Approximately 11% of women will undergo a surgical procedure for the treatment of pelvic organ prolapse (POP) or urinary incontinence by age 80 years. Abdominal sacrocolpopexy has been found in multiple studies to have high long-term success rates for repair of severe vault prolapse. Robotic or laparoscopic sacrocolpopexy offer similar success to an open approach. This article describes the techniques of laparoscopic sacrocolpopexy and robotic sacrocolpopexy. The role of hysteropexy for the treatment of POP is also discussed.
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The abdominal sacrocolpopexy offers high long term success for the management of apical prolapse and can be performed using an open, laparoscopic, or robotic approach.
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The laparoscopic and robotic approaches offer decreased blood loss and decreased length of hospital stay with similar complication rates compared to the open procedure.
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Hysteropexy may be used to treat uterine prolapse in select patients with decreased morbidity compared to pelvic organ prolapse repair performed with concomitant hysterectomy.
Introduction
Approximately 11% of women will undergo a surgical procedure for the treatment of pelvic organ prolapse (POP) or urinary incontinence by age 80 years. There are varying reports of the incidence of vaginal vault prolapse following hysterectomy, with Marchionni and colleagues reporting the incidence of vaginal vault prolapse at 4.4% following hysterectomy based on examination. When hysterectomy was performed for prolapse, the subsequent incidence of vaginal vault prolapse was 11.6%. It is estimated that 1 in 9 women will undergo a hysterectomy in their lifetime. Following hysterectomy, the median time to vault prolapse is reported at around 15.8 years (range 0.4–48.4 years). There are multiple surgical approaches available to manage apical prolapse, with many studies evaluating for the repair that offers the most effective, safe, and durable treatment, as the reoperation rate for POP may be as high as 30%. Goals of surgical repair for POP include relief of symptoms, restoration of support to pelvic structures, prevention of new defects in pelvic support, prevention of new symptoms, and improvement or maintenance of urinary, bowel, and sexual function. Surgical treatment options include both vaginal and abdominal approaches along with the option of laparoscopic and robotic procedures. Abdominal sacrocolpopexy (ASC) has been found in multiple studies to have high long-term success rates for repair of severe vault prolapse, and the focus of this article is describing laparoscopic sacrocolpopexy (LSC) and robotic sacrocolpopexy (RSC). The role of hysteropexy for the treatment of POP is also discussed.
Relevant anatomy and evaluation
POP is defined as the descent of one or more of the pelvic organs. It is estimated that 50% of parous women lose pelvic floor support. Swift showed in an observational study that 50% of women presenting for an annual pelvic examination had stage II to III POP. The study consisted of 497 women with a mean age of 44 years, and the incidence increased to 74% with age older than 70 years. Parity, increased age, constipation, and obesity are some of the reported risk factors for developing POP, with obesity being the primary risk factor for developing post-hysterectomy vaginal vault prolapse in one study. In this report, the incidence of obesity was 45% among those who developed prolapse following hysterectomy, compared with 10.5% in those who did not develop vaginal vault prolapse.
There are multiple structures providing support for the female pelvic organs including bone, muscle, and endopelvic fascia. The pelvic floor consists of the pelvic diaphragm, made up of the levator ani group, coccygeus muscles, and surrounding fascia. From these structures, a shelf of muscle is formed that attaches to the pelvic side wall by the arcus tendineus fasciae pelvis that runs between the pubic symphysis and the ischial spine. The upper vagina rests on this shelf, creating its natural axis, which is horizontal. Vaginal prolapse may occur when this axis is altered. DeLancey described 3 levels of vaginal support within the pelvis: level I or apical support, level II or lateral support, and level III or distal support. Suspension of the vaginal apex is the result of level I support, and apical or vaginal vault prolapse is the consequence when this level of support is lost. There are ligamentous supports to the female pelvic organs also, with the upper vagina and the uterus having support from the cardinal and uterosacral ligaments. The cardinal ligaments extend between the cervix and pelvic side wall while the uterosacral ligaments run from the sacrum to the cervix and vaginal fornices, and these structures can be damaged by a hysterectomy. Fig. 1 illustrates vaginal vault prolapse.
Symptoms of POP include pelvic bulge, pelvic pressure, pelvic pain, back pain, voiding complaints, bowel symptoms, dyspareunia, or difficulty walking or sitting. The most common presenting symptom is pelvic bulge, which is reportedly present in 94% to 100% of patients. Obtaining a thorough history and proper counseling of the patient can help reduce postoperative patient dissatisfaction, especially in cases where patients falsely attribute symptoms to their prolapse that, in actuality, are caused by unrelated medical conditions. In such cases patients may have false expectations, compromising the success of the procedure performed. A thorough pelvic examination is vital in the evaluation for POP, and one should distinguish between anterior, apical, and posterior prolapse, which is important in determining the appropriate treatment. Care should also be taken to evaluate for voiding dysfunction such as urinary incontinence, as Mayne and Assassa reported that up to 45% of women older than 40 years have symptoms of voiding dysfunction, and up to 26% of these women will have clinically significant symptoms. Identifying the presence of voiding dysfunction is important, as concomitant procedures may need to be considered at the time of prolapse repair and these coexisting conditions may affect the patient’s expectations. Having the patient stand, if they are physically able, during the physical examination is preferred, and the patient should be asked to strain during the examination to assess the maximum degree of prolapse along with the function of the pelvic muscles. If the patient has any evidence of anterior prolapse, the examiner should reduce the prolapse and instruct the patient to Valsalva to evaluate for the presence of urinary incontinence, as there are reports of stress urinary incontinence (SUI) being present concomitantly in up to 38% and urge incontinence in 26% of those with POP. One should also consider checking a postvoid residual, as there is a risk of preoperative urinary retention, particularly in older women. It is reported that 89% of these women will have resolution of their urinary retention following treatment of their POP. The staging used to grade POP is:
Stage 0: No prolapse present
Stage I: Distal portion of prolapse greater than 1 cm above hymen
Stage II: Distal portion of prolapse within 1 cm of hymen, either above or below
Stage III: Distal portion of prolapse greater than 1 cm below hymen but not complete eversion
Stage IV: Complete vaginal eversion.
The pelvic organ prolapse quantification (POPQ) system standardizes the staging of POP ( Fig. 2 ) using reference points within the vagina to characterize the level and location of prolapse present. Using this system, point C represents the cervix or vaginal cuff; a negative value is assigned when prolapse is proximal to the hymen, and a positive number assigned when prolapse extends distal to the hymen.
Relevant anatomy and evaluation
POP is defined as the descent of one or more of the pelvic organs. It is estimated that 50% of parous women lose pelvic floor support. Swift showed in an observational study that 50% of women presenting for an annual pelvic examination had stage II to III POP. The study consisted of 497 women with a mean age of 44 years, and the incidence increased to 74% with age older than 70 years. Parity, increased age, constipation, and obesity are some of the reported risk factors for developing POP, with obesity being the primary risk factor for developing post-hysterectomy vaginal vault prolapse in one study. In this report, the incidence of obesity was 45% among those who developed prolapse following hysterectomy, compared with 10.5% in those who did not develop vaginal vault prolapse.
There are multiple structures providing support for the female pelvic organs including bone, muscle, and endopelvic fascia. The pelvic floor consists of the pelvic diaphragm, made up of the levator ani group, coccygeus muscles, and surrounding fascia. From these structures, a shelf of muscle is formed that attaches to the pelvic side wall by the arcus tendineus fasciae pelvis that runs between the pubic symphysis and the ischial spine. The upper vagina rests on this shelf, creating its natural axis, which is horizontal. Vaginal prolapse may occur when this axis is altered. DeLancey described 3 levels of vaginal support within the pelvis: level I or apical support, level II or lateral support, and level III or distal support. Suspension of the vaginal apex is the result of level I support, and apical or vaginal vault prolapse is the consequence when this level of support is lost. There are ligamentous supports to the female pelvic organs also, with the upper vagina and the uterus having support from the cardinal and uterosacral ligaments. The cardinal ligaments extend between the cervix and pelvic side wall while the uterosacral ligaments run from the sacrum to the cervix and vaginal fornices, and these structures can be damaged by a hysterectomy. Fig. 1 illustrates vaginal vault prolapse.
Symptoms of POP include pelvic bulge, pelvic pressure, pelvic pain, back pain, voiding complaints, bowel symptoms, dyspareunia, or difficulty walking or sitting. The most common presenting symptom is pelvic bulge, which is reportedly present in 94% to 100% of patients. Obtaining a thorough history and proper counseling of the patient can help reduce postoperative patient dissatisfaction, especially in cases where patients falsely attribute symptoms to their prolapse that, in actuality, are caused by unrelated medical conditions. In such cases patients may have false expectations, compromising the success of the procedure performed. A thorough pelvic examination is vital in the evaluation for POP, and one should distinguish between anterior, apical, and posterior prolapse, which is important in determining the appropriate treatment. Care should also be taken to evaluate for voiding dysfunction such as urinary incontinence, as Mayne and Assassa reported that up to 45% of women older than 40 years have symptoms of voiding dysfunction, and up to 26% of these women will have clinically significant symptoms. Identifying the presence of voiding dysfunction is important, as concomitant procedures may need to be considered at the time of prolapse repair and these coexisting conditions may affect the patient’s expectations. Having the patient stand, if they are physically able, during the physical examination is preferred, and the patient should be asked to strain during the examination to assess the maximum degree of prolapse along with the function of the pelvic muscles. If the patient has any evidence of anterior prolapse, the examiner should reduce the prolapse and instruct the patient to Valsalva to evaluate for the presence of urinary incontinence, as there are reports of stress urinary incontinence (SUI) being present concomitantly in up to 38% and urge incontinence in 26% of those with POP. One should also consider checking a postvoid residual, as there is a risk of preoperative urinary retention, particularly in older women. It is reported that 89% of these women will have resolution of their urinary retention following treatment of their POP. The staging used to grade POP is:
Stage 0: No prolapse present
Stage I: Distal portion of prolapse greater than 1 cm above hymen
Stage II: Distal portion of prolapse within 1 cm of hymen, either above or below
Stage III: Distal portion of prolapse greater than 1 cm below hymen but not complete eversion
Stage IV: Complete vaginal eversion.
The pelvic organ prolapse quantification (POPQ) system standardizes the staging of POP ( Fig. 2 ) using reference points within the vagina to characterize the level and location of prolapse present. Using this system, point C represents the cervix or vaginal cuff; a negative value is assigned when prolapse is proximal to the hymen, and a positive number assigned when prolapse extends distal to the hymen.
Treatment options and goals of repair
Treatment consists of obliterative or restorative procedures. Colpocleisis, an obliterative procedure, is an option for patients who no longer desire sexual intercourse or have other medical comorbidities that make more invasive procedures less appealing, while still offering the patient a high success rate reported at 90% to 100%. The goals of a restorative procedure, which can be performed via a transvaginal or transabdominal approach, are restoration of vaginal anatomy with preservation of vaginal axis, length, and function. When approaching vaginal vault prolapse transvaginally, treatment consists of fixation of the vaginal apex to the sacrospinous ligaments, uterosacral ligaments, or ileococcygeus muscles. Traditional advantages of a transvaginal approach compared with ASC included decreased operative time, recovery time, and cost, and avoidance of an abdominal incision. Not all of these advantages hold true with the introduction of minimally invasive repairs such as LSC and RSC, and a significant disadvantage with a transvaginal repair is the consistently lower long-term success rate in comparison with an abdominal approach.
The mainstay of transabdominal repairs for the management of vaginal vault prolapse is ASC, which provides high success rates and durable results. When success is defined as a lack of apical prolapse, long-term success is obtained in 78% to 100% of patients following ASC. A Cochrane review of the surgical management of POP identified 40 randomized controlled trials comparing vaginal sacrospinous ligament suspension with ASC, and found that there was a decreased incidence of recurrent vaginal vault prolapse and dyspareunia with ASC. Also, in patients with persistent apical prolapse the stage was lower following ASC versus vaginal repair. The ASC consists of fixation of mesh to the anterior and posterior aspects of the vaginal apex that extends to the sacral promontory. Among synthetic grafts, monofilament, large-pore polypropylene mesh (Type 1) grafts have the lowest rate of erosion reported. Advantages of the ASC in managing vaginal vault prolapse are support of the vault to the anterior surface of the sacrum preserving (or restoring) the normal axis of the vagina, preservation of maximal vaginal depth, and strength to weakened native tissue with the use of synthetic suspensory material. Preservation of vaginal depth is important in patients who desire continued sexual activity, particularly in patients with an already foreshortened vagina from previous surgery. Fig. 3 illustrates the end result following sacrocolpopexy.
Laparoscopic sacrocolpopexy
With the introduction of less invasive approaches, sacrocolpopexy has become a more attractive option because it provides a highly successful repair along with a better cosmetic result and a shorter recovery time. In recent years there has been a significant amount of data published evaluating LSC and RSC and the outcomes after these procedures. Regarding conventional laparoscopy for the repair of vaginal vault prolapse, published comparative studies evaluating LSC versus ASC show similar success rates along with similar complication rates. In a study by Klauschie and colleagues, patients were evaluated for mean improvement in reference point C in the POPQ grading system following LSC and ASC, with no significant difference noted between the 2 groups. High anatomic success along with high patient satisfaction was reported in a review of 11 series of LSC, which included more than 1000 patients, with mean anatomic success rate of 92% (range 75%–100%) and mean patient satisfaction of 94.4% (range 79%–98%). Another benefit of a laparoscopic approach other than better cosmesis is the enhanced view of pelvic anatomy secondary to magnification and the increased field of view.
The surgical procedure is described here; however, as with any procedure, there are variations depending on the surgeon’s preference and experience. Patients are placed in the lithotomy position and then are put into steep Trendelenburg position to allow a view of the pelvis free of small bowel. First, pneumoperitoneum is obtained and ports are placed. Of note, the associated pneumoperitoneum can facilitate the dissection of an associated enterocele by producing ballooning of the enterocele. One may use any of the multiple port configurations described in the literature. A few of these configurations are described here, with one possible layout consisting of a 10-mm umbilical port for the camera, two 5-mm ports placed two-thirds of the distance between the umbilicus and anterior superior iliac spine on each side, and either a 5- or 10-mm port halfway between the umbilicus and pubic symphysis. Another configuration is placement of a 10-mm camera port at the umbilicus, two 5-mm ports placed 5 cm above and medial to the anterior superior iliac spine on each side, a 5-mm port placed halfway between the lateral and umbilical ports on one side, and a 10-mm port placed in the same position on the contralateral side. In a recent randomized controlled trial comparing LSC with RSC, 4 ports were placed for an LSC: a 5-mm umbilical port for the camera, two 10- or 12-mm ports in the lower quadrants, and one 5-mm port placed lateral to the rectus muscle 9 cm subcostally on one side. Once port placement is complete, the sigmoid is retracted to the left, allowing identification of the sacral promontory. The sacral promontory is identified and the overlying peritoneum is incised, which is then carried inferiorly into the pelvis staying lateral to the rectum and being careful to avoid the right ureter. When working in the area of the sacrum, care should be taken to avoid damaging the presacral veins, as significant hemorrhage may occur. Attention is then turned to the vaginal apex, and at this point placement of a vaginal retractor aids in identifying the limits of the vaginal vault by deflection of the vagina. Fig. 4 shows an example of a customized hand-held retractor, although others describe using retractors such as an end-to-end anastomotic sizer or ring forceps. The dissection of the anterior and posterior vaginal walls starts with incising the peritoneum over the vaginal apex. Anteriorly, the bladder is dissected off of the vagina for at least a few centimeters, using forceps and scissors with electrocautery, and this should be a relatively bloodless plane. Posteriorly, the rectovaginal space is entered and rectum is dissected away from the posterior vagina. Like the various port-placement configurations that may be used, there are also variations in the graft placed. The authors prefer to use a preformed Y-shaped piece of mesh whereas some use separate strips of mesh for the anterior and posterior vagina. There are also groups that report only placing mesh along the posterior vaginal wall, and one series reports attachment of the posterior mesh to the levator ani instead of the posterior vagina. Suture material should be nonabsorbable, and full-thickness sutures are placed in an interrupted fashion to securely attach the mesh graft to the vaginal apex. Interrupted sutures are then placed through the anterior longitudinal ligament and periosteum of the sacrum, avoiding the presacral veins. These sutures are used to secure the long arm of the Y-shaped graft to the sacral promontory while avoiding excessive tension on the vaginal apex. Knots may be tied with either an intracorporeal or extracorporeal technique, depending on the surgeon’s preference. The mesh may be secured to the sacral promontory using tacks rather than sutures. As one of the reported disadvantages of LSC is knot tying, one may consider using a disposable suturing device, such as the Endostitch (US Surgical Corp., Norwalk, CT, USA) to make laparoscopic suturing easier. The last step of the procedure is closing the peritoneum over the graft.
