As previously mentioned, I make a point to ask about sexual function. If the woman is elderly and has no intention of being sexually active again, I may consider a very tight or obliterative repair because these are much less invasive than conventional repairs.
Is one surgical route superior?
- There is no consensus among experts as to the preferred route of surgery for advanced pelvic organ prolapse.
KARRAM: Numerous vaginal, abdominal, and laparoscopic procedures have been described. Which route do you prefer?
BRUBAKER: I don’t prefer any laparoscopic procedures, but I am flexible about vaginal or abdominal approaches.
Among vaginal procedures, I prefer uterosacral suspension at the time of hysterectomy, or the Michigan modification of sacrospinous ligament suspension when the patient has already undergone hysterectomy.
As for abdominal procedures, I prefer sacrocolpopexy with Mersilene mesh.
In my hands, these reconstructive procedures give predictable results that allow me to appropriately counsel patients preoperatively.
KARRAM: Why do you dislike the laparoscopic approach?
BRUBAKER: It is not a matter of “dislike,” but a matter of getting the most reliable result for my patient. When scientific evidence from well-done clinical trials demonstrates the equivalency of laparoscopic procedures, I fully anticipate incorporating them into my practice. Similarly, the novel use of the robot may be useful in reconstructive pelvic surgery.
Laparoscopic repair can produce good results in the right hands
PARAISO: I prefer the laparoscopic and vaginal routes. In fact, I have converted most abdominal procedures to laparoscopic access. I have nearly 10 years of experience with laparoscopic sacrocolpopexy, with excellent success.
My colleagues and I did a cohort study that showed equal cure rates for this procedure, compared with open sacrocolpopexy.1 I also have had great success with the vaginal route when performing uterosacral vaginal vault suspensions.
Patients are referred to me or seek me out specifically for minimally invasive procedures, so the majority of operations I perform are laparoscopic procedures with or without vaginal procedures, or vaginal procedures alone.
Vaginal approach is possible in high percentage of cases
SHULL: I probably perform 98% of reconstructive cases transvaginally. If the woman has urinary incontinence as well as prolapse, I usually perform a midurethral sling procedure along with the repair.
KARRAM: I do roughly 90% of prolapse repairs transvaginally. For the last 6 to 8 years, my colleagues and I have utilized a high uterosacral vaginal vault suspension to support the vaginal cuff. We do so in conjunction with a modified internal McCall-type procedure to obliterate the cul-de-sac. We also do site-specific anterior and posterior colporrhaphy as needed, and a synthetic midurethral sling if the patient has stress incontinence.
In very young patients (under 35 years of age) or those who have substantial recurrent prolapse or a prolapsed foreshortened vagina, we consider abdominal sacrocolpopexy with synthetic mesh as our primary operation. In such cases, we commonly perform retropubic repair for incontinence and paravaginal defects, as well as posterior repair and perineorrhaphy.
I have very little experience with laparoscopic prolapse repairs.
Abdominal sacrocolpopexy is anatomically superior
KARRAM: Dr. Brubaker, you just chaired a consensus panel on pelvic organ prolapse for the International Consultation on Incontinence. This panel reviewed all the published literature on the topic. What conclusions did it reach about the various surgical procedures for pelvic organ prolapse?
BRUBAKER: The “big picture” findings were that abdominal sacrocolpopexy is anatomically superior to the other procedures, but carries a higher rate of short-term morbidity than transvaginal procedures. Since that panel, a review on sacrocolpopexy by Nygaard et al2 highlighted the strengths, weaknesses, and uncertainties of this procedure.
We found no indications for routine use of ancillary materials when performing primary transvaginal repairs.
What is the best operation for advanced prolapse?
- The best procedure depends on the patient’s health, type and extent of prolapse, and sexual activity. Surgical history also is key.
KARRAM: Let’s say a 60-year-old woman with advanced, symptomatic, primary pelvic organ prolapse presents to you for surgical treatment. The findings include posthysterectomy vaginal vault prolapse with a large cystocele, large rectocele, and an enterocele. What operation would you perform?
SHULL: I would probably elect a transvaginal approach using the uterosacral ligaments to suspend the cuff and reapproximate the connective tissue of the anterior and posterior compartments. My colleagues and I described this technique.3
PARAISO: If the patient is physically and sexually active and willing to undergo synthetic graft implantation, I would perform laparoscopic sacrocolpopexy, especially if previous transvaginal apical suspension has failed, if she has a foreshortened vagina, or if she has denervation of her pelvic floor.