Diagnosis and Management of Complex Pelvic Floor Disorders in Women

Abdominal Approaches

Pelvic organ prolapse can also be approached through an abdominal technique. The classic description for vaginal vault prolapse repair is the abdominal sacrocolpopexy. This involves fixating the vaginal apex to the anterior longitudinal ligament at the sacral promontory. Hysterectomy is performed at the same setting if still in situ. A strip of lightweight polypropylene mesh is sutured to the anterior and posterior vaginal walls after dissecting the bladder and rectum off, then suspended in a tension-free manner to the sacrum. Large trials with long-term follow-up show durability of this repair. Seven-year follow-up of a large NIH-sponsored trial comparing sacrocolpopexy with and without urethropexy found 31/181 (17%) with anatomic prolapse beyond the hymen [32]. Of these women one-third had involvement of the vaginal apex, though 50% of women were asymptomatic. Overall, 95% of women had no retreatment for pelvic organ prolapse. A surprising finding was a 10.5% mesh exposure rate with a mean follow-up of 6.1 years. Previously, abdominally placed mesh was thought to be much safer than transvaginal mesh, but exposure rates are roughly similar in newer studies at high-volume, fellowship-trained centers [33]. The largest advance in abdominal prolapse surgery has come with the adoption of laparoscopic and robotic-assisted technology. Minimally invasive approaches to abdominal surgery have resulted in less blood loss and shorter length of stay, though longer operative times [34]. Short- and medium-term outcomes have been compared to the open techniques in smaller single-center series. At least 1 randomized trial comparing laparoscopic to robotic sacrocolpopexy showed similar complications and perioperative outcomes, though the robotic technique was more costly [35].

Stress Urinary Incontinence Procedures

When SUI is identified preoperatively, treatment should be considered at the time of prolapse repair [32,36]. The gold standard for treatment of SUI with urethral hypermobility has been placement of a synthetic mid-urethral sling. There are several types of slings available, mainly categorized as retropubic, transobturator, or single-incision “mini-slings.” In a multicenter study by the Urinary Incontinence Treatment Network (UITN), patient satisfaction after retropubic and transobturator sling placement was studied 12 months after surgery. Both groups had a high satisfaction rate (from 85% to 90%) for urine leakage, urgency, and frequency [37]. There was no significant difference in outcomes between the 2 approaches. Several other studies and systematic reviews have also shown excellent long-term results with sling treatment. In the recently published 5-year follow-up of the Trial of Mid-Urethral Slings (TOMUS), researchers demonstrated an 80% to 85% patient satisfaction rate with a 10% adverse event rate. Of these adverse events, only 6 were classified as serious requiring surgical, radiologic, or endoscopic intervention [38].

If the patient has SUI but no urethral hypermobility, consider intrinsic sphincter deficiency as the etiology of her incontinence. In that case, injectable therapy with urethral bulking agents is an effective treatment. Some commonly used injectables include carbon beads (Durasphere), calcium hydroxylapatite (Coaptite), bovine collagen (Contigen), and silicon particles (Macroplastique). In a Cochrane review of injectable therapy, they compared urethral injection to conservative treatment with physical therapy and noted an improvement with injection at 3 months. Surgical treatment was overall more effective; however, 50% of the women that received a collagen injection were satisfied at 12 months after the procedure. They also note lower morbidity for this procedure compared to surgery [39].