REVIEW

CURRENT
OPINION Apical prolapse repair: weighing the risks
and benefits
Audra Jolyn Hill and Matthew D. Barber

Purpose of review
This article reviews the current literature regarding surgical repair of vaginal apical prolapse and discusses
the risks and benefits of various surgical approaches.
Recent findings
Vaginal uterosacral ligament suspension has similar anatomic and subjective outcomes to sacrospinous
ligament fixation at 1 year. Native tissue vaginal repairs offer decreased morbidity compared with mesh-
augmented sacrocolpopexy; however, sacrocolpopexy has greater anatomic success. Minimally invasive
sacrocolpopexy appears to be equivalent to open abdominal sacrocolpopexy. Native tissue repairs and
transvaginal mesh kits support the vaginal apex with similar results; however, long-term follow-up is
needed. Robotic and laparoscopic sacrocolpopexy are equally effective in restoring the vaginal apex.
Summary
Surgical restoration of the vaginal apex can be accomplished via a variety of approaches and techniques.
When deciding on the proper surgical intervention, the surgeon must carefully calculate the risks and
benefits of each procedure while incorporating the patient’s individual medical and surgical risk factors.
Lastly, a discussion regarding the patient’s overall goals of care is paramount to the decision-making
process.
Keywords
apical prolapse, apical support, sacrocolpopexy, sacrospinous colpopexy, uterosacral colpopexy

INTRODUCTION McCall culdoplasty, iliococcygeus fixation, sacrospi-

Surgical repair of the prolapsed vaginal apex can be
accomplished via vaginal or abdominal routes. It can
also be performed using suture and native tissue (i.e.
native tissue repair) or augmented with either a syn-
thetic mesh or biologic graft. When deciding on the
route of surgical intervention, providers and patients
must weigh the risks and benefits of each procedure
carefully. The decision process involved with select-
ing the proper surgical procedure is complex and
involves a multitude of factors. These include overall
health status, medical and surgical histories, severity
of pelvic organ prolapse (POP), and the patient’s goals
of care. Additionally, surgeon experience, cost of the
procedure, risk of recurrent disease and individual
operative risks are important considerations when
deciding between surgical interventions. This review
will discuss the risks and benefits of apical prolapse
repair for various routes.
VAGINAL PROLAPSE REPAIRS
There are a variety of procedures performed vagi-
nally to restore the vaginal apex. They include
nous ligament fixation (SSLF) and uterosacral liga-
ment suspension (USLS). These procedures are
typically performed using native tissue and include
the use of delayed absorbable and/or permanent
sutures. Obliterative procedures, such as Le Fort
colpocleisis or colpectomy, should be considered
in patients with apical prolapse who no longer desire
vaginal intercourse. Colpocleisis is associated with
high postoperative patient satisfaction and provides
a durable repair with a relatively low risk of recur-
rence [1–3]. A detailed review of the indications,
risks and benefits of obliterative procedures are
beyond the scope of this review.
Department of Urogynecology, Pelvic Reconstructive Surgery, Ob/Gyn
and Women’s Health Institute, Cleveland Clinic, Cleveland, Ohio, USA
Correspondence to Audra Jolyn Hill, MD, 9500 Euclid Avenue, Desk
A-81, Cleveland, OH 44195, USA. Tel: +1 216 445 0439;
e-mail: Hilla8@ccf.org
Curr Opin Obstet Gynecol 2015, 27:373–379
DOI:10.1097/GCO.0000000000000203

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Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.

Urogynecology
KEY POINTS

Uterosacral ligament suspension and SSLF are similar
procedures for the correction of pelvic organ prolapse.

TVM kits have similar success rates compared with
native tissue for vaginal apical prolapse repairs.

Robotic and LSC are equally effective at restoring the
vaginal apex.

Native tissue vaginal pelvic organ prolapse repair
offers decreased morbidity compared with mesh-
augmented sacrocolpopexy, although with a decreased
rate of long-term anatomic success.

Patients’ goals of care along with surgeon experience,
risks and benefits should be included in the decision
process when selecting the proper surgical procedure
for apical prolapse.
MCCALL CULDOPLASTY
The McCall culdoplasty was initially described as a
procedure performed at the time of vaginal hyster-
ectomy whereby the proximal uterosacral ligaments
were plicated in the midline to obliterate the
posterior cul de sac in order to prevent future enter-
ocele formation. Modifications of this procedure
have evolved over time and may include internal
and external sutures with or without the use of
delayed and/or permanent suture (Fig. 1). Currently,
data describing outcomes are limited to
FIGURE 1. McCall culdoplasty.
374 www.co-obgyn.com
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
retrospective series, with rates of reoperation for
prolapse ranging from 0 to 14% [4].
ILIOCOCCYGEUS FIXATION
Suspension of the vaginal apex to the bilateral ilio-
coccygeus fascia was initially described in 1963 [5]
and is an acceptable alternative to restore apical
support. Research surrounding iliococcygeus sus-
pensory procedures is primarily limited to case series
and retrospective cohorts. In 2001, Maher et al. [6]
performed a retrospective case–control study com-
paring iliococcygeus fixation (n ¼ 50) with sacrospi-
nous colpopexy (n ¼ 78). Subjective and objective
success was similar between the two groups (91 vs.
94%) and (54 vs. 67%) with mean follow-up time
ranging from 19 to 21 months [6]. Recently, a pro-
spective study was performed evaluating the efficacy
and safety of iliococcygeus fixation over a 5-year
period. Forty-four women with symptomatic
vaginal vault prolapse (at least stage 2 Pelvic Organ
Prolapse Quantification) completed the study. The
overall success rate, which included both subjective
and objective measures along with reoperation
rates, was found to be 84.1% in this patient popu-
&
lation [7 ].
SACROSPINOUS LIGAMENT FIXATION
Suspension of the vaginal apex to the sacrospinous
ligament is another transvaginal procedure that is
used to restore apical support. It may be performed
either unilaterally or bilaterally and is usually
accomplished via an extraperitonal route. If per-
formed unilaterally, the vaginal axis is deviated
towards the ipsilateral sacrospinous ligament
FIGURE 2. Sacrospinous ligament fixation.
Volume 27
Number 5
October 2015

(Fig. 2). SSLF has been evaluated in numerous pro-
spective and retrospective cohort studies with
reported anatomical success rates ranging from 64
to 97% [4]. Patient satisfaction following SSLF
ranges from 80 to 90% [8–10]. In 2007, a systematic
review and meta-analysis by Morgan et al. [10] found
an overall failure rate of any compartment to be
28.8% [confidence interval (CI) 18.4, 36.3] with the
anterior compartment being the most likely site
of recurrence. This may be due to the deflection
of the vaginal axis posteriorly leaving the anterior
compartment more susceptible to a larger intra-
abdominal pressure burden. Postoperative compli-
cations include buttock pain and neurovascular
injury. Buttock pain occurs in 3–15% of patients
and typically resolves within 6 weeks following the
& &
surgical procedure [11 ,12 ]. Neurovascular injuries
are rare, but if they do occur, typically involve the
pudendal, inferior gluteal, and/or sacral nerves
or vessels.
UTEROSACRAL LIGAMENT SUSPENSION
USLS involves attachment of the vaginal apex to the
proximal uterosacral ligaments via an intraperito-
neal approach (Fig. 3 a and b). Multiple variations in
the surgical procedure exist and usually surround
the number and type of sutures (delayed absorbable
and/or permanent) used during the repair. Ana-
tomic success rates range from 48 to 96% with a
mean reoperation rate for prolapse of 5.8% [4]. A
meta-analysis identified pooled rates of anatomical
success (Pelvic Organ Prolapse Quantification stage
(a)
(b)
FIGURE 3. Uterosacral ligament suspension.
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Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Apical prolapse repair Hill and Barber
0–1) of 98.3% (CI 95.7, 100) for the apical segment
[13].
Complications surrounding USLS include both
bowel and urinary events. A retrospective review of
over 900 patients who underwent USLS identified an
overall adverse event rate of 31.2%, with 20.3%
being attributed to a postoperative urinary tract
infection. Rates of pulmonary and cardiac events
were 2.3%, whereas the rate of ileus and small bowel
obstruction were less than 0.5%. The composite
recurrence rate was 14.4% (which included both
anatomic and symptomatic-based criteria) with a
median follow-up time period of 6.9 (range, 0.2–
93.8) months, with 55% of sites of recurrence occur-
ring in the anterior compartment. Retreatment of
prolapse was seen in 3.4% of patients and included
&&
both surgical and pessary management [14 ].
In 2014, a comparison of surgical outcomes
between USLS and SSLF in women with uterine or
posthysterectomy apical prolapse was reported by
the National Institute of Child Health and Human
&
Development Pelvic Floor Disorders Network [12 ].
Success was defined as composite outcome measure-
ment and included the absence of the following:
descent of the vaginal apex more than one third of
the vaginal canal, anterior or posterior vaginal wall
beyond the hymen, bothersome vaginal bulge
symptoms as reported on the Pelvic Floor Distress
Inventory and any form of retreatment for prolapse
(surgery or pessary). A total of 374 patients were
included in this trial (188 USLS, 186 SSLF). At 2 years,
there was no statistical difference between the two
groups for surgical success (USLS, 64.5% vs. SSLF,
63.1%) with an adjusted odds ratio of 1.1 (CI 0.7,
1.7). Additional outcomes measured at 2 years
included bothersome vaginal bulge symptoms
(18.0%), anterior or posterior prolapse beyond the
hymen (17.5%) and retreatment with surgery or
pessary (5.1%) with no differences between groups.
Perioperative events were similar between the two
groups, with the most common event being bladder
perforation associated with retropubic midurethral
sling placement. Neurological pain requiring inter-
vention was higher in the SSLF group (12.4 vs. 6.9%,
P ¼ 0.0749), whereas the rate of intraoperative ure-
teral obstruction was noted in six (3.2%) patients
who underwent USLS compared with zero patients
&
in the SSLF group [12 ].
USLS may also be performed via abdominal
route through an open or laparoscopic approach.
A retrospective review comparing vaginal utero-
sacral suspension (96 patients) and laparaoscopic
uterosacral suspension (22 patients) was performed
by Rardin et al. [15] and found no significant differ-
ences in adverse events, subjective or anatomic out-
comes.
www.co-obgyn.com 375
Urogynecology

TRANSVAGINAL MESH APICAL REPAIR

Transvaginal mesh (TVM) kits were initially
introduced with the overall goal of increasing
long-term success rates of vaginal prolapse repairs.
However, in 2008 the Food and Drug Adminis-
tration (FDA) released a report on the compli-
cations noted with TVM use, and in 2011, the
FDA stated that in most cases, prolapse repair does
not require the use of surgical mesh [16]. If mesh is
to be used for prolapse repair, surgeons need to
obtain specialized training and provide patients
with extensive counselling regarding the mesh-
related risk profile. This review will only discuss
the TVM kits that are currently available in the
United States: Elevate (American Medical Systems,
Minnetonka, Minnesota, USA) and Uphold (Bos-
ton Scientific, Marlborough, Massachusetts, USA).
Both kits are mesh-augmented prolapse repairs
that use the bilateral sacrospinous ligaments for
apical support.
A recent cohort study compared Elevate
anterior and posterior prolapse repair system with
native tissue vaginal repair in 201 patients. At
12 months, there were significant differences in
the rate of success in the anterior compartment of
the mesh group (98 vs. 87%, P ¼ 0.006); however,
similar success rates were identified in the apical
compartment (99 vs. 96%, P ¼ 0.317). Sexual qual-
ity-of-life scores did not differ between the two
groups when compared with differences in pre-
operative and postoperative values (P ¼ 0.57);
however, these findings are limited given the
1-year follow-up time frame. As expected, the
mesh repair group had a higher incidence of
mesh extrusion (3%) and one patient required
surgical correction due to persistent mesh
&&
exposure [17 ]. Two-year assessment of subjective
and objective outcomes in 42 women using the
&
Elevate system was evaluated by Rapp et al. [18 ].
Stage II POP recurrence was found in 9.5% (4/42) of
patients; however, only two were symptomatic.
Compared with baseline values, significant
improvements were noted in vaginal symptoms,
sexual function and lower urinary tract symptoms
&
at 2 years [18 ].
Another TVM system, Uphold sacrospinous is
currently being studied by the Pelvic Floor Disorders
Network to compare subjective and objective suc-
cess at 3 years for vaginal hysterectomy with USLS to
hysteropexy using the Uphold sacrospinous mesh
system. This Study of Uterine Prolapse Procedures –
Randomized Trial has recently completed enrol-
ment with results tentatively planned for 2018
[19]. Of note, FDA’s 522 postmarket surveillance
studies are underway for both the Uphold and the
Elevate systems.
FIGURE 4. Sacrocolpopexy.
ABDOMINAL APICAL PROLAPSE REPAIR
Abdominal sacrocolpopexy (ASC) involves the
attachment of the vaginal apex to the anterior
longitudinal ligament on the sacrum using either
a synthetic mesh or biologic graft (Fig. 4). This can
be performed via an open or minimally invasive
approach. Sacrocolpopexy is a procedure that may
be reserved for patients with a high risk of recurrent
prolapse, concurrent intra-abdominal disorder, pre-
viously failed vaginal prolapse repairs and/or
foreshortened vagina.
Open ASC has been considered the ‘gold stand-
ard’ for prolapse repair with long-term success rates
of 78–100% with a median reoperation rate for
recurrent prolapse of 4.9% [20]. However, long-term
data following ASC suggest the estimated prob-
ability of treatment failure for composite prolapse
may be as high as 48% at 7 years. Additionally, the
rate of mesh exposure was found to be 10.5% [21].
Increased risk factors for mesh complications fol-
lowing ASC were identified in women with at least
stage 3 POP, or concomitant hysterectomy and/or
&&
more than three concomitant procedures [22 ]. The
2013 Cochrane review compared SSLF with ASC, and
found that ASC had superior anatomical outcomes,
but with increased operative room time, longer
recovery and overall elevated cost [23].
MINIMALLY INVASIVE ABDOMINAL
SACROCOLPOPEXY
Compared with open ASC, minimally invasive sac-
rocolpopexy decreases overall morbidity and offers a
&& & && &&
durable repair [24 ,25–27,28 ,29 ,30,31,32 ]. In
2013, Freeman et al. [33] conducted a multicenter,
prospective equivalence trial comparing open ASC

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October 2015

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with laparoscopic sacrocolpopexy (LSC). A total of
57 patients were randomized, and at 1 year, there
was no difference in patient satisfaction or rates of
recurrent prolapse between the two interventions.
Minimally invasive techniques for performing
sacrocolpopexy include both traditional laparo-
scopy and robotic approaches. Multiple retro-
spective and cohort studies have evaluated LSC
and robotic-assisted laparoscopic sacrocolpopexy
(R-LSC) in regards to both objective and subjective
outcomes, durability of repair and overall feasibility
&
[28 ].
Paraiso et al. [30] reported a randomized con-
trolled trial on 78 women with symptomatic vaginal
vault prolapse who underwent LSC or R-LSC.
Patients who underwent a R-LSC experienced a
longer operative time (67 min mean difference,
P < 0.0001), increased postoperative pain up to
6 weeks following surgery and required a longer
use of anti-inflammatory agents (20 vs. 11 days)
compared with LSC. At 1 year, there was no differ-
ence between anatomic and quality-of-life measures
between the two groups. Additionally, the cost of
R-LSC was higher compared with LSC ($16 278 vs.
$14 342, P ¼ 0.008), which the authors attributed to
longer operative room costs.
In 2014, Anger et al. compared LSC and R-LSC in
a randomized fashion for patients with sympto-
matic stage II POP. The focus of this study was to
compare overall cost and relevant outcomes follow-
ing each surgical intervention. Patients who under-
went R-LSC had an average of 24.4 min increase in
operative time (202 vs. 179 min, P ¼ 0.03); however,
the total surgical time was not statistically different
between the two groups (246 vs. 225 min, P ¼ 0.11).
The authors attributed the increased operative time
in the R-LSC to docking of the robot. Pain with
normal activities was elevated in the robotic
patients 1 week following surgery (3.5 vs. 2.6), but
by 2 weeks, the pain levels were similar to patients
who underwent laparoscopy. Adverse events (intra-
operatively or postoperatively) did not differ
between the two groups. Additionally, anatomic
outcomes and quality-of-life measures were similar
at 6-month follow-up. When evaluating the cost
comparison between LSC and R-LSC, cost was bro-
ken down into day of surgery costs and total 6-week
costs. Day of surgery costs and total 6-week costs
were initially higher in the R-LSC group; however,
after removal of the initial purchase cost and main-
tenance fees for the robot, the cost difference was no
&&
longer significant [24 ].
A number of studies have been performed look-
ing at the cost of robotic sacrocolpopexy compared
with the open and/or laparoscopic approaches
[34,35]. The majority are retrospective in nature
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Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Apical prolapse repair Hill and Barber
and report different cost variables, making overall
comparisons difficult. In 2010, Judd et al. [35]
reported on the use of a decision analytical model
for comparing LSC to R-LSC cost based on their own
institutional data. Their model suggested R-LSC was
more expensive ($7353 vs. $5792) and the robotic
approach only became cost equivalent when the
operating room time was reduced to 149 min. Given
the variability in the data, additional prospective
trials are needed comparing the various routes with
similar cost variables and predefined outcomes (i.e.
operating room time).
Complications following sacrocolpopexy can
occur with either an open or minimally invasive
approach. Adverse events associated with open ASC
are similar to those associated with open abdominal
pelvic surgery, that is, wound complications,
haemorrhage, and damage to surrounding organs.
A multicenter retrospective review comparing out-
comes of open vs. minimally invasive sacrocolpo-
pexy was performed on over 1000 women. ASC was
found to have a higher overall rate of complications
(20.0 vs. 12.7%, P ¼ 0.001). The minimally invasive
group was found to have a shorter length of stay,
decreased blood loss, but longer operative times
&&
compared with ASC [29 ]. When comparing ASC
with R-LSC, the rates for intraoperative injury to
pelvic organs, infection and thrombotic events are
&&
similar [25,26,31,36]. Unger et al. [37 ] performed a
retrospective analysis comparing perioperative and
postoperative adverse events in 406 women who
underwent either R-LSC or LSC. Rates of bladder
injury (3.3 vs. 0.4%, P ¼ 0.04) and estimated blood
loss more than 500 ml (2.5 vs. 0%, P ¼ 0.01) were
found to be higher in the robotic group compared
with traditional laparoscopy. Rates of mesh erosion,
bowel obstruction, cardiac and pulmonary events
were similar between the two groups with a median
follow-up time of 195 days (interquartile range
73.5–427 days). The overall conversion rate to an
open ASC was 1.9% and was performed due to
suboptimal visualization, bowel injury, adhesions,
presacral bleed or pulmonary compromise. Mesh
exposure was identified in 2.7% of patients with
no difference between the two groups (R-LSC 3.3
vs. LSC 2.4%, P ¼ 0.62) [37 ].
&&
Sacrocolpopexy offers a durable repair of the
vaginal apex, yet carries the increased risk of mesh
complications compared with native tissue repairs.
In 2015, a systematic review conducted by Siddiqui
&&
et al. [38 ] compared outcomes after mesh sacro-
colpopexy with native tissue vaginal repairs. Mesh
sacrocolpopexy was found to have a significantly
greater likelihood of anatomic ‘success’ compared
with native tissue vaginal repairs [pooled odds ratio
2.04 (CI 1.12, 3.72)]. The data were limited or
www.co-obgyn.com 377
Urogynecology
inconsistent regarding all-cause reoperation rates,
postoperative urinary and bowel function, and
sexual function between the two groups. When
comparing adverse events between native tissue
vaginal repair and mesh sacrocolpopexy, ileus or
small bowel obstruction (0.2 vs. 2.7%, P < 0.01)
along with mesh or suture complication (0.4 vs.
4.2%, P < 0.01) remained significant in the mesh-
augmented group.
CONCLUSION
In summary, surgical procedures for apical prolapse
can be performed via a vaginal or abdominal
approach. Selection of the correct procedure is a
complex decision process and involves a multitude
of factors. These factors include severity of prolapse,
risk of adverse events, medical comorbidities,
surgeon experience, and importantly, the individual
patient’s goals of care. Vaginal approaches appear to
have overall decreased morbidity, whereas mesh
sacrocolpopexy offers increased rates of anatomic
success.
Acknowledgements
None.
Financial support and sponsorship
None.
Conflicts of interest
There are no conflicts of interest.
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