareperformed
annuallyintheUnitedStates[1,2].Elevento19percentofwomenwillundergosurgeryforPOPorincontinence
byage80to85years,and30percentofthesewomenwillrequireanadditionalPOPorincontinencesurgery[3,4].
Anteriorvaginalwallprolapsewithoutconcomitantapicalprolapseisuncommon[5],andapicalprolapserepair
shouldbeincludedinthemajorityofpelvicreconstructivesurgeryprocedures.
Reconstructiveproceduresforprolapseofthevaginalapexarereviewedhere.EvaluationofwomenwithPOP,
conservativemanagement,andchoosingaprimarysurgicalprocedurearediscussedseparately.Obliterative
proceduresforPOP(colpocleisis)arealsodiscussedseparately.(See"Pelvicorganprolapseinwomen:An
overviewoftheepidemiology,riskfactors,clinicalmanifestations,andmanagement"and"Vaginalpessary
treatmentofprolapseandincontinence"and"Pelvicorganprolapseinwomen:Choosingaprimarysurgical
procedure"and"Pelvicorganprolapseinwomen:Obliterativeprocedures(colpocleisis)".)
TERMINOLOGYTheInternationalContinenceSocietydefinesapicalvaginalprolapseasanydescentofthe
vaginalcuffscarorcervix,belowapointwhichis2cmlessthanthetotalvaginallengthabouttheplaneofthe
hymen[6].Theclinicalsignificanceofapicaldescentthatisnotbeyondthehymenisunclear,ashalfof
asymptomaticwomenpresentingforroutinegynecologiccarehaveprolapsetothehymen[7].Similarly,studies
suggestthatprolapsebecomessymptomaticwhentheleadingedgeprotrudesbeyondthevaginalopening[8].
However,isolatedanteriorvaginalwalldefectsareuncommon.Therefore,iftheanteriorvaginalwallprotrudes
beyondthehymen,theapexlikelyhasinadequatesupport,aswell[5,9].
ANATOMYANDMECHANISMSOFINJURYApicalprolapsereferstothedownwarddisplacementofthe
vaginalapex(figure1).Thevaginalapexiseithertheuterusandcervixor,inwomenwhohaveundergonesubtotal
ortotalhysterectomy,thecervixorvaginalcuff.
Supportofthevaginalapexisprimarilyderivedfromtheintegrityoftheuterosacralandcardinalligaments,the
continuityoftheendopelvicfascia,andaneuromuscularlyintactlevatoranimuscle(figure2).Theetiologyof
apicalprolapseislikelyrelatedtoconnectivetissue,neural,and/ormusculardefectsinthesenormalsupports.
Itisraretofindisolatedapicalprolapseorisolatedprolapseoftheanteriororposteriorvaginalwalls,sincethe
defectsintheconnectivetissue,neuralpathways,andmusclearenotconfinedtoonesite[9,10].
Theanatomyofthefemalepelvicfloorisdiscussedindetailseparately.(See"Pelvicorganprolapseinwomen:An
overviewoftheepidemiology,riskfactors,clinicalmanifestations,andmanagement",sectionon'Anatomyof
pelvicsupport'.)
RISKFACTORSTheriskfactorsfordevelopingapicalprolapsearegenerallythesameasfordeveloping
anteriororposteriorvaginalwallprolapse.(See"Pelvicorganprolapseinwomen:Anoverviewofthe
epidemiology,riskfactors,clinicalmanifestations,andmanagement",sectionon'Riskfactors'.)
Themostcommonriskfactorsassociatedwithapicalprolapsearevaginalparity(numberofvaginaldeliveries)and
previoushysterectomy[11,12].Theriskofprolapseafterhysterectomywasillustratedinacasecontrolstudyin
which160,000womenwhounderwenthysterectomyweresignificantlymorelikelythanagematchedcontrolsto
requiresubsequentpelvicfloorrepair(3.2verus2.0percent)[13].Womenwhohaveprolapseatthetimeof
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hysterectomyhaveanevenhigherriskofsubsequentsurgeryforpelvicorganprolapse(POP).Acasecontrol
studyofwomenwhounderwenthysterectomyreportedthattheriskofsubsequentPOPrepairwas5foldinthose
whohadahistoryofvaginaldelivery,8foldinthosewhohadpriorsurgeryforPOPorurinaryincontinence,and
almost13foldinthosewhohadgrade2orhigherprolapseatthetimeofhysterectomy[14].Surgeonsshould
resuspendthevaginalapexwhenperforminghysterectomyfornonprolapseindicationstominimizethisrisk.
CANDIDATESFORAPICALPROLAPSEREPAIRIndicationsforapicalprolapserepairaregenerallythe
sameasforotherpelvicorganprolapse(POP)repairprocedures,ie,symptomaticprolapseinwomenwhodecline
orfailconservativetherapyandwhocantoleratesurgery.Prolapseisnottypicallysymptomaticuntilthevagina
protrudesthroughthehymen.(See"Pelvicorganprolapseinwomen:Choosingaprimarysurgicalprocedure",
sectionon'Candidatesforsurgicaltreatment'and"Pelvicorganprolapseinwomen:Anoverviewofthe
epidemiology,riskfactors,clinicalmanifestations,andmanagement",sectionon'Clinicalmanifestations'.)
PREOPERATIVEEVALUATIONANDPREPARATIONInwomenplanningsurgicalrepairofapicalprolapse,
surgeonsshouldassesseachvaginalcompartment(apical,anterior,andposterior)forthepresenceofsupport
defectsorprolapse.Inaddition,pelvicorganprolapse(POP)oftencoexistswithurinaryand/oranalincontinence.
Duringthehistoryandphysicalexamination,thepresenceandseverityofeachofthesedisordersshouldbe
assessed,asthisinformationmayaltersurgicaldecisionmaking.
Aspectsofpreoperativeevaluationandpreparationthatarespecifictoapicalprolapserepairarediscussedinthis
section.GeneralprinciplesofevaluationofwomenundergoingPOPrepairarediscussedindetailseparately.(See
"Pelvicorganprolapseinwomen:Diagnosticevaluation".)
InformedconsentandpatientgoalsSurgeonsshoulddiscusswitheachwomanthepelvicsymptomsthatare
bothersometoherandtheireffectsonherqualityoflife.Thishelpstosetrealisticgoalsforreconstructivesurgery
andassesspostoperativeimprovement.PatientsatisfactionaftersurgeryforPOPandurinaryincontinence
correlateshighlywithachievementofselfdescribedpreoperativesurgicalgoals,butpoorlywithobjectiveoutcome
measures[1517].
Informedconsentforrepairofapicalprolapseshouldincludeadiscussionoftheriskofpersistentorrecurrent
prolapseattheapex,anterior,orposteriorvaginalwalls.Sincesomewomendevelopstressurinaryincontinence
(SUI)followingapicalprolapserepair,surgeonsshouldalsodiscusstheriskofdevelopingincontinence,aswellas
therisksandbenefitsofperformingaprophylacticincontinenceprocedureversusdeferringanincontinence
procedureuntilsymptomsdevelop.(See'Evaluationofurinarydysfunction'below.)
OtherimportantitemstodiscusswithwomenplanningapicalPOPsurgeryincludepotentialpostoperativechanges
insexualfunctionandmeshrelatedcomplicationsifmeshwillbeusedfortherepair.(See"Overviewof
transvaginalplacementofmeshforprolapseandstressurinaryincontinence",sectionon'Complications'.)
HistoryThemostcommonclinicalmanifestationofprolapseofthevaginalapexisabulgeorprotrusionfrom
thevagina(picture1).Protrusionofthevaginamayresultinvaginaldischargeand/orbleedingfromulceration.
Othersymptomscommonlyreportedbywomenwithapicalprolapsearevoidingdifficultyandconstipationsome
womenneedtoreducetheprolapseusingafingerinthevagina(ie,splint)tourinateordefecate.
Womenwithadvancedanteriororposteriorvaginalwallprolapsemayhavesimilarsymptomsandpelvic
examinationisneededtoascertainthesite(s)andstageofprolapse.Investigatorsdemonstratedthatrestorationof
thevaginalapexduringprolapseexaminationfixesanteriorvaginalwalldefects50percentofthetimeand
posteriorvaginalwalldefects30percentofthetime[18].
PhysicalexaminationAthoroughspeculumandbimanualpelvicexaminationareperformed.Weperform
apicalprolapseassessmentinitiallywiththewomanstandingandstraining.Eachvaginalcompartment(apical,
anterior,andposterior)shouldthenbeexaminedwiththewomensupine.Theapicalprolapsecanbevisualized
duringspeculumexaminationwiththewomanstrainingasthespeculumisslowlywithdrawnfromtheupperthird
ofthevagina.Insomewomenwithadvancedapicalprolapse,protrusionoftheapexisvisibleatorbeyondthe
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vaginalintroitusbeforethespeculumisinserted(picture1).
Sinceisolatedapicalprolapseisrare,carefulassessmentoftheanteriorandposteriorwallisimportant[9].
Thefindingsoftheexaminationshouldberecordedusingaquantitativeandreproduciblemethodforrecording
POP.ThesystemcurrentlyrecommendedbytheInternationalContinenceSocietyandtheAmerican
UrogynecologicSocietyisthepelvicorganprolapsequantitation(POPQ)system(figure3andfigure4)[19].(See
"Pelvicorganprolapseinwomen:Diagnosticevaluation",sectionon'Speculumandbimanualexamination'.)
EvaluationofurinarydysfunctionApicalprolapsefrequentlycoexistswithurinaryincontinenceorurinary
retention,andwomenplanningapicalprolapserepairshouldbeevaluatedfortheseconditions.
UrinaryincontinenceWomenwithsymptomsofbothPOPandSUIaretreatedwithacombinedprolapse
repairandcontinenceprocedure.
ManywomenwithstageIIorgreaterapicalprolapseremaincontinentdespitelossofanteriorvaginaland
bladder/urethralsupport.However,13to65percentofcontinentwomendevelopsymptomsofstressincontinence
aftersurgicalcorrectionoftheprolapse[7,2022].Thislikelyoccursbecausetheprolapsekinksandobstructsthe
urethrathisobstructionisalleviatedwhentheprolapseisrepaired.Thisisreferredtoas"occult"or"potential"
stressincontinence.WomenwithstageIPOPareunlikelytohaveurethralobstructionandresultantoccultstress
incontinence[7,2022].
Allwomenwithapicalprolapseshouldhaveapreoperativeevaluationforoccultstressincontinencewithclinicalor
urodynamicurinarystresstestingwithreductionofprolapse,althoughpreoperativeprolapsereductiontestingdoes
notaccuratelypredictpostoperativeurinaryincontinence.Approximately40percentofwomenwithnegative
testingwilldeveloppostoperativestressincontinencehowever,demonstrationofstressincontinenceduring
reductiontestingisassociatedwithratesofSUIofupto60percentofafterprolapsesurgery[23].(See"Pelvic
organprolapseandstressurinaryincontinenceinwomen:Combinedsurgicaltreatment",sectionon'Detecting
occultincontinence'.)
ForcontinentwomenwithstageIIorgreaterPOPwhoundergoabdominalsacralcolpopexy,highqualitydata
indicatethatbothersomestressincontinenceislesslikelytodevelopinwomenwhoundergoaconcomitantBurch
colposuspensionratherthansacralcolpopexyalone.Whiletherearefewerdataregardingprophylacticsurgeryfor
stressincontinenceinwomenundergoingtransvaginalapicalprolapserepair,itappearssuchpreventivesurgeryis
safeandeffectiveinthispopulation.CombinedsurgeryforPOPandSUIisdiscussedindetailseparately.(See
"Pelvicorganprolapseandstressurinaryincontinenceinwomen:Combinedsurgicaltreatment",sectionon'POP
withnosymptomsofSUI'.)
UrinaryretentionUrinaryretentionisevaluatedbymeasuringapostvoidresidualurinevolume(PVR)
within10minutesafterthepatienthasvoided.Ingeneral,aPVRoflessthan50mLisconsideredadequate
emptying,andaPVRgreaterthan200mLisconsideredinadequate.AnelevatedpreoperativePVRnormalizes
aftersurgicalcorrectionofprolapseinover90percentofwomen[24,25].
EvaluationofdefecatorydysfunctionWomenwithPOPshouldbeaskedaboutsymptomsofdefecatory
dysfunction(eg,constipation,theneedtoplacepressureon,orsplint,theposteriorvaginalwalltodefecate,anal
incontinence).Suchsymptomsshouldbeevaluatedpriortosurgery,asappropriate.(See"Pelvicorganprolapsein
women:Anoverviewoftheepidemiology,riskfactors,clinicalmanifestations,andmanagement",sectionon
'Defecatorysymptoms'and"Fecalincontinenceinadults:Etiologyandevaluation".)
SURGICALPLANNINGIssuesspecifictoplanningrepairofapicalprolapsearediscussedinthissection.
Generalprinciplesofsurgicaldecisionmakingregardingpelvicorganprolapse(POP)(eg,obliterativeversus
reconstructivesurgery,concomitanthysterectomy)arediscussedseparately.(See"Pelvicorganprolapsein
women:Choosingaprimarysurgicalprocedure",sectionon'Candidatesforsurgicaltreatment'.)
AbdominalversusvaginalapproachThechoiceofsurgicalrouteforrepairofapicalprolapseiscontroversial.
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Openabdominalrepairsaremoreeffectiveinrestoringvaginaltopography,butvaginalrepairsincurlessserious
morbidityandhaveashorterrecovery[26].Laparoscopicandroboticapproachesmayoffertheimprovedvaginal
supportassociatedwithopenproceduresandtheshorterrecoveryofvaginalprocedures.
Twocommonapicalprolapseprocedures,abdominalsacralcolpopexyandvaginalsacrospinousligament
suspension(SSLS),werecomparedinametaanalysisofthreerandomizedtrialsincluding321women.Attwo
yearfollowup,abdominalsacralcolpopexyhadasignificantlylowerrateofrecurrentvaginalvaultprolapsethan
SSLS(4versus15percentRR0.2,95%CI0.070.8)[26]however,reoperationratesinthefirsttwoyearsdid
notdiffersignificantly(7versus16percentRR0.5,95%CI0.21.1).Themetaanalysisislimitedbythesmall
numberofpatientsandshortperiodoffollowup.
Contrarytotraditionalbeliefs,themetaanalysisdemonstratedthattotalcomplicationratesweresimilarforthe
vaginalandabdominalapproaches.Similarly,anothermetaanalysisaddressedtheseverityofcomplicationsin
abdominalsacralcolpopexyandtransvaginalapicalsuspensionprocedures.Thisstudyincludedthesamethree
randomizedtrials,aswellas103observationalstudies[27].Similartothemetaanalysisofrandomizedtrials,total
complicationratesappearedsimilarforabdominalcomparedwithvaginalprocedures(17.1versus15.3).However,
theabdominalapproachwasassociatedwithahigherfrequencyofcomplicationsinvolvingsurgicalorradiologic
intervention(5.8versus2.1percent)testsofstatisticalsignificancewerenotreported.
Anotherdifferencebetweensurgicalproceduresisthatabdominalsacralcolpopexy,butnottraditionalvaginal
procedures,hasthepotentialformeshrelatedcomplications.Thereweretoofewmeshrelatedcomplicationsto
reportinthemetaanalysisofrandomizedtrials[26],butthereportedincidenceinasystematicreviewof
abdominalsacralcolpopexywasapproximately3percentusingpolypropylenemesh[28].
Womenwhounderwentabdominalsacralcolpopexywerelesslikelytodeveloppostoperativedyspareuniathan
thosewhounderwentSSLS(16versus36percentRR0.4,95%CI0.20.9)[2931].Ratesofdyspareuniawere
highforbothsurgicalapproacheshowever,thedataregardingdyspareuniawereonlyavailablefor106patients.A
literaturereviewofobservationalstudiesreportedgeneralimprovementinsexualfunctionfollowingsacral
colpopexyanddyspareuniaratesof3to10percentafterSSLS[32].Similarly,sexualfunctionandpainwith
intercourseimprovedoneyearaftersacralcolpopexyintheColpopexyandUrinaryReductionEfforts(CARE)trial
[33].
TheonlydisadvantagesofsacralcolpopexycomparedwithSSLSinthemetaanalysisofrandomizedtrialswere
increasedoperativeduration(anaverageof21minuteslonger),recoverytime(anaverageof8dayslonger),and
expense[26].
Insummary,abdominalsacralcolpopexyismoreeffectiveinrestoringvaginaltopographywithoutasignificant
increaseinmorbiditywhencomparedtoSSLSandmaybemoreappropriateforwomenwithriskfactorsfor
prolapserecurrence,includingyoungage,obesity,stageIIIorIVPOP,andpreviousfailedPOPrepair[3437].
Rareriskfactorsforrecurrentprolapsearebladderexstrophyorspinabifida[38,39].Abdominalproceduresalso
appeartoresultinalowerincidenceofdyspareunia.Otherreasonstochooseanabdominalapproachare:
insufficientvaginallengthfortransvaginalrepairandotherindicationsforabdominalsurgery(eg,ovarian
cystectomy).
Ontheotherhand,transvaginalrepairisperformedin80to90percentofprolapsesurgeriesintheUnitedStates
[2,3,40].Vaginalsurgeryhasashorteroperativedurationandrecoverythanopenabdominalsacralcolpopexy.For
thesereasons,itisoftenselectedforwomenwithincreasedsurgicalrisk.Inaddition,thetransvaginalapproach
canbeeasilycombinedwithothervaginalprocedurescommonlyperformedinwomenwithPOP(eg,vaginal
hysterectomy,midurethralslingplacement).Withtheincreasinguseoflaparoscopicandroboticalternativesto
laparotomywhenperformingsacralcolpopexy,theshorterrecoveryanddecreasedmorbidityassociatedwith
vaginalapproachesmaybecomelessimportant.
Insummary,whenplanningsurgeryforqualityoflifedisorders,suchasapicalprolapse,factorsbeyondsimple
anatomicoutcomesshouldbeconsideredandweighedbyeachwomanwithhersurgeon.Selectingtheoptimal
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operationfortreatmentofapicalprolapseiscomplicatedandimpactedbynumerousfactors,includingindividual
womensgoalsforsurgery,aswellasherriskofprolapserecurrence,abilitytotoleratesurgery,andpreferences
regardingrecoverytimeandriskofdyspareunia(algorithm1).Giventhecurrentdata,abdominalsacralcolpopexy
offersbetteranatomicoutcomesthanSSLSformostwomenundergoingapicalprolapserepair.Avaginalapproach
isareasonablealternativeforwomenwithprimaryprolapsewhoarehavingconcomitantvaginalsurgery,risk
factorsformeshrelatedcomplications(eg,smoking,immunosuppression),orwhoplaceahighpriorityonashort
recoveryperiodoravoidinganabdominalincision.(See"Overviewoftransvaginalplacementofmeshforprolapse
andstressurinaryincontinence"and"Woundinfectionfollowingrepairofabdominalwallhernia".)
Uterosacralligamentsuspension(ULS)andiliococcygeussuspensionareothertransvaginalapproachesforapical
prolapserepair.TherearenocomparativestudiesbetweenULSandabdominalsacralcolpopexy.Thus,any
recommendationregardingusinganabdominalversusvaginalapproachwouldhavelowerconfidenceduetothe
lackofdirectevidenceforalltransvaginalprocedures.(See'Uterosacralligamentsuspension'belowand
'Iliococcygeussuspension'below.)
ConcomitantrepairofothersitesofprolapseApicalprolapsealmostalwayscoexistswithothersitesof
POP(anteriororposterior).Itiscontroversialwhetherrepairofapicalprolapseissufficienttosupporttheanterior
andposteriorvaginalwallsorifadditionalproceduresarerequiredtoaddressanteriorand/orposteriorprolapse.If
thevaginalmuscularisiswellsuspendedattheapex,manyanteriorandposteriordefectswillalsoresolve
conversely,correctionofanteriororposteriorprolapsedoesnotrepairapicaldescent.Anteriorvaginalwall
prolapse,inparticular,ishighlycorrelatedwithapicalprolapse.Theapproachtoconcomitantrepairofmultiple
sitesofprolapsevariesbysurgicalrouteandbysiteofprolapse.Adetaileddiscussionoftheconcomitantrepairof
multiplesitesofprolapsecanbefoundseparately.(See"Pelvicorganprolapseinwomen:Choosingaprimary
surgicalprocedure",sectionon'Concomitantrepairofapicalandanteriororposteriorprolapse'.)
ConcomitantsurgeryforstressurinaryincontinenceManywomenwithapicalprolapsehavecoexisting
urinaryincontinence,asnotedabove.(See'Evaluationofurinarydysfunction'above.)
Burchcolposuspensionperformedconcurrentlywithabdominalsacralcolpopexyisdiscussedbelow.(See
'ConcomitantBurchcolposuspension'below.)
WomenwithsymptomaticurinaryincontinenceWomenwithsymptomsofbothPOPandstress
incontinencearetreatedwithacombinedprolapserepairandcontinenceprocedure.(See"Pelvicorganprolapse
andstressurinaryincontinenceinwomen:Combinedsurgicaltreatment",sectionon'Symptomaticprolapseand
incontinence'.)
WomenatriskforocculturinaryincontinenceForwomenwithstageIIorgreaterPOPwhoare
undergoingabdominalsacralcolpopexy,highqualitydatasupportaconcomitantBurchcolposuspensionrather
thansacralcolpopexyalone.Forcontinentwomenundergoingtransvaginalprolapserepair,thedecisionofwhether
toperformaconcomitantmidurethralslingdependsuponpatientpreferenceregardingtheriskofdevelopingstress
urinaryincontinence(SUI)comparedwiththeriskofperioperativecomplications.
CombinedsurgeryforPOPandstressincontinenceisdiscussedindetailseparately.(See"Pelvicorganprolapse
andstressurinaryincontinenceinwomen:Combinedsurgicaltreatment",sectionon'POPwithnosymptomsof
SUI'and"Pelvicorganprolapseandstressurinaryincontinenceinwomen:Combinedsurgicaltreatment",section
on'Summaryandrecommendations'.)
EVALUATINGAPICALPROLAPSEPROCEDURESSurgicaloutcomesofpelvicorganprolapse(POP)
treatmentshaverangedovertheyearsfrompatientsreportsthattheyarehappyorcuredtostrictanatomic
criteriaforcureregardlessofpatientsatisfaction.Improvementinobjectivelymeasuredoutcomesaftersurgerydo
notalwayscorrespondtopatientsatisfaction[15,16].Morerecently,expertsagreethatoutcomesliteratureshould
includebothameasureofsubjectivecure(baseduponthepatient'sreportofcureorimprovement)andameasure
ofobjectivecureusingavalidatedPOPmeasuringsystem.Astudylookedatcureratesusingavarietyof
anatomicandsubjectivedefinitionsinacohortofwomentwoyearsafterabdominalsacralcolpopexy[41].
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Reportedcureratesrangewidely,from19percentto97percent,dependingonthedefinitionusedwithpatient
reportsofnobulgebeyondthehymenbeingmostassociatedpatientsownassessmentofimprovement.These
datashouldnotbeoverinterpretedtomeanobjectiveoutcomesarenotvaluable,asthefollowupperiodinthis
studywasshort(onlytwoyears)andanatomicoutcomestendtoworsenovertime.
ABDOMINALSACRALCOLPOPEXYAbdominalrepairofapicalprolapseisperformedbysecuringthe
anteriorandposteriorvaginalwallsviasurgicalmeshtotheanteriorlongitudinalsacralligamentoverlyingthe
sacralpromontory.Thisreestablishesanearlyhorizontalvaginalaxis[42].Theventralabdominalwallandround
ligamentsshouldneverbeusedbecauseofthehighriskofrecurrentprolapse.
Abdominalsacralcolpopexy(attachmentbetweenthesacralpromontoryandthevaginavaultinwomenwhohave
undergonetotalhysterectomy)isthemostcommonlyperformedprocedure.Uterineorcervixsparingprocedures
include:sacralhysteropexy(attachmentbetweenthesacralpromontoryandtheloweruterus)andsacral
cervicopexy(attachmentbetweenthesacralpromontoryandthecervix).
Typically,ahysterectomyisdoneatthetimeofapicalpelvicorganprolapse(POP)repairinwomenwith
uterovaginalprolapse.Whilenoprospectivecomparativestudiesareavailabletodetermineifoutcomesare
improvedwithconcomitanthysterectomy,severalsmallstudiessuggestthatPOPoutcomesarenotworseand
operatingtimesareshorterwithuterinepreservation[43,44].Aretrospectivecohortstudycomparedthreegroups
(hysterectomyplussacralcolpopexy,sacralhysteropexy,andhysterectomyplusuterosacralsuspension)and
showedasixfoldincreaseinPOPrecurrenceintheuterosacralsuspensiongroup[45].
Concomitanthysterectomyatthetimeofprolapserepairisdiscussedindetailseparately.(See"Pelvicorgan
prolapseinwomen:Choosingaprimarysurgicalprocedure",sectionon'Concomitanthysterectomy'.)
ProcedureOpenabdominalsacralcolpopexyisperformedthroughalowerabdominalincision,typicallya
Pfannenstiel,althoughthereareincreasingnumbersofsacralcolpopexiesbeingdonelaparoscopicallyorwith
roboticassistedlaparoscopicprocedures.
Acommonlyperformedtechniqueistoattachapermanentmeshtotheposteriorvaginatotheleveloftherectal
reflectionandtotheanteriorvaginaforadistanceof4cm,orjustabovethebladdertrigone.Itisacceptabletouse
ameshfashionedintoaYconfigurationortousetwoseparatestripsofmesh.Alternatively,theposteriormesh
mayextendtotheperinealbody,addingsupporttothisarea(sacralcolpoperineopexy).Tworowsofsuturesare
thenusedtowidelyattachthemeshtothevaginatodistributethetensionthesuturesshouldapproximatethe
meshtothevaginalwallsforadistanceofseveralcentimeters.Permanentsuturesaretypicallyusedtoattachthe
meshtothevaginaandsacrum.Secondarytoconcernaboutvaginalerosionofpermanentsutures,some
surgeonsarestartingtousedelayedabsorbablesutures.IntheColpopexyandUrinaryReductionEfforts(CARE)
trial(arandomizedtrialthatcomparedabdominalsacralcolpopexywithandwithoutBurchcolposuspension)of322
womenundergoingabdominalsacralcolpopexywithpermanentsutures,onlythreeparticipantshadavaginal
erosionofthepermanentsutureinthefirsttwoyearsaftersurgery[46].Thesuturewassimplyremovedinall
threepatientstwohealedwithoutfurtherproblem,andtheotherwaslosttofollowup.Giventhelackofhigh
qualitydatasupportingcomparableanatomicand/orsymptomaticoutcomeswithuseofdelayedabsorbable
suturesandtheminimalrisksassociatedwithpermanentsuture,patientsshouldbecounseledappropriatelyif
nonpermanentsuturesareused.
Failuretoattachthemeshanteriorlyresultsinanteriorvaginalwallrecurrenceratesofalmost30percent[47].The
optimalapproachforposteriorvaginalwallattachmentisunclearhowever,simplyattachingthemeshtothe
rectovaginalseptumtomaintaincontinuitywiththeperinealbodyresultsinhighsuccessrates[48].Themesh
erosionratesreportedfromabdominovaginalattachmentofthemeshtotheperinealbodyhavevariedwidely(7to
40percent)[49,50].
Afterexposingthepresacralspace,thefreeendofthemeshisattachedtotheanteriorlongitudinalligamentatthe
sacralpromontoryusingtwoorthreepermanentsutures.
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AvoidingpresacralhemorrhageLacerationofthepresacralvenousplexusleadstoprofusehemorrhage.
Carefuldissectionmustbeusednearthesacrum.Thesuturesareplacedthroughthesacral(anteriorlongitudinal)
ligamentjustbelowthesacralpromontorysinceplacementloweronthesacrum,attheS3toS4level,ismore
likelytoresultinpresacralhemorrhageandplacementonthepromontorymaydeviatethevaginalaxistoofar
forward.
ChoosingasurgicalmeshSimplesuturingoftheapicalvaginalskintothesacrumisalsoregardedas
insufficientfixationandlikelytoresultinrecurrentprolapse.Thebesttypeofmeshandsuturematerialremains
controversial,butmostsurgeonsagreethatsyntheticnonabsorbablematerialsshouldbeused.Syntheticmesh
sacralcolpopexyhasconsistentlyoutperformedthebiologicgraftmaterials(autologous,allogeneic,xenograft)in
randomizedtrials,butattheexpenseofhighermesherosionrates[28,42,51].Inasystematicreviewof65studies
(threewererandomizedtrials),theaveragerateofsyntheticmesherosionwas3.4percent,thelowestratewasfor
polypropylene(0.5percent)comparedwithothertypesofsyntheticmesh,suchaspolyethyleneor
polytetrafluoroethylene(3.1to5.0percent)[28].
Onrareoccasions,asurgeonmayalsofaceanintraoperativedecisiononwhethertousesyntheticorbiologic
meshinthefaceofabowelinjuryorconcomitantsigmoidresectionwithreanastomosisforthetreatmentofrectal
prolapse.Sinceitisoftennotadvisabletoplacesyntheticnonabsorbablematerialsduringprocedures
contaminatedbybowelcontents,thesechoicesshouldbedeterminedbycarefullyweighingtheriskandbenefits
foranindividualpatient.
Surgicaltreatmentofprolapseofthevaginalapexwithvaginalmeshkitsisincreasinglycommon,although
outcomedataarelacking[52].Similartoanteriorvaginalmeshplacement,useofapicalvaginalmeshmaybe
associatedwithsignificantcomplications[27,53].
OutcomeAsystematicreviewofstudiesfrom1966to2004reportedthatanatomicsuccessratesafter
abdominalsacralcolpopexyrangefrom76to100percentwitha4percent(range0to18percent)reoperationrate
forprolapse[28].
Theneedforconcomitantanteriororposteriorvaginalwallrepairsatthetimeofsacralcolpopexyiscontroversial.
Thistopicisdiscussedindetailseparately.(See"Pelvicorganprolapseinwomen:Choosingaprimarysurgical
procedure",sectionon'Abdominalroute'.)
OneyearoutcomesoftheCAREtrialshowedthatabdominalsacralcolpopexyperformedwithorwithoutposterior
vaginalwallrepairresultedinstatisticallyandclinicallysignificantimprovementsinbowelsymptoms,including
obstructivedefecationandposteriorvaginalwalltopographyregardlessofconcomitantposteriorrepair[8].
Likewise,therewasnodifferenceinanteriorvaginalwallsupportinwomenwhohadaconcomitantparavaginal
repairandthosewhodidnot.Anotherstudyof149womenwithadvancedprolapsewhounderwentsacral
colpopexywithoutanyconcomitantrepairsdemonstratedexcellentanatomicoutcomesoneyearaftersurgery[54].
TwoyearoutcomesoftheCAREtrialshowedthat95percentofwomenhadsupportofthevaginalapexwithin2
cmofthetotalvaginallengthand3percenthadundergonereoperationforprolapse[55].Womenreported
significantimprovementinpelvicfloorsymptomsandsexualfunctionusingvalidatedquestionnaires.Inaddition,
correctionofapicalprolapseviaabdominalsacralcolpopexywithorwithoutBurchcolposuspensionsignificantly
reducedbladdersymptomsotherthanincontinence,bothirritative(eg,urgency,frequency,nocturia)and
obstructive(eg,intermittentflow,strainingtovoid,sensationofincompleteemptying,poorstream)[56].Atone
year,participantsreportedasignificantdecreaseinobstructivedefecatorysymptoms,fecalincontinenceand
anorectalpain[8].Newonsetfecalincontinencewithactivity,aswellaspainpriortoandwithdefecation,were
morelikelytobereportedbywomenwhohadaconcomitantposteriorrepairprocedurethanbythosewhodidnot.
SevenyearoutcomesoftheCAREtrialshowedthattheestimatedprobabilitiesoftreatmentfailureforthe
urethropexygroupandthenourethropexygroup,respectively,were0.27and0.22foranatomicPOPand0.29and
0.24forsymptomaticPOP[57].Mesherosionprobabilityatsevenyearswas10.5percent.Longtermstudies
reportthat,at10to14yearsafterabdominalsacralcolpopexy,2to26percentofwomenhadundergone
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reoperationforprolapse[58].
ComplicationsThemostfrequentlyreportedintraoperativeandpostoperativecomplicationsofopenabdominal
sacralcolpopexyinclude[28]:
Incisionalproblems4.6percent
Bloodtransfusion4.4percent
Ileus3.6percent
Thromboembolicevent3.3percent
Cystotomy3.1percent
Enterotomy1.6percent
Studiesconsistentlyreportthatgastrointestinalcomplications,suchassmallbowelobstructionorileus,occur
afterapproximately1to5percentofabdominalsacralcolpopexyprocedures[28,59].IntheCAREtrial,4of322
womenrequiredreoperationforsmallbowelobstructionandallwereassociatedwithincisionalproblems.No
intraoperativebowelinjurieswerereported[59].
Presacralhemorrhageisthemostconcerningintraoperativecomplicationandcanhavelifethreatening
consequences.Reconstructivesurgeonsshouldbepreparedtomanagepresacralhemorrhageandhavebonewax,
concavethumbtacks,andthrombinimmediatelyavailable.(See"Managementofhemorrhageingynecologic
surgery"and"Managementofhemorrhageingynecologicsurgery",sectionon'Presacralbleeding'.)
Mesherosionratesvarydependingonthetypeofmeshused.Syntheticnonabsorbablemeshistypicallyused
and,asnotedabove,asystemicreviewfoundthattheaveragerateoferosionforalltypesofsyntheticmeshwas
3.4percent,witharateof0.5percentforpolypropylenemesh[28].(See'Choosingasurgicalmesh'above.)
Severalstudiesreporthighermesherosionrateswhensacralcolpopexyisperformedwithconcomitanttotal
hysterectomy,butthisisnotuniversallyreported[46,60].Inalargemulticenterstudyofwomenundergoing
abdominalsacralcolpopexy,concomitanttotalhysterectomywasmorecommoninwomenwhodevelopedamesh
orsutureerosion(60percentversus24percent),resultinginanearlyfivefoldincreasedriskofmesherosionin
womenwithaconcomitanthysterectomy[46].SomedatasuggestthatsmokinganduseofePTFEmesh(Gore
tex)arealsoriskfactorsformesherosionfollowingsacralcolpopexy[46,61].
LaparoscopicorroboticproceduresSacralcolpopexyistraditionallyperformedthroughalaparotomy
however,conventionalandrobotassistedlaparoscopicapproacheshavegainedpopularity.Inaddition,singleport
laparoscopicprocedureshavebeenreported[62].(See"Robotassistedlaparoscopy"and"Abdominalaccess
techniquesusedinlaparoscopicsurgery",sectionon'Singleincisionsurgery(SIS)'.)
Observationaldatasuggestthattheconventionallaparoscopicandrobotassistedroutesresultinashorterhospital
stay(eg,onetotwoversusthreetofourdays),fastertimetorecovery,andlesspostoperativepainthan
laparotomy,withcomparableshorttermefficacy[27,6366].Someretrospectivestudieshavealsofounda
significantdecreaseinbloodloss(eg,60to150mLless)withlaparoscopicprocedures[63,65].Adisadvantageof
laparoscopicproceduresisalongeroperativeduration(eg,onetotwohourslonger).Inaddition,roboticprocedures
aremorecostlythanlaparotomyorconventionallaparoscopy[67,68].AUnitedKingdommulticenterrandomized
equivalencetrialcomparedopentolaparoscopicsacralcolpopexy.Atoneyear,therewerenodifferencesin
anatomicorsubjectivepelvicflooroutcomeshowever,bloodloss,postoperativehemoglobinvalues,andhospital
staywerebetterinthelaparoscopicarm[69].Manysurgeonshaveadoptedahighersacralfixationpointwhen
performinglaparoscopicandroboticprocedures.Casereportsofvertebraldiscitis[70]andcadavericandmagnetic
resonanceimagingstudiessuggestthattoavoiddisccomplications,suturesshouldbeplacedinferiortothe
promontorytoavoidtheintravertebraldisc[71,72].
Performingsacralcolpopexyrequiressuturing,whichismoredifficulttodowithconventionalthanduringrobot
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assistedlaparoscopy.Forthisreason,somesurgeonspreferroboticassistedlaparoscopy.However,two
randomizedtrialshavefoundthatroboticcomparedwithconventionallaparoscopicsacralcolpopexyhasalonger
operativeduration(24to67minuteslonger)andhighercosts,withsimilarcomplicationratesandshortterm
outcomes[73,74].
Althoughfurtherstudiesarenecessarytoascertaintheroleforroboticversuslaparoscopicsacralcolpopexy,
currentdatasuggestthatthelaparoscopicroutemaybemorecosteffectiveandconfersomebenefitstothe
patients.
CONCOMITANTBURCHCOLPOSUSPENSIONBurchcolposuspension(alsoreferredtoasretropubic
urethropexy)isaneffectiveprocedureforthetreatmentandpreventionofstressurinaryincontinence(SUI).This
procedurehadbeenwidelyused,buthasnowbeenlargelyreplacedbymidurethralslingprocedures.Thisisdueto
theincreasedoperativedurationandriskofcomplicationsforaBurchprocedurecomparedwithamidurethralsling.
(See"Surgicalmanagementofstressurinaryincontinenceinwomen:Choosingaprimarysurgicalprocedure",
sectionon'Midurethralslingsversusotherprocedures'.)
Incurrentpractice,Burchcolposuspensionistypicallyperformedmostlyincombinationwithanabdominal
sacrocolpopexyinwomenwithsymptomaticSUIorasaprophylacticprocedureinwomenwithadvancedprolapse
whoarelikelytodevelopSUIaftersacralcolpopexy.Thetwoproceduresarebothperformedviaanabdominal
incision,andthus,traditionallyhavebeendonetogether.However,somesurgeonsprefertoperformamidurethral
slingprocedureevenforwomenundergoingabdominalsacralcolpopexy.
Combinedprolapseandcontinencesurgeryandchoiceofaconcomitantprocedurearediscussedindetail
separately.(See"Pelvicorganprolapseandstressurinaryincontinenceinwomen:Combinedsurgicaltreatment"
and"Surgicalmanagementofstressurinaryincontinenceinwomen:Choosingaprimarysurgicalprocedure",
sectionon'Coexistentsuiandpelvicorganprolapse'.)
IndicationsandpreoperativeevaluationTheBurchcolposuspensionisindicatedforwomenplanningsurgical
treatmentofSUI,andforwomenwhopreferthisproceduretoothertypesofsurgery.Burchcolposuspensionis
intendedtosupportthebladderneckandproximalurethratopreventdownwarddescentofthesestructuresandto
allowforurethralcompressiontherefore,itisnotanappropriateoperativechoiceforwomenwithouturethral
hypermobility.
ThepreoperativeevaluationofwomenpriortoaBurchprocedureisthesameasforothersurgicaltreatmentsfor
SUI.(See"Surgicalmanagementofstressurinaryincontinenceinwomen:Preoperativeevaluationforaprimary
procedure".)
OutcomeBurchcolposuspensionisaneffectiveprocedureforthetreatmentofSUI.Randomizedtrialdata
showthatthelongtermsuccessrateiscomparableorslightlylowerthanformidurethralslings(70versus63
percentinonetrial[75])orfascialslings(24versus31percentinonetrial[76,77]).Thesuccessratesreportedin
thesetrialsrepresentarigorouscompositemeasureofseveralendpoints(subjectiveandobjectiveoutcomes).
Patientsatisfactionratesafterbothproceduresaremuchhigher,approaching80percent.
Manytrialsevaluatingcontinenceproceduresexcludewomenwhoareundergoingconcomitantprolapserepair.
TheonlytrialtoevaluateBurchproceduresthatincludedconcurrentprolapserepairprocedureswastheStress
IncontinenceSurgicalTreatmentEfficacyTrial(SISTEr)[76,77].TheSISTErtrialassigned655womenat9United
StatessiteswithSUItoundergoBurchcolposuspensionorarectusfascialslingprocedure.Fortyeightpercentof
womenintheBurcharmunderwentconcomitantprolapserepair,includingapicalsuspensionand/oranteriorand
posteriorrepair.Usingastringentcompositeoutcome,overallsuccessat24monthswassignificantlylowerafter
Burchcolposuspension(38versus47percent),althoughsatisfactionwasconsiderablyhigherat78percent(86
percentinslingarm).Byfiveyearsaftersurgery,overallcontinenceratesdecreasedandremainedsignificantly
lowerintheBurcharmthanintheslingarm(24versus31percent).NohighqualitydataexistcomparingBurch
colposuspensiontomidurethralslinginwomenwithprolapse.FortyeightpercentofwomenassignedtoBurchand
55percenttoslingunderwentconcomitantprolapsesurgery,includinganteriorrepairs,vaginalandabdominal
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apicalsuspensionprocedures,andhysterectomy.Continenceoutcomesdidnotdifferbasedonconcomitant
prolapsesurgery.Therewasnoclinicallyorstatisticallysignificantinteractionbetweenconcomitantsurgeryand
incontinenceoutcomesineitherarm[76].
BurchcolposuspensionisalsosafeandeffectiveforthepreventionofSUIinwomenundergoingabdominalsacral
colpopexyforapicalprolapse.ThiswasdemonstratedintheColpopexyandUrinaryReductionEfforts(CARE)
trial,whichisdescribedindetailseparately.(See"Pelvicorganprolapseandstressurinaryincontinencein
women:Combinedsurgicaltreatment",sectionon'Abdominalapproach'.)
ProcedureBurchcolposuspensionismostcommonlyperformedthroughalowtransverseabdominalincisionit
mayalsobeperformedlaparoscopically.
Regardlessofrouteofaccess,inaBurchcolposuspension,theavascularretropubicspaceisexposedbilaterally
andthebladdermobilizedfromthepubicsymphysis.Withthesurgeonsnondominanthandinthevaginaelevating
theanteriorvaginalwall,twosuturesareplacednearfullthicknessthroughtheanteriorvaginaoneithersideofthe
midurethra(figure5andfigure6andfigure7).Twoadditionalsuturesareplacedthroughthevaginaoneitherside
oftheurethrovesicaljunction.AllsuturesarethenplacedthroughCoopersligamentwiththemidurethralsutures
medialontheligamenttotheurethrovesicaljunctionsutures.ThesuturearmsaretiedaboveCoopersligamentso
theurethrovesicaljunctionissupportedthereshouldgenerallybeanapproximately2cmsuturebridgebetween
thevaginaandCoopersligamenttopreventovercorrectionoftheurethrovesicaljunctionandurinaryretention.
Intraoperativecystoscopyshouldbeperformedafterproceduretoensurenosutureswereplacedintothebladder
andbilateralbriskeffluxofurine.
LaparoscopicrouteBurchcolposuspensioncanbeperformedlaparoscopically.Thereisnodifferencein
efficacybetweentheopenandlaparoscopicapproachestotheBurchprocedure,butlaparoscopicprocedureshave
somewhatlowercomplicationrates[78,79].WesuggestlaparoscopicratherthanopenBurchcolposuspension.
However,routineuseofthelaparoscopicBurchprocedureislimitedbytheavailabilityofsurgeonswiththe
appropriateskills.Thus,opencolposuspensionshouldbeperformedifthesurgeonisnotexperiencedinthe
laparoscopictechniqueforthisprocedure.
OpenandlaparoscopicBurchcolposuspensionwerecomparedinametaanalysisof10randomizedtrials[80].
ShorttermsubjectivecureratesforlaparoscopiccomparedwithopenBurchcolposuspensionweresimilar(at18
monthfollowup:78versus83percent,RR1.0,95%CI0.91.0)[80].Thelowerrateofperioperativecomplications
(eg,infection,hemorrhage)forlaparoscopicproceduresjustreachedstatisticalsignificance(15versus18percent,
RR0.74,95%CI0.580.96).Laparoscopicprocedureswereanaverageof14minuteslonger.Themain
advantagesofthelaparoscopicapproachwereashorterhospitalstay(anaverageofoneday)andafasterreturn
tonormalactivity(10dayssooner).ThelongtermeffectivenessofopenBurchcolposuspensionrangesfrom70to
90percentat5to10yearsfollowingsurgery[8183].
DataalsosuggestsimilaroutcomesafterlaparoscopicBurchcomparedwithmidurethralslingprocedures.One
randomizedtrialreportedincontinenceratesof58and48percentfourtoeightyearsafterlaparoscopicBurch
colposuspensionormidurethralsling[84].
Whenusingthisapproach,somesurgeonsmodifythetechniquetousemeshandtackersratherthansuturing,
whichcanresultinsignificantmorbidity[85].Giventhepaucityofoutcomedataandmorbidityusingthese
modifications,wedonotmodifytheprocedurethiswayinourpractice.
Complications
VoidingdysfunctionandurgencyincontinenceHistorically,Burchcolposuspensionwasassociatedwith
highratesofdenovovoidingdysfunctionandurgencyurinaryincontinence.However,welldesignedstudieshave
reportedlowcomplicationrates.IntheSISTErrandomizedtrial,postoperativeurinaryfunctioncomplications
included:prolongedvoidingdysfunction(2percent)andnewonseturgencyincontinence(3percent)[76].In
anotherrandomizedtrial,therewasnosignificantdifferenceintherateofvoidingdysfunctioninwomenwho
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underwentBurchcomparedwithamidurethralslingprocedure[86].ForBurch,theproportionofwomenwho
requiredcatheterizationatsixmonthfollowupwas8percent,whichwashigherthanintheSISTErtrial,butthis
decreasedwithtime.Twoyearsaftersurgery,2.4percentofwomenrequiredintermittentselfcatheterization.
UrinarytractinfectionPostoperativeurinarytractinfectionisthemostcommonlyreportedadverseevent
followingaBurchprocedure,32to50percentinrandomizedtrials[76,86].Theincidenceofcystitisorsymptoms
ofurinarytractinfection(withorwithoutpositiveculture)ishighestinthefirst6months,butthisissuepersistsin
2to9percentofwomenupto24monthsaftersurgery[87].
ApicalprolapseEarlyreportssuggestedratesofenteroceleofupto17percentfollowingBurch
colposuspension[88,89].Thisisthoughttooccurasaresultofthemoreanteriorangulationofthevaginaasa
resultoftheprocedure,allowingtheposteriorcompartmenttobecomemoresubjecttothepressuretransmission
ofintraabdominalpressure.Asanexample,inonestudy,nearly5percentofwomenwithstageIIprolapse
requiredreoperationrateforprolapse[86].Onphysicalexamination,therateofwomenwithapicalprolapse
increasedfrom21percentpreoperativelyto63percentat24months18percentofthewomenwithprolapsewere
symptomatic.Ofcourse,thisstudydidnotincludewomenwhounderwentconcomitantapicalprolapserepair.
OthercomplicationsAdditionaladverseeventsreportedinwomenwhounderwenttheBurch
colposuspensioninclude:incidentalcystotomy(3percent),surgicalwoundcomplicationsrequiringsurgery(2.4
percent),recurrentcystitisleadingtodiagnosticcystoscopy(1.5percent),bleeding(1percent),ureteralinjury(1
percent),incidentalvaginotomy(0.5percent),ureteralvaginalfistula(0.5percent),erosionofsutureintothe
bladder(0.5percent),andpyelonephritis(0.5percent)[76].
Summary
Burchcolposuspensionisasafe,effectivetreatmentforSUIinwomenwithandwithoutconcomitantpelvic
organprolapse(POP).
OpenandlaparoscopicBurchcolposuspensionresultinsimilarsubjectiveandobjectiveoutcomesforthe
treatmentofSUIinwomen.
OpenandlaparoscopicBurchcolposuspensionresultinsimilaroutcomestoretropubicmidurethralsling
procedures.
BurchcolposuspensionshouldbeconsideredforthepreventionofSUIinstresscontinentwomenundergoing
abdominalsacralcolpopexy.
VAGINALPROCEDURESWhenthevaginalrouteisused,thevaginalapexissuspendedtoaligamentinthe
pelvis,eitherthesacrospinousligament,iliococcygeusfascia,ortheuterosacralligament.Ofthese,onlythe
sacrospinousisatrueligament.Thisistypicallyperformedinwomenwhohaveundergonetotalhysterectomy,
althoughcervixanduterinesparingproceduresarepossible.Vaginalproceduresrequireasufficientvaginallength
toreachthesupportingligament.
Sacrospinousligamentsuspension(SSLS)wasthemostcommonlyusedtransvaginalprocedureforapical
prolapserepair.However,morerecently,uterosacralligamentsuspension(ULS)hasgainedpopularity.The
uterosacraltechniquewasintroducedinthe1920s,butinthehalfcenturythatfollowed,reconstructivesurgeons
seemedtoshiftfocusawayfromtheuterosacralligamentstomoresturdysitesoffixation,suchastheSSLS[90].
HighratesofrecurrentanteriorvaginalwallprolapsearecommonafterSSLS,sosurgeonsattemptedtofinda
moreanatomicsitetoattachtheapextopreventdefectsinothercompartments.Uterosacralandiliococcygeus
suspensionaretwosuchattempts.
Ingeneral,surgeonsintheUnitedStatesuseaULSwhenperformingconcomitantvaginalhysterectomy,while
SSLSisusedmorecommonlyforposthysterectomyprolapserepair.However,bothproceduresmaybe
performedinwomenwithapriorhysterectomyoratthetimeofconcomitanthysterectomy.
Nohighqualityevidenceisavailabletoguidesurgeonsregardinguterinepreservationatthetimeofvaginalapical
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suspensionprocedures.Asmall,nonrandomizedprospectivetrialcomparedwomenundergoingsacrospinous
cervicopexywithuterinepreservationandthoseundergoingSSLSwithvaginalhysterectomy[91].Uterine
preservationwasassociatedwithlessbloodlossandshorteroperatingtimes.Anatomicpelvicorganprolapse
(POP)outcomesandreoperationforPOPweresimilarforbothgroups.Uterineconservationatthetimeof
prolapserepairisdiscussedindetailseparately.(See"Pelvicorganprolapseinwomen:Choosingaprimary
surgicalprocedure",sectionon'Concomitanthysterectomy'.)
SacrospinousligamentsuspensionSSLS(alsoreferredtoassacrospinousligamentfixation)isthemost
commonlystudiedtransvaginalprocedurefortreatingvaginalvaultprolapse.
AlthoughSSLSmayalsoimproveanteriorvaginalwallprolapse,itislesseffectiveforthisindication.Thus,
womenwithlargeanteriorwalldefectsinadditiontoapicaldefectsmaybenefitfromanothertypeofprolapse
repair,whichbettersupportstheanteriorvaginaorconcomitantanteriorcolporrhaphy.(See"Pelvicorganprolapse
inwomen:Choosingaprimarysurgicalprocedure",sectionon'Concomitantrepairofapicalandanterioror
posteriorprolapse'.)
SSLSisgenerallyperformedunilaterally.Mostsurgeonsprefertherightsidesincethebowelenterstherectumon
theleftside[32].SomesurgeonshaveproposedbilateralSSLS,althoughthevalueofthismodificationhasnot
beenproven[92,93].Useofthebilateraltechniquedependsuponadequatevaginallengthandwidth.
ProcedureBeforestartingtheprocedure,thepatientisexaminedtoensurethatthevaginaislongenough
toreachthesacrospinousligament.WomenwhodonothavesufficientvaginallengthforSSLSmaybe
candidatesforabdominalsacralcolpopexy.
Thesacrospinousligamentextendsfromtheischialspinestothelowerportionofthesacrumandcoccyx(figure8
andfigure9).Thecoccygeusmusclefollowsthesamepathasthesacrospinousligamenttogethertheyare
referredtoasthecoccygeusmusclesacrospinousligamentcomplex(figure10).Theligamentcanbeidentifiedon
pelvicexaminationbypalpatingtheischialspineandtracingposteriorlyandmediallytothesacrum[94].Marking
suturesareplacedonthevaginalepitheliumatthesitewhereitwillattachtothesacrospinousligament.
SeveraltechniquesarecommonlyusedwhenperformingaSSLS.Inonemodification,theperirectalspaceis
enteredbyopeningtheposteriorvaginainthemidlinefromtheperinealbodytotheapex.Thevaginalepitheliumis
thenseparatedfromtheunderlyingmuscularis.Thedissectioniscontinuedtotheleveloftheischialspine.The
rectovaginalspaceisopenedbygentlypushingtherectummediallythenperforatingtherectalpillar(areolartissue
thatextendsfromtherectumtothearcustendineusfasciapelvisandoverliesthelevatormuscle)(figure11)[95].
Oncetheperirectalspaceisentered,theischialspinecanbepalpatedandtheligamentfoundmedially.Along
rightangleretractor(eg,BrieskyNavratril)isplacedontheischialspinetoprotectthepudendalneurovascular
bundleandtwoothersareusedtoretractthebladdersuperiorlyandtherectummedially.
Withtheligamentclearlyvisible,twotothreesuturesareplacedthroughtheligamentapproximatelyoneandone
halffingerbreadthsmedialtotheischialspine.Severaltechniquesanddevicesareavailabletoassistplacingthe
suturethroughtheligament(eg,Miyahook,Deschampsligaturecarrier,laparoscopicsuturingdevices)[32].
Aftersecuringthesuturestotheligamentcomplex,eachofthesuturesisplacedthroughthemuscularisonthe
undersurfaceoftheposteriorvaginalepitheliumandtiedbyapulleystitch,whilethefreeendofthesutureisheld.
Tractiononthefreeendofthesuturedrawsthevaginalapexdirectlyontothesacrospinousligamentandthe
sutureistied.
AnothercommonmodificationoftheSSLSisthe"MichiganModification"technique[96,97].IntheMichigan
Modification,allfourvaginalwallsaredirectlyapproximatedtothesacrospinousligament(insteadofjustthe
posteriorvaginalwall).Thepointoneachvaginalwallthatreachestheligamentisidentifiedandtheintervening
diamondofvaginalepitheliumisexcised.Thesuturesareplacedthroughthesacrospinousligament,asdescribed
above,thensewnthroughtoboththeanteriorandposteriorvaginaandtiedtotheligament.Alonglasting
absorbablesutureisused.Thegoalofthismodificationistodecreasetheriskofananteriorvaginalwall
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recurrencealthoughithasnotbeenevaluatedincomparativestudieswithstandardSSLS,caseseriesreporthigh
longtermsatisfactionratesaftertheprocedure.Asinglesitestudyreportedthat76percentofwomenwere
completelyorverysatisfiedatleastfiveyearsafterSSLS[97].
AvoidingnerveentrapmentThereareseveraltechniquestodecreasetheriskofentrapmentofthe
sciaticnerveoritsbrancheswhenthesuturesareplaced.Oneapproachistoperforatethesacrospinousligament
withtheneedleinaverticalratherthanhorizontalorientation,therebyattemptingtoplacethesutureparalleltothe
courseofthesenerves.Also,sincethesenervesdidnottravelinthelateralthirdsegmentofthesacrospinous
ligament,placementofthefixationsutureswithinthisregionisanotherapproachtodecreasetheriskofnerve
injury.RegionalanesthesiaofprolongeddurationshouldnotbeusedpostoperativelyinwomenundergoingSSLS,
sincethismaymaskthesymptomsofnerveentrapment.(See'Complications'below.)
OutcomeInaliteraturereviewofmostlyobservationalstudies,cureratesofprolapserelatedsymptoms
rangedfrom70to98percent(onlyfourstudiesreportedsubjectiveresults)andtherangeofobjectivecurerates
was67to97percent[32].RecurrenceofapicalprolapseafterSSLShasbeenreportedin2to19percentof
womenandofanteriorvaginalwallprolapsein6to29percent[29,30,96,98105].Therefore,asnotedabove,
womenwithlargeanteriorwalldefectsinadditiontoapicaldescentmaybenefitfromanadditionaltypeofprolapse
repair,whichmoredirectlyaddressessupportoftheanteriorvagina.Astudythatfollowedwomenfor2to15years
reportedthat16percenthadprolapsesymptoms[106].
Regardingbowelsymptoms,reliefofconstipationwasreportedinseveralstudies[32].Dataregardingfecal
incontinencewereinconsistent,withsomestudiesreportingimprovementinpatientswithpreoperativesymptoms,
andothersreportingdenovoincontinenceinsomepatients.
ComplicationsSeriouscomplicationsareuncommonfollowingSSLS.Aliteraturereviewofmostly
observationalstudiesthatincluded1922SSLSproceduresreportedthefollowingcomplicationrates[32]:
Cystitis4.5percent
Fever,secondarywoundhealing,abscess,orsepticemia4.1percent
Ureteralkinking,problemswithurination2.9percent
Pain(unclassified,gluteal,orbladder)2.0percent
Hemorrhage/bloodtransfusion1.9percent
Nervedamage(eg,sciaticnerve)1.8percent
Injurytopelvicorgans0.8percent
Pelvicorvaginalvaulthematoma0.4percent
Infectiouscomplicationsarethemostcommontypeofadverseevent,andaregenerallymild(eg,cystitis).
Lowerurinarytractcomplicationsinvolvingureteralimpingementorinjurymayalsooccurcystotomyisinfrequent
[99].Enterotomyandpostoperativebowelcomplicationsarerare,astheprocedureismeanttobeextraperitoneal.
Adiscussionoflowerurinarytractinjuryingynecologicsurgerycanbefoundseparately.(See"Urinarytractinjury
ingynecologicsurgery:Evaluationandmanagement".)
HemorrhageduringSSLSismostcommonlyduetolacerationoftheinferiorglutealorpudendalvessels[107].
Pudendalhemorrhageisbesttreatedbytightlypackingtheischiorectalfossaandwaitingforhemostasis.Further
discussionofhemorrhageduringgynecologicsurgerycanbefoundseparately.(See"Managementofhemorrhage
ingynecologicsurgery".)
Postoperativepainornervedysfunctionislikelyduetoinjurytothebranchesofthesciaticnervethatcrossthe
sacrospinousligament,basedonanatomicstudiesincadavers[108].Ifthesciaticnerveisentrappedinthe
suture,theclassictriadofnervesentrapmentwillpresent(paresthesias,pain,temporaryreliefwithinjectionof
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localanesthetic).Thepatienttypicallyawakenswithseverebuttockpainradiatingdowntheposteriorleg.Delayin
diagnosisandtreatmentcanresultinpermanentneuropathytherefore,asnotedabove,regionalanesthesiaof
prolongeddurationshouldnotbeusedforthistypeofsurgery.Upondiagnosisofnerveentrapment,thepatient
shouldbetakenbacktotheoperatingroomimmediatelytohavethesuturesremoved.
TheeffectofSSLSonsexualfunctionhasnotbeenwellstudied.Manystudieshavenotevaluatedthisoutcome
andsomewomenwhoundergoapicalprolapserepairarenotsexuallyactive[32].Therateofdyspareuniawas36
percentinpooleddatafromthreerandomizedtrialsinwhichSSLSwascomparedwithabdominalsacralcolpopexy
[26].(See'Abdominalversusvaginalapproach'above.)Incontrast,observationalstudieshavereported
dyspareuniain3to10percentofwomenwhounderwentSSLS[32].
UterosacralligamentsuspensionULShasincreasedinpopularity.Theuterosacralligamentsarethoughtto
beoneofthemainconnectivetissuesupportsfortheuppervagina.
ProcedureThisprocedureistypicallyperformedtransvaginally,butitcanalsobedonelaparoscopically.
(See"Laparoscopicsurgeryforrepairofpelvicfloordefects",sectionon'Uterosacralligamentvaultsuspension'.)
Theuterosacralligamentsaremadeofsmoothmuscle,connectivetissue,andnerves.TheyoriginatefromtheS1
toS4vertebraetoinsertnearthecervix(figure12).
ThekeytosuccessfulULSissimultaneouscorrectionofalldefectsintheapicalendopelvicfascia.Theanterior
andposteriorvaginalmuscularis[109]neartheapexshouldbedirectlyapproximatedtoensurethecontinuityof
thevaginalmuscularis.
InthemostcommonlyperformedULStechnique,theanteriorandposteriorvaginalwallsareopenedinthemidline
theenterocelesacisidentified,ifpresent[110].Theperitonealcavityisenteredandtheuterosacralligaments
identified.AnAllisclampcanbeusedtotenttheuterosacralligament,makingiteasiertoidentify.Therectumis
retractedmedially.
Twoorthreepermanentsuturesarepassedthroughtheuterosacralligamentoneachside.Theseareplaced1.5
centimetersmedialand1.5centimetersposteriortotheischialspine.Thesuturesarenumberedsequentiallywith
labeledKellyclamps,onethroughsix,tofacilitatevaginalplacement.Inserialfashion,onearmofeachsutureis
passedthroughtheanteriormuscularissurroundingthevaginalapexandtheotherthroughtheposteriorendopelvic
fascia.Thesuturestherebycrossthewidthofthevaginalapex.Allsuturesarethentied,reapproximatingthe
anteriorandposteriorvaginalmuscularis,closinganypotentialenteroceledefect,andelevatingthevaginalapex
towardthesacrum.
Retrospectivechartreviewof248proceduresfoundthat1percentwithpermanentsutureshadlossofsupport
beyondthehymenversus6percentindelayedabsorbablegroup[111].
AvoidingordetectingureteralinjuryTheaveragedistancefromthelateralaspectofthesuspension
suturestothemedialborderoftheureterswas14mminacadaverstudy[112].Cystoscopyshouldbeperformed
aftertyingthesuturesduetoasignificantrateofureteralkinkingduringthisprocedure.
AvoidingnerveentrapmentCadavericstudiessuggestahigherriskofsacralnerveentrapmentwhen
uterosacralsuturesareplacedusingadeep,dorsal,posteriortechniqueandsuggestthatsacralnerveinjurymay
beminimizedbytentingtheligamentventrallypriortoplacingsutures[113].
OutcomeAmetaanalysisof10observationalstudiesevaluatedULSin930womenasuccessfulanatomic
outcomewasdefinedasPOPQstage0or1[114].Theratesofasuccessfuloutcomeforeachcompartment
were:apical(98percent),anterior(81percent),andposterior(87percent).Metaanalysisofsubjectiveoutcomes
wasnotpossibleduetomethodologicdifferencesacrossstudiesreliefofprolapsesymptomswasreportedby82
to100percentofpatients(thisoutcomewasonlyreportedbyfivestudies).Reoperationforsymptomaticprolapse
wasreportedin9percentofwomen(reportedbyfourstudies).Therewerefewreportsofsignificantimprovement
inbowelsymptoms.
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ComplicationsComplicationsofULSareuncommon.Themetaanalysisdescribedinthepreceding
sectionreportedthefollowingcomplicationsrates[114]:
Ureteralobstruction1.8percent
Bloodtransfusion1.3percent
Pelvicorganinjury0.4percent
Ureteralobstructionisthemostcommoncomplication.Cystoscopyshouldbedoneroutinelyatthecompletionof
eachcasetopreventdelayedrecognitionofureteralinjury.Ureteralkinkingfromtheuterosacralsutureisfound
duringroutineintraoperativecystoscopyinupto11percentofcases[115,116].Ifbothuretersdonoteffluxbriskly,
themostlateralsuture(closesttotheureter)onthatsideshouldberemoved.Typically,removingthissutureis
sufficienttorestorebriskureteraleffluxwithoutfurthersequelae,althoughureteralinjuryrequiring
ureteroneocystostomyhasbeenreported.(See"Diagnosticcystourethroscopyforgynecologicconditions",section
on'Indications'.)
ThesacralnervescanbeligatedifULSsuturesareplacedlateraltotheligamentfibersortoodeepintothepelvic
sidewall[112,117,118].Inaretrospectivecaseseries,7of182womenwhohadundergoneaULSdeveloped
sensoryneuropathyandpainintheS2toS3dermatomesimmediatelypostoperatively[118].Threeofthese
womenhadreductionofpainwhensuspensionsutureswereremovedwithinfourdaysaftersurgery.
IliococcygeussuspensionIliococcygeussuspensionissimilartotheSSLS,butusestheiliococcygeusfascia
overthelevatorplateinsteadofthesacrospinousligament.Proposedadvantagesoftheiliococcygeussuspension
comparedwithSSLSarelowerrisksofanteriorvaginalwallrecurrenceandinjurytothepudendalneurovascular
bundle,butthesebenefitsremainunproven.Therearefewdataregardingthisprocedure.Inacasecontrolstudyof
128women,onetotwoyearfollowup,subjectivesuccessratesweresimilarforiliococcygeussuspensionand
SSLS(91versus94percent),butobjectivesuccessoccurredsignificantlymorefrequentlyinwomenwho
underwentSSLS(53versus67percent)[119].Perioperativecomplicationsweresimilarforthetwoprocedures.
SomedatasuggestthatvaginallengthmaybelongerfollowingiliococcygeussuspensioncomparedwithSSLS
[120].
VaginalmeshkitsOnesystematicreviewofarticlesreportingoutcomesofvaginalmeshproceduresforapical
prolapseconcludedthatvaginalmeshseemedtoeffectivelycureapicalPOPhowever,longtermanatomicand
functionaldatawereneeded,aswellascomparativestudiestotraditionalPOPrepairs[53].Highcomplication
rateswerefoundwithapicalmeshprocedures(upto17.6percent)withmesherosionanddyspareuniamost
common.Incontrast,authorsofanothersystematicreviewofvaginalmeshproceduresforPOPconcludedthat
therewereinsufficientdatatodetermineefficacyofvaginalmeshproceduresforapicalPOP[52].Thissystematic
reviewalsofoundhighcomplicationratesassociatedwithvaginalmeshplacement,includinggrafterosioninupto
30percent,urinarytractinfectionsinupto19percent,andvisceralinjuryinupto3percent.Arandomizedtrial
comparedatotalvaginalmeshprocedure(Proliftthisdevicehasnowbeenremovedfromthemarket)with
laparoscopicsacralcolpopexy[121].Attwoyearfollowup,womeninthesacralcolpopexygrouphada
significantlyhigherobjectivesuccessrate(77versus43percent)andalowerreoperationrate(5versus22
percent).Thisstudywaslimitedbymethodologicissues.Safetyissuesregardingtransvaginalplacementofmesh
orbiograftsarediscussedindetailseparately.(See"Overviewoftransvaginalplacementofmeshforprolapseand
stressurinaryincontinence".)
ComparingamongvaginalproceduresTheprincipalchoiceisbetweenSSLSandULSforsurgeons
performingnativetissuetransvaginalapicalprolapserepair.ULSpotentiallyimprovesanteriorvaginalwallsupport
comparedtoSSLS.Ontheotherhand,theriskofureteralinjuryandneedforcystoscopyforULSare
disadvantagesforthisprocedurecomparedwithSSLS.
RandomizedtrialdatasuggestthattheefficacyofULSandSSLSarecomparablefortreatingapicalprolapse
however,therisksandbenefitsoftheproceduresdifferslightly.TheOperationsandPelvicMuscleTraininginthe
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ManagementofApicalSupportLoss(OPTIMAL)randomizedtrialcomparedULSwithSSLSin374womenwith
POPQstage2to4apicalvaginalprolapseallparticipantsalsohadstressurinaryincontinenceandunderwenta
concomitantretropubicmidurethralslingprocedure[122].Theprimarysurgicaloutcomewasacompositemeasure
ofsurgicalsuccess,definedastheabsenceofallofthefollowing:(1)vaginalapicaldescenttomorethanone
thirdofthevaginallength(2)anteriororposteriorvaginalwalldescentbeyondthehymen(3)bothersomevaginal
bulgesymptomsand(4)retreatmentofprolapsebyeithersurgeryorpessary.Twoyearsaftersurgery,59.2
percentofULSand60.5percentSSLSmetthisdefinitionofsuccess(oddsratio[OR]0.9,95%CI0.61.5).There
werenosignificantdifferencesbetweenULSandSSLSinmostperioperativeoutcomes,includingbloodlossand
severeintraoperativeorpostoperativeadverseevents.However,womenwhounderwentULShadasignificantly
lowerrateofneurologicpainrequiringintervention(6.9versus12.4percentOR0.5,95%CI0.21.0).Painalso
persistedtothefourtosixweekpostoperativevisitinfewerwomenfollowingULS(0.5versus4.3percent).
UreteralobstructionoccurredinsixwomenintheULSgroup(3.2percent)andnoneintheSSLSgrouphowever,
mostcasesweredetectedandtreatedintraoperatively.Attwoyearfollowup,therewasnosignificantdifference
intheprimaryoutcomebetweentheULSandSSLSgroups(surgicalsuccess59.2versus60.5percentOR0.9,
95%CI0.61.5).
Itisimportanttonotethatthistrialalsocomparedperioperativebehavioraltherapywithpelvicfloormuscletraining
withusualcare.Inasubgroupanalysisoftheusualcaregroup,attwoyearfollowup,ULShadasignificantly
lowerrateofapicaldescentthanSSLS(8.6versus20.8percentOR0.3,95%CI0.10.9).Amongwomenwho
receivedusualcare,bothersomevaginalbulgesymptomswerealsolowerintheULSgroup(15.4versus21.1
percent),althoughthestatisticalsignificancewasnotreported.Ratesofretreatmentwerenotreportedforthis
subgroupanalysis.ThisraisesthequestionofwhetherULSisthesuperiorprocedureformostwomen,sincemost
womenreceiveusualcare.Thepelvicfloormuscletrainingaspectofthetrialisdiscussedindetailbelow.(See
'Pelvicfloormuscletraining'below.)
AmetaanalysisofobservationalstudiessuggestsULSresultsinexcellentapicaloutcomeshowever,anterior
success(stage0orI)rateswereonly67percentinwomenwithpreoperativestageIIIprolapse[114].
Giventheavailabledata,outcomesappearsimilarforULSandSSLS.However,risksandbenefitsdifferslightly,
sopatientsshouldbecounseledregardingaslightlyhigherriskofpersistentneurologicpainthatmayrequire
reinterventionafterSSLScomparedwiththeincreasedriskforureteralobstructionwithULS.
POSTOPERATIVECAREPostoperativecareissimilarforbothvaginalandabdominalapproacheshowever,
recoveryafterabdominalsacralcolpopexymaybeslowerthantransvaginalproceduresduetotheabdominal
incision.Thepostoperativecoursewillalsovaryaccordingtowhetherconcomitantprocedureswereperformed
(eg,hysterectomy,surgeryforstressurinaryincontinence).
Wegivepatientsstandardinstructionsregardingpostoperativepaincontrol,bleeding,signsofinfection,and
gastrointestinalfunction.Weadvisenosexualintercourseforsixweekstoavoiddisruptionoftherepair.
Weseepatientsattwoweekspostoperativelyforroutinefollowup.Weperformawoundcheckandspeculum
examination.Fewdataareavailabletoguidepostoperativecareandmostrecommendationsarebasedonthe
surgeon'sexperienceandpreferences.
Routinedischargeinstructionscanbefoundseparately.(See"Patientinformation:Careaftergynecologicsurgery
(BeyondtheBasics)".)
PelvicfloormuscletrainingPelvicfloormuscletrainingisoftenusedasaninitialtreatmentforpelvicorgan
prolapse(POP)orstressurinaryincontinence(SUI).Manycliniciansalsoadvisepatientstoperformthese
exercisesfollowingpelvicfloorreconstructivesurgery.However,thereisnothighqualityevidencetosupportthe
efficacyofperioperativeuse.ThiswasinvestigatedintheOperationsandPelvicMuscleTraininginthe
ManagementofApicalSupportLoss(OPTIMAL)randomizedtrial(n=374)thatcomparedsacrospinousligament
suspension(SSLS)withuterosacralligamentsuspension(ULS),aswellasperioperativebehavioraltherapywith
pelvicfloormuscletraining(BPMT)withusualcarebehavioraltherapyincludededucationonbehavioralstrategies
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toreduceurinaryandcolorectalsymptoms[122].Allparticipantsalsohadstressurinaryincontinenceand
underwentaconcomitantretropubicmidurethralslingprocedure.BPMTcomparedwithusualcaredidnotresultin
asignificantdifferenceinurinarysymptomsatsixmonthsorprolapseoutcomesattwoyears.
Thesurgicaloutcomesofthetrialarediscussedindetailabove.(See'Comparingamongvaginalprocedures'
above.)
SUMMARYANDRECOMMENDATIONS
Apicalprolapseisthedescentofuterus,cervix,orvaginalvault(figure1).Commonsymptomsofapical
prolapseareavaginalbulge,difficultyvoiding,orconstipation.(See'Anatomyandmechanismsofinjury'
above.)
Surgicalcandidatesforapicalprolapseincludesymptomaticwomenwhohavefailedordeclinedconservative
management.Prolapseistypicallyachronicproblem,andwomenoftenprefersurgerytoconservative
therapysincesuccessfulsurgerydoesnotrequireongoingmaintenancetocontrolsymptoms.(See
'Candidatesforapicalprolapserepair'above.)
Apicalprolapserepairviaopenabdominalsacralcolpopexyismoreeffectiveatrestoringvaginaltopography
thantraditionalvaginalrepairs,althoughsubjectiveoutcomesaresimilarafterthetwotypesofprocedures.
Wesuggestabdominalsacralcolpopexyratherthantransvaginalrepairformostwomenundergoingapical
prolapserepair(Grade2C).(See'Abdominalversusvaginalapproach'above.)
Laparoscopicsacrocolpopexyisaseffectiveasopensacrocolpopexy,butresultsindecreasedbloodloss
andshorterhospitalstays.(See'Laparoscopicorroboticprocedures'above.)
Forwomenwithapicalprolapseundergoingabdominalsacralcolpopexy,werecommendsyntheticmesh
overbiografts(Grade1B).Syntheticmeshuseinsacralcolpopexyreducestheriskofrecurrentapical
prolapse.(See"Overviewoftransvaginalplacementofmeshforprolapseandstressurinaryincontinence".)
Avaginalsurgicalapproachisareasonablealternativetoanabdominalapproachforwomenwhocannot
tolerateabdominalsurgery,havenoriskfactorsforprolapserecurrence(eg,youngage,obesity,stageIIIor
IVPOP,previousfailedPOPrepair),arehavingconcomitantvaginalsurgery,haveriskfactorsformesh
relatedcomplications(eg,concomitanthysterectomy,smoking,immunosuppression,obesity),orwhoplace
ahighpriorityonashortrecoveryperiodoravoidinganabdominalincision.(See'Abdominalversusvaginal
approach'aboveand'Comparingamongvaginalprocedures'above.)
Tranvaginalapicalrepairproceduresincludesacrospinousligamentsuspension(SSLS)anduterosacral
ligamentsuspension(ULS).Theefficacyofthesetwoproceduresappearscomparable,buteachprocedure
isassociatedwithdifferentrisksofcomplications.(See'Comparingamongvaginalprocedures'above.)
Forwomenundergoingrepairofapicalprolapse,aconcomitantcontinenceprocedureoftenperformedtotreat
orpreventstressurinaryincontinence.Midurethralslingsarethepreferredconcomitantprocedureifavaginal
routeisusedforprolapserepairsomesurgeonsalsoplaceamidurethralslingatthetimeofabdominal
sacralcolpopexy.(See'Concomitantsurgeryforstressurinaryincontinence'above.)
ForwomenundergoingBurchcolposuspension,wesuggestalaparoscopicratherthanopenapproach(Grade
2A).Opencolposuspensionshouldbeperformedifthesurgeonisnotexperienceinthelaparoscopic
techniqueforthisprocedure.(See'ConcomitantBurchcolposuspension'above.)
UseofUpToDateissubjecttotheSubscriptionandLicenseAgreement.
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Topic8073Version20.0
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GRAPHICS
Uterineprolapse
ProlapseoftheUterusProlapseoftheuterusresultsfromweaknessofthe
supportingstructuresofthepelvicfloor,andisoftenassociatedwitha
cystoceleandrectocele.Inprogressivestages,theuterusbecomes
retrovertedanddescendsdownthevaginalcanaltotheoutside.Infirst
degreeprolapse,thecervixisstillwellwithinthevagina.Inseconddegree
prolapse,itisattheintroitus.Inthirddegreeprolapse(procidentia),the
cervixandvaginaareoutsidetheintroitus.
Reproducedwithpermissionfrom:Bickley,LS,Szilagyi,P.Bates'GuidetoPhysical
ExaminationandHistoryTaking,EighthEdition.Philadelphia:LippincottWilliams&
Wilkins2003.Copyright2003LippincottWilliams&Wilkins.
Graphic67287Version3.0
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DeLanceylevelsofvaginalsupport
LevelIconsistsofthecardinalanduterosacralligaments,andsuspendsthe
vaginalapex.LevelIIconsistsoftheendopelvicfasciaconnectionstothearcus
tendineusfasciapelvis,whichattachesthevaginatotheaponeurosisofthe
levatorani.LevelIIIconsistsoftheperinealbodyandincludesinterlacingmuscle
fibersofthebulbospongiosus,transverseperinei,andexternalanalsphincter.
Reproducedwithpermissionfrom:Walters,MD,Karram,MM.Urogynecologyand
reconstructivepelvicsurgery,3rded,MosbyElsevier,2007.Copyright2007Elsevier.
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Completevaginalvaultprolapse
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Pelvicorgansupportquantitation
Sixsites(pointsAa,Ba,C,D,Bp,Ap),genitalhiatus(gh),perineal
body(pb),andtotalvaginallength(tvl)usedforpelvicorgansupport
quantitation.
ReproducedwithpermissionfromBump,RC,Mattiasson,A,B,K,etal,AmJ
ObstetGynecol1996175:10.Copyright1996Mosby,Inc.
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Threebythreegridusedtoexpressthequantified
pelvicorganprolapse(POPQ)system
Aa:pointAoftheanteriorwallBa:pointBoftheanteriorwallC:cervixor
cuffD:posteriorfornixgh:genitalhiatuspb:perinealbodytvl:totalvaginal
lengthAp:pointAoftheposteriorwallBp:pointBoftheposteriorwall.
Reproducedwithpermissionfrom:Harvey,MA,Versi,E.Urogynecologyand
pelvicfloordysfunction.In:Kistner'sGynecologyandWomen'sHealth,7thed,
Ryan,KJ,Berkowitz,RS,Barbieri,RL,Dunaif,A(Eds),St.Louis,Mosby1999.
Copyright1999Elsevier.
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Choosingaprimaryprocedureforpelvicorgan
prolapse:Majordecisionpoints
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Medialdisplacementofthebladderforsuture
placementduringBurchprocedure(retropubic
colposuspension)
Robinson,D,Norton,PA.DiagnosisandManagementofUrinaryIncontinence.
In:GynecologicSurgery.Mann,WJ,Stovall,TG(Eds),ChurchillLivingstone,
NewYork1996.p.713.
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SutureplacementinendopelvicfasciaforBurchprocedure
(retropubiccolposuspension)
Robinson,D,Norton,PA.DiagnosisandManagementofUrinaryIncontinence.In:
GynecologicSurgery.Mann,WJ,Stovall,TG(Eds),ChurchillLivingstone,NewYork1996.
p.715.
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SutureplacementthroughCooper'sligamentfor
Burchprocedure(retropubiccolposuspension)
Robinson,D,Norton,PA.DiagnosisandManagementofUrinaryIncontinence.
In:GynecologicSurgery.Mann,WJ,Stovall,TG(Eds),ChurchillLivingstone,
NewYork1996.p.714.
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Superiorviewoffemalepelvis
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Bonesandligamentsofthepelvis
(A)Thejointsoftheadultpelvicgirdleincludethesacroiliacjointsandthe
pubicsymphysis.Thelumbosacralandsacrococcygealarejointsofthe
axialskeletondirectlyrelatedtothepelvicgirdle.(BandC)Theligaments
ofthepelvisareshown.
*Inferiorpelvicaperture.
Reproducedwithpermissionfrom:MooreKL,DalleyAR.ClinicallyOriented
Anatomy,5thed,LippincottWilliams&Wilkins,Philadelphia2006.Copyright
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2006LippincottWilliams&Wilkins.www.lww.com.
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Musclesofthefemalepelvicfloor
Musclesoftheanteriorpelvisandpelvicfloor.
Reproducedwithpermissionfrom:Clay,JH,Pounds,DM.BasicClinicalMassageTherapy:Integrating
AnatomyandTreatment.Baltimore:LippincottWilliams&Wilkins,2003.Copyright2003Lippincott
Williams&Wilkins.
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Musclesofthefemalepelvicfloor
Pelvicdiaphragmviewintothepelvicfloorillustratingthemusclesofthepelvic
diaphragmandtheirattachmentstothebonypelvis.
Reproducedwithpermissionfrom:LifeART.Copyright2010LippincottWilliams&Wilkins.All
rightsreserved.
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Uterosacralligamentsandendopelvicfascia
Thecervixmeasuresapproximately2.5cminheight.Anteriorly(A)the
cervixisseparatedfromthebladderbytheendopelvicfascia(arrow).
Posteriorly(B)thecervixliesbelowtheuterosacralligamentsandis
coveredwithperitoneum,whichreflectsofftheposteriorvagina(culde
sac).
Reproducedwithpermissionfrom:Baggish,MS,Valle,RF,Guedj,H.Hysteroscopy:
VisualPerspectivesofUterineAnatomy,PhysiologyandPathology.Philadelphia:
LippincottWilliams&Wilkins,2007.Copyright2007LippincottWilliams&
Wilkins.
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Disclosures
Disclosures:KimberlyKenton,MD,MS,FACOG,FACSNothingtodisclose.LindaBrubaker,MD,FACS,FACOGNothingto
disclose.KristenEckler,MD,FACOGNothingtodisclose.
Contributordisclosuresarereviewedforconflictsofinterestbytheeditorialgroup.Whenfound,theseareaddressedbyvettingthroughamultilevel
contentisrequiredofallauthorsandmustconformtoUpToDatestandardsofevidence.
Conflictofinterestpolicy
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