In the majority of cases, the indications for surgical intervention are related to a negative impact on quality of life measures secondary to pelvic organ prolapse. An asymptomatic prolapse does not require repair. Commonly reported symptoms include pelvic “heaviness” or a vaginal bulge. Superimposed voiding symptoms are also not unusual due to simultaneous bladder prolapse including hesitancy, intermittency, slow stream, feeling of incomplete bladder emptying, urgency, and frequency. The symptoms may be linked to intermittent or complete bladder outlet obstruction [5, 6]. Manual reduction of the prolapsed vagina may be necessary to facilitate urination or defecation (“splinting”). Constant irritation and exposure of vaginal mucosa may result in edema, bleeding, and ulcerations which can be quite painful. Patients who develop functional and/or structural outlet obstruction are at risk for hydronephrosis and renal insufficiency. Correction of the anatomical defect will only be curative in patients able to void with a normal detrusor contraction paired with pelvic floor relaxation. Alternatively, intermittent catheterization may be required to effect emptying of the bladder.

Conservative measures which should be employed prior to operative intervention are lifestyle changes such as weight loss and tobacco cessation, pessary, topical estrogen, vaginal lubricants, and pelvic floor exercises, especially when the prolapse is mild. Regardless, surgery may be indicated depending on the severity of the prolapse, patient symptoms, upper urinary tract dysfunction related to the prolapse, patient willingness, and existing medical comorbidities.

The goals of surgical repair are restoration of normal vaginal anatomy in combination with relief of associated bladder/bowel symptoms and sexual dysfunction related to the prolapse [3]. It is important to note that the correlation between objective and subjective outcomes of pelvic organ prolapse is not always direct. Post-operatively, the patient may demonstrate full correction of the anatomical defect with persistent symptomatology [7–10].

In order to optimize surgical outcomes, the patient must be fully evaluated to allow for correction of any reversible conditions which could impair recovery. Chronic conditions should be stabilized, estrogenic status of the vaginal tissues improved, and the patient counseled regarding appropriate expectations. In our clinic, a preoperative serum laboratory workup includes electrolytes, BUN, creatinine, glucose, PT/PTT. Additional values are ordered as indicated based on existing co-morbidities. In diabetic patients, hemoglobin A1c is evaluated to assess for control of blood glucose. Any concerning results are investigated further with specialty consultation and/or imaging.

Fluoroscopic urodynamic studies with and without reduction of the prolapse is performed prior to surgical intervention to quantify detrusor contractility, vesicoureteral reflux (laterality and severity), bladder outlet obstruction and occult stress incontinence. It is important to perform these studies on all patients with Grade 2 or higher anterior prolapse in order to better counsel the patient preoperatively. Further, urodynamic evaluation is recommended by the International Continence Society (ICS) in cases characterized by any pre-operative voiding dysfunction [11]. If occult stress incontinence is found, (i.e. asymptomatic patient with stress incontinence demonstrated with prolapse reduction), then concomitant continence repair needs to be discussed during preoperative counseling. If urodynamic detrusor overactivity is identified, the patient should be made aware of the potential for long-term pharmacologic therapy or alternate measures should urgency or urge incontinence persist past the early post-operative phase.

Critical assessment of the quality of the vaginal tissues is important prior to embarking on a surgical repair. Vaginal estrogen is prescribed for all patients preoperatively unless contraindicated. If the vaginal epithelium is severely atrophied, edematous, or even ulcerated, we recommend 6–8 weeks of supplemental topical estrogen with serial reexamination every two weeks. Depending on severity, estrogen cream is prescribed daily and once the tissues appear to be improving, we transition to bi-weekly applications. When patients are transitioned to biweekly applications, we also fit them for a pessary in clinic, if they do not already have one, to protect the tissues from exposure. Once the vaginal tissues appear healthy, we then plan for repair. We do not take patients to the operating room until they have received a minimum of 4 weeks of topical estrogen treatment, regardless of the state of their tissues.

The final step prior to proceeding with surgery is urinalysis and urine culture. A positive urine culture warrants appropriate antimicrobial therapy with confirmation of a negative culture prior to the operative date.

Prior to a trip to the operating room, the surgical risks, benefits and alternatives must be reviewed with the patient. Preoperative counseling will be tailored to the individual according to previous surgeries and comorbidities; however, we will discuss the most common risks along with pertinent published data as detailed below. These include recurrent prolapse, complications related to the use of mesh (synthetic and biologic), damage to surrounding structures and de novo lower urinary tract symptoms.

It is also important to discuss with your patient the risks of adjacent organ injury, especially due to the dissection required for paravaginal repair. Adjacent organs include the bladder, ureters, pudendal, perineal and obturator nerve bundles. In general, bladder perforation is quoted at 3.5 %, and inguinal pain as 2.5 %, however this was seen to be associated primarily with the use of trocar-based mesh kits [12, 13]. Neuropathic pain has been quoted as 3 % most likely due to remaining in the dorsal lithotomy position for an extended period of time, or concomitant procedures performed with the vaginal paravaginal repair such as sacrospinous fixation, etc. Benson et al described pudendal and perineal neuralgia during vaginal paravaginal repair in the form of increased terminal motor latency, which resulted in a preference for the abdominal approach [14]. However, it is important to note that preoperative terminal motor latency was already prolonged in this cohort as a function of the prolapse.

Other reported complications include changes in lower urinary tract and sexual function. New onset stress urinary incontinence, urge incontinence, urinary retention and dyspareunia have been documented. Approximately 35–40 % of patients with occult stress incontinence report resolution of their stress incontinence with POP surgery alone [15, 16]. Reported rates of de novo stress incontinence are between 4 and 12.3 %, with the higher end of the range being related to trocar based mesh-repair [11, 13]. Some have theorized that this is due to mesh overcorrection of the bladder neck and urethra leading to lower maximal urethral closure pressures. Studies have found that preoperative urgency and urge incontinence usually persists after POP repair in patients with detrusor overactivity on preoperative urodynamics [15]. This suggests that urgency symptoms in the absence of urodynamically demonstrated detrusor overactivity are related to the prolapse itself. Thus, patients should be counseled regarding the possibility of continued urgency in those with urodynamically documented DO; conversely the absence of urodynamic correlation with symptoms pre-operatively is more likely to indicate post POP repair resolution. De novo urgency and urge incontinence has been quoted at 28 % in one study, however this is usually rare and not widely reflected in the literature [7]. Urinary retention requiring catheterization after anterior prolapse repair approximates 1 % and is rarely mentioned in paravaginal repair studies. This was found at 2 months in the Altman trial in both the anterior colporrhaphy and paravaginal cohort, however this resolved spontaneously [13]. Prolonged retention was seen in another study of patients who underwent all types of anterior repair in which large post void residuals resolved after 1 month and those who did not, were related to advanced age or a neurogenic cause of detrusor underactivity [15]. New onset dyspareunia ranges around 10 %, however it is important to note that the majority of patients with dyspareunia also have resolution of these symptoms postoperatively [12]. Further, there does not appear to be any difference in de novo dyspareunia rates between native repairs or mesh usage [12, 15, 17].

Risk of bleeding and infection are always present in any operative procedure. The risk of infection ranges between 2 and 4 % and is mostly associated with a urinary tract infection; significant bleeding ranges between 0.5 and 3 % [13]. All patients are given antibiotic prophylaxis according to the SCIP guidelines; however, risk factors include patient comorbidities, current urinary tract infection at time of surgery, or prolonged catheter requirement. During more extensive dissections, as is the case in paravaginal repairs, bleeding risk is increased. As such, there is increased risk of hemorrhage with the use of paravaginal repair (including mesh kits) versus an anterior colporrhaphy, as the lateral pelvic side-walls need to be accessed for adequate placement.

Our surgical technique begins with preoperative antibiotics consisting of a first generation cephalosporin according to Surgical Care Improvement Project (SCIP) guidelines [18]. First, a Foley catheter is inserted to fully decompress the bladder and placed to drainage. An Allis clamp is positioned approximately 2 cm inferior to the meatus in the midline to mark the distal aspect of the vaginal incision and to assist with retraction. A weighted vaginal speculum is placed within the vagina (Fig. 7.1) and clipped to the drapes. The incision is marked in the midline from 2 cm below the urethral meatus towards the vaginal apex/cuff. We use Vasopressin 20 units diluted in 100 mL of 0.9 % normal saline for hydrodissection. Using a 23-gauge needle, the mixture is injected just deep to the vaginal epithelium. The vasopressin facilitates separation of the tissues in the correct planes, but also assists with hemostasis. Allis clamps are placed on the lateral edges of the incision and dissection is directed laterally using sharp and blunt methods to the level of the ischiopubic ramus until the arcus tendinous fascia pelvis (ATFP) is palpated bilaterally. We evaluate the pubocervical fascia strength at this juncture to evaluate the need for biological graft augmentation. Central defect plication (Chap. 6) is performed at this juncture if required (Fig. 7.2). We then attempt to palpate the ischial spine. From the vaginal approach, the ischial spine is difficult to reach in some patients, unlike the laparoscopic or abdominal/retropubic approach. If the ischial spine is not palpated initially, then the incision is extended to the vaginal cuff until the ischial spine is identified. Sacrospinous ligament vault fixation can be performed concurrent with this repair if vault suspension is indicated, as demonstrated in the video. Detachment of any remaining lateral attachments will be necessary to reach the ATFP (Fig. 7.3). Zero PDS sutures are then placed at 1 cm intervals into the ATFP bilaterally starting at ischial spine (Fig. 7.4). If no graft is planned, the sutures are passed into the adjacent pubocervical fascia. If the graft, for example porcine dermis (Pelvicol™), is planned, it is initially cut into a trapezoidal configuration with the broad base measuring the length between bilateral ischial spines and the narrow apex measuring the distance between the ATFP at the distal (introital) aspect of the incision. It is important to not “over-trim” the graft prior to placement, as it can always be modified once the initial suturing takes place. The sutures are secured to the graft leaving the knot laterally and tied beginning with those most proximal (Figs. 7.5, 7.6, 7.7, 7.8, and 7.9). Once the tying process is completed, cystoscopy is performed to confirm efflux of bilateral ureters. Intravenous dye can be used to assist with identifying ureteral efflux, if necessary. The vaginal epithelium is minimally trimmed and closed with a 2-0 vicryl suture in a running fashion, not locked, as we believe this can shorten the vaginal length. Irrigation is performed and hemostasis assured. The repair is visualized and palpated to exclude tethering and confirm good support (Figs. 7.10 and 7.11). A vaginal pack impregnated with Premarin cream is then placed and left for 24 h. K-Y® Jelly or RepHresh™ lubricant can also be used if the patient has a history of hormone-sensitive breast or gynecologic cancer.