A study of more than 300 physical exam findings in women with POP demonstrated a strong association and linear relationship between the pelvic organ prolapse quantification (POP-Q) points C (at the cervix or vaginal cuff) and Ba (the most prolapsed point of the anterior wall). The corresponding posterior wall point, Bp, was also associated with C, but not as strongly [20]. Thus, when advanced apical prolapse is present, anterior wall defects are very likely to be present simultaneously.

The converse may be true as well; that is, a pelvic exam on women with advanced POP (54% stage 3 POP) with simulated apical support accomplishes significant reduction in point Ba. Lowder et al. reported a series of nearly 200 POP-Q exams before and after simulated support (achieved by positioning posterior blade of a standard Graves speculum over the posterior vagina to lift the apex) which revealed mean change in point Ba of 3.5 cm with apical suspension. This achieved Ba above −1 station in over half of patients [21]. By contrast, the maximum point of posterior prolapse, Bp, changed significantly less, by 1.9 cm (p < 0.001), with simulated apical support.

These two studies highlight DeLancey’s theory of the critical role of Level I vaginal support on the anterior and posterior compartments, and particularly the former. A discussion of anterior compartment outcomes with ASC/RASC follows below and is summarized in Table 3.1.

The strong link between anterior and apical vaginal prolapse is well-demonstrated in the literature—both in their coexistence and in the ability of apical repair to improve anterior wall defects. Many surgeons feel that the reduction of cystocele accomplished with apical suspension is enough to obviate the routine need for concomitant anterior colporrhaphy when both defects are present. Modification in mesh anchoring techniques may contribute to improved cystocele reduction . Particularly during RASC , which can have longer operating room times than LASC or ASC [19], the positioning changes and maneuvering of multiple surgical access points for subsequent colporrhaphy adds to prolonged patient time in lithotomy and its associated risks. Many surgeons suggest that concurrent repair can be avoided. It may achieve more optimal anatomic outcomes, but patient relief of bothersome vaginal bulge symptoms can be achieved with reduction of prolapse proximal to the hymen [6]. Recent literature has demonstrated that, while objective anatomic outcomes are important to incorporate, definitions of surgical success should also incorporate subjective patient-based outcomes, such as relief of bothersome vaginal bulge symptoms. With such a staged approach, the number of symptomatic patients requiring a second surgery may be minimal and perhaps better selected.

Two ASC series used mesh that was broadly attached to the vagina posteriorly, as distal as the rectal reflection [22, 23]. Anatomic persistent or de novo anterior wall prolapse was noted in 25–29% of women with short-term follow-up. However, in one study prolapse symptoms were only present in 3%, and no subjective or QOL outcomes were reported in the other. Subsequent anterior repair was reported in zero patients at 3 months and one (0.7%) at 12 months in the two series. The authors concluded that cure rates for apical support were excellent with this distal posterior mesh technique , but anterior wall recurrences were common and warranted further study for optimal management. More studies are needed on patient factors and optimal surgical techniques for multi-compartment prolapse.

One randomized trial of ASC compared to vaginal vault repair with sacrospinous ligament fixation (SSLF) demonstrated similar rates of vault suspension above the hymen and relief of prolapse symptoms at 2 years [14]. One third of the 47 women in the ASC group had colposuspension for stress incontinence (SUI), which does provide some degree of anterior wall support. None of these women went on to have a subsequent repair of anterior wall defects, and three (7%) had asymptomatic grade two or higher cystocele. The cumulative risk of anterior and vault prolapse recurrence was significantly lower in the ASC group (13% vs. 45%, p = 0.01). An important technique point in this ASC series was the application of a polypropylene mesh along the anterior vaginal wall to the level of the bladder trigone.

Four series of RASC without concomitant vaginal repair and with short or intermediate follow-up have recently been published [24–27]. Three of these specifically described a technique with distal anterior anchoring of mesh. Distal landmarks included the trigone or as low as the level of the urethrovesical junction. Two of these studies enrolled women with high-grade apical prolapse; the others include women with only 50–73% vault prolapse. The outcomes were heterogeneous and incompletely reported, in part due to limited follow-up. One study reported subjective outcomes using validated symptom questionnaires that met pre-defined criteria for success in 75%, and symptom scores were improved over baseline at median 2 years follow-up [25]. Another study reported symptomatic persistent or recurrent prolapse in 6% of 52 women at a median of 42 months [24]. Subsequent anterior colporrhaphy was later performed in 0–2.9% of patients at median follow-up of 13 weeks to 5 years. Higher recurrence rates coincided with longer follow-up [24, 26, 27]. These RASC-only reconstructions appear to confirm DeLancey’s theory and others’ observations that apical suspension is paramount, and in some cases the only repair needed, for anterior wall defects.

Despite the strong link between anterior and apical vaginal prolapse , only a concomitant vaginal procedure allows the surgeon to directly address that individual compartment. Early pioneers of the ASC recommended routine concurrent anterior colporrhaphy [1, 12]. Indeed, most published series do include vaginal repairs per the surgeon’s discretion. The guiding rationale and impact of this subjective expert judgment on outcomes are difficult to parse out in published trials and series. This represents an inherent systematic bias that cannot be measured without direct comparison to a series without routine colporrhaphy.

Benson et al. published a series of 40 ASC for vault and anterior wall prolapse with 30% concomitant anterior colporrhaphy [2]. At 2.5 years, 84% had resolution of symptoms, and four (11%) underwent subsequent anterior colporrhaphy . A larger series of ASC with six (2.4%) concomitant anterior repairs had only four (1.9%) subsequent prolapse repairs at 2 years [28]. This variability may be related to the inclusion criteria that favored more significant baseline anterior (as opposed to vault) prolapse, small numbers, different rates of concomitant repairs, or the mesh anchoring techniques that were not well-described in either study. Unfortunately, neither study differentiated whether any anterior wall recurrences happened in those who underwent concomitant anterior repair up front. Snyder and Krantz published one of the first series utilizing mesh anchoring distal to the apex for procidentia in 1991 by fixing polytetrafluoroethylene or dacron graft along the “full extent of the rectovaginal septum” posteriorly. Ninety-eight percent of patients were post-hysterectomy. An unspecified fraction of concomitant anterior colporrhaphies were performed per surgeon discretion, and they reported no reoperation for prolapse and 24 (21%) asymptomatic anatomic recurrences (compartment not specified) at mean 5 years follow-up [15]. Targeted investigations evaluating the effects of concomitant repair stratified by patient-specific and surgical factors have not been performed.

An RASC series by Barboglio et al. with 12 months’ follow-up was published for 92 women, of whom two (2.2%) underwent concomitant anterior colporrhaphy. Ultimately, seven (8%) had anterior compartment prolapse, and two (2.2%) underwent subsequent prolapse repair (baseline performance of concomitant anterior compartment repair was not reported). The relative absence of robotic series utilizing concomitant vaginal repairs may be the result of a change in surgeon preference with time and the adoption of robotic techniques. Comparative studies, and long-term studies with uniform outcomes and follow-up, are needed to ascertain the value of anterior colporrhaphy at the time of RASC.

Regardless of whether concomitant anterior repair is used at the time of ASC, the rates of subsequent anterior repair are overall low. Whether there is a difference in the rate of reoperation for prolapse between these groups cannot be determined from these series, not only because much of the data is retrospective and not comparative, but also because the different inclusion criteria and procedure selection introduce significant bias that must be acknowledged when reviewing the outcomes. It appears that, if the anterior vaginal wall is supported by the colpopexy mesh, and the graft is attached distally, anterior repair is unlikely to be needed in many patients. An exception would be the patient desiring uterine preservation. If a posterior strip sacrocolpopexy is performed (without an attachment to the anterior vaginal wall or cervix), the anterior vaginal wall may be at higher risk of recurrence.

Seventy-six percent of women with multi-compartment defects have a posterior defect [6]. In response to evidence that apical suspension may address anterior compartment defects better than posterior wall defects [2], some surgeons modified the mesh attachment technique to target that anatomy [16]. While traditional posterior colporrhaphy plicates the posterolateral rectovaginal fascia into the midline in a compensatory reconstruction that imposes a barrier between rectum and vagina, distal mesh anchoring on the vagina during sacrocolpopexy can restore the normal fascial continuity between level III and level II supports, as described by DeLancey [29]. Pulling the perineal body superiorly toward the apex will repair some types of rectocele and perineal descent. However, if the defect is a disruption of the lateral attachments of the perineal membrane (urogenital diaphragm), this cannot be addressed from an abdominal approach and may need to be approached vaginally.

Some surgeons advocate for traditional posterior repair with perineorrhaphy or defect-directed repair by the vaginal approach at the time of ASC [30, 31]. Others have proposed that posterior support can be adequately achieved from the abdominal approach alone with distal mesh anchoring [15, 16]. Unfortunately, discrete comparative data to clarify outcomes by a particular approach are muddled by the surgeon practice preferences utilized in retrospective sacrocolpopexy series. The available evidence outcomes for ASC/RASC on the posterior compartment are reviewed below (summarized in Table 3.2).