Surgical management of urinary incontinence and pelvic organ prolapse

Contributors of Campbell-Walsh-Wein, 12th edition

Siobhan M. Hartigan, Christopher R. Chapple, Roger R. Dmochowski, Jack C. Winters, Ryan M. Krlin, Barry Hallner, Alex Gomelsky, Roger R. Dmochowski, Anne P. Cameron, Dirk J.M.K. Deridder, Tamsin Greenwell, Lindsey Cox, Eric S. Rovner, Hunter Wessels, and Alex J. Vanni.

Vaginal and abdominal reconstructive surgery for pelvic organ prolapse (POP)

Preoperative considerations

Because pelvic organ prolapse (POP) predominantly impacts quality of life, consideration must be given to prolapse stage, patient’s symptoms, and the degree of bother. As patients’ expectations and readiness to undergo surgery for POP impact their satisfaction and how they perceive their improvement , success after POP surgery must consider patient satisfaction along with symptom improvement .

Surgical management of pelvic organ prolapse ( Table 17.1 )

Anterior compartment ( Table 17.2 ).

Since these are commonly combined central and lateral defects, an anterior colporrhaphy ( Fig. 17.1 ) that corrects only central defects should be combined with a paravaginal repair ( Fig. 17.2 ). Various grafts have been used to augment anterior compartment repair. It is essential for women with high-grade POP to undergo evaluation for stress urinary incontinence (SUI) with prolapse reduced, as the rate of occult SUI is 8.3%–66.1%. Antiincontinence surgery should be performed in select patients concomitantly with POP repair.

Table 17.1

Surgical Approach to Pelvic Organ Prolapse

POP-Q SITE	VAGINAL	ABDOMINAL
Aa Urethra	Anterior repair Bladder neck suspension Sling	Retropubic urethropexy
Ba Bladder	Anterior repair Paravaginal repair Colpocleisis	Wedge colpectomy Paravaginal repair ASC
C Cervix/cuff	Uterosacral ligament suspension Iliococcygeus suspension Sacrospinous fixation Manchester operation Hysteropexy Vaginal hysterectomy Colpocleisis	Abdominal hysterectomy Uterosacral ligament suspension ASC Uterine suspension
D Cul-de-sac	McCall culdoplasty	Halban culdoplasty Moschcowitz culdoplasty
Ap	Rectovaginal plication (posterior repair) Site-specific repairs	Colpoperineopexy

ASC, Abdominal sacrocolpopexy; POP-Q, pelvic organ prolapse-quantification.

Table 17.2

Surgical Repairs for Anterior Compartment Pelvic Organ Prolapse

Anterior colporrhaphy	• Plication of pubocervical fascia to repair a central defect ( Fig. 17.1 ) • Anatomic cure: 37%–100% • De novo/occult SUI: 41%–66%; de novo OAB: 5%–7% • Postoperative urinary retention or incomplete emptying—usually transient • Cystoscopy should be performed to rule out bladder or ureteral injuries • Dyspareunia: 3.1%–19%
Paravaginal repair	• Reattachment of the pubocervical fascia to the ATFP to repair a lateral compartment defect • Vaginal ( Fig. 17.2 ) or abdominal ( Fig. 17.3 ) approaches, including open, laparoscopic, or robotic Fig. 17.3 Abdominal paravaginal repair. Paravaginal defect repair as viewed from the retropubic space: approximation of the pubocervical fascia medially to the arcus tendineus fascia pelvis laterally with 2-0 braided nonabsorbable suture. Note the vertical orientation of the vaginal vessels in relation to the transverse orientation of the bladder vessels. Inset shows suture being passed beneath the vaginal vessels to ensure generous purchase of pubocervical fascia and control of hemostasis. a, Artery; n, nerve. (From Bruce RG, El-Galley R, Galloway NT. Paravaginal defect repair in the treatment of female stress urinary incontinence and cystocele. Urology 1999;54:647-651.) • Anatomic cure: 67%–100%
	More serious complications vs. colporrhaphy (bleeding requiring transfusion (12%), neuropathy from lithotomy, ureteral obstruction, vaginal abscesses)
Anterior colporrhaphy with grafts	• Augmented repair by attaching a graft to ATFP and/or obturator internus fascia laterally ± central plication sutures • Multiple graft materials have been used to augment anterior colporrhaphy • Lower objective failure rates than colporrhaphy alone but no difference in subjective cure Mesh complications: 11.4% extrusion, 6.8% requiring surgical intervention (see Complications Related to Mesh)

ATFP , Arcus tendineus fasciae pelvis; OAB , overactive bladder; SUI , stress urinary incontinence.

Apical compartment ( Table 17.3 ).

The vaginal apex is the cornerstone of vaginal support , and failure to ensure apical support at the time of POP repair will increase the risk of recurrence exponentially. Surgical correction can be approached vaginally, abdominally, and robotically or laparoscopically, with or without uterine preservation (see Uterine Prolapse later). In younger, sexually active, and more-physically active women, the data favor abdominal sacrocolpopexy (ASC) for its durability and preservation of functional vaginal length. Women undergoing vaginal procedures are more likely to have SUI, dyspareunia, and recurrent prolapse necessitating repeat surgery.

Table 17.3

Surgical Repairs for Apical Compartment Pelvier

Uterosacral ligament suspension	• Suturing USL at the level of the ischial spine to pubocervical and rectovaginal fascia ( Figs. 17.5–17.7 ) Fig. 17.5 To identify the uterosacral ligament, an Allis clamp is placed on the vaginal epithelium at the right apex and pulled straight upward. With the right uterosacral ligament on tension, the uterosacral ligament is visible in the pelvis. Inset, A long Allis clamp is used to grasp the right uterosacral ligament. (Modified from Walters MD, Muir TW. Surgical treatment of vaginal apex prolapse: transvaginal approaches. In: Vasavada S, Appell R, Sans P, Raz S, eds. Female urology, urogynecology and voiding dysfunction . New York: Marcel Dekker, 2005:663-676.) Fig. 17.6 High uterosacral ligament vaginal vault suspension. Three sutures are placed from lateral to medial in each uterosacral ligament. The sutures are brought through the vaginal muscularis anteriorly (pubocervical fascia) and posteriorly (rectovaginal fascia). Fig. 17.7 (A) Three permanent sutures are placed in each of the uterosacral ligaments medial to the ischial spine. (B) One end of each of the six sutures is placed serially across vaginal apex through the anterior endopelvic fascia and the other end through the posterior endopelvic fascia. (C) All sutures are tied to reapproximate the anterior and posterior vaginal muscularis, to close any potential enterocele defect, and to elevate the vaginal apex toward the sacrum. (Copyright 2008 Loyola University Health System. Used with permission from Mary Pat Fitzgerald, MD.) • Vaginal or abdominal approach • Minimizes injury to pudendal and gluteal vessels compared with SSL • Mean objective success rate: 85% (48%–96%) • Ureteral kinking/injury: 1%–11% Can be done as a hysteropexy if sparing uterus
Sacrospinous ligament fixation	• Unilateral (right side preferred) or bilateral suture fixation of the vaginal apex to the SSL medial to the ischial spine ( Fig. 17.8 ) • Vaginal approach, either anteriorly or posteriorly • Alters vaginal axis if unilateral fixation • Success rates: 64%–96% • Gluteal pain—pudendal nerve entrapment: 15% • Particularly vulnerable to anterior compartment recurrence: 7.6%–92% (not all require surgery) Can be done as a hysteropexy if sparing uterus
Iliococcygeus suspension	• Bilateral anchoring of the vaginal vault through the pubocervical and rectocervical fascia to the fascia of the iliococcygeus muscle distal to the ischial spine near the insertion of the ATFP ( Fig.17.9 ) Fig. 17.9 Iliococcygeus fascia suspension. (A) With the surgeon’s finger deflecting the rectum downward, the right iliococcygeus fascia sutures is placed. Inset , View of the dissected vagina. (B) Abdominal view of the endopelvic fascia. Approximate location of the sutures are delineated by the + sign. (From Walters M, Karram M. Urogynecology and reconstructive pelvic surgery, 3rd ed. Philadelphia: Mosby, 2006.) • Vaginal approach, either anteriorly or posteriorly Cure rate: 53%–96%; buttock pain: 19%
Abdominal sacrocolpopexy	• Securing vaginal cuff to anterior longitudinal ligament at the sacral promontory with mesh or autologous fascial graft • Open, laparoscopic, or robotic approaches; success rates >90% • Minimally invasive approaches have lower complication rates • Vaginal mesh exposure: 0.8%–9.9% • Up to 20% recur with distal anterior/posterior defects requiring secondary vaginal repair

ASC , Abdominal sacrocolpopexy; SSL , sacrospinous ligament; USL , uterosacral ligament.

Obliterative Procedures – In patients who no longer desire to be sexually active, a colpocleisis, with or without prior or concomitant hysterectomy, should be considered. Colpocleisis entails the removal of vaginal epithelium and use of purse-string sutures to sequentially reduce the prolapse proximally. The patient must still be screened for occult SUI, and urologists should offer concomitant antiincontinence procedures, as indicated.

Uterine Prolapse – Vaginal hysterectomy alone is not an adequate treatment for a patient with uterine prolapse. Vaginal apex suspension, or at minimum McCall culdoplasty ( Fig. 17.4 ), should be performed at the time of hysterectomy for uterine prolapse to reduce the risk of recurrence. Barring contraindications, uterine-sparing approaches to POP repair are gaining popularity and may also be offered ( Table 17.4 ).

Table 17.4

Contraindications for Uterine Preservation

Modified from Ridgeway BM. Does prolapse equal hysterectomy? The role of uterine conservation in women with uterovaginal prolapse. Am J Obstet Gynecol 2015 Dec; 213(6): 802-809. doi: 10.1016/j.ajog.2015.07.035. Epub 2015 Jul 28. PMID: 26226554.

Postmenopausal bleeding

Current or recent cervical dysplasia

Familial cancer syndrome, BRCA1 and BRCA2

Hereditary nonpolyposis colonic cancer syndrome

Tamoxifen therapy

Uterine abnormalities

Fibroids, adenomyosis, abnormal endometrial sampling

Abnormal uterine bleeding

Inability to comply with routine gynecologic surveillance

Cervical elongation (relative contraindication)

Posterior compartment ( Table 17.5 ).

Symptoms include vaginal bulging, defecatory dysfunction (stool trapping requiring vaginal splinting, urgency, constipation), and dyspareunia. Repair traditionally entails a midline posterior colporrhaphy, with or without graft augmentation. However, if a discrete defect in the fascia can be identified, a site-specific repair can be attempted. Although midline fascial plication remains the standard of care for posterior compartment prolapse, there is largely a lack of evidence comparing the two procedures. Because of the increase in postoperative dyspareunia, plication of the levator ani muscles should not be performed. If introital laxity is encountered, perineorrhaphy can be performed in conjunction with posterior repairs.

Table 17.5

Surgical Repairs for Posterior Compartment Pelvic Organ Prolapse

Posterior colporrhaphy	• Midline plication of the rectovaginal fascia ( Fig. 17.10 ) • Anatomic cure: 82%–92% • Has been augmented with grafts; no studies show a benefit • Defecatory dysfunction (e.g., constipation, anismus) may persist
Site-specific repair	• Repair of discrete defect in rectovaginal fascia, most commonly transverse ( Fig. 17.11 ) • A discrete defect may not always be identified • Anatomic cure: 56%–100% • Anatomic correction does not always correlate with symptom relief, but symptom relief should be the priority for surgical success

Surgery for female SUI

SUI is the involuntary loss of urine on effort or physical exertion and with increased intra-abdominal pressure. Two types of SUI have been suggested: urethral hypermobility ( a hypermobile but otherwise healthy urethra, due to weakened support of the proximal urethra) and intrinsic sphincter deficiency (ISD) (a deficiency of the urethral sphincter mechanism). ISD is urodynamically defined as a leak point pressure (LPP) <60 cm H ₂ O or a maximum urethral closing pressure [MUCP] <20 cm H ₂ O. It is likely that ISD coexists with hypermobility in most cases. However, there is no consistency in the existing data to support that ISD influences either the outcomes or type of surgical treatment. Therapeutic options generally fall into one of seven categories ( Box 17.1 ). Choice of surgery should take into account surgeon preference, coexisting problems, the patient’s anatomic features, and her general health.

Box 17.1

Surgical Methods

Open retropubic colposuspension
Laparoscopic retropubic colposuspension
Suburethral sling procedure
Needle suspension
Periurethral injection
Artificial sphincter
Vaginal anterior repair (anterior colporrhaphy)

Retropubic suspension surgery

Retropubic colposuspension surgically lifts tissues near the bladder neck and proximal urethra behind the anterior pubic bone. Retropubic procedures have traditionally been used when hypermobility was thought to be the cause of a woman’s SUI. If significant ISD is present, it is hypothesized, but unproven, that SUI will persist after retropubic suspension. In such circumstances, a colposuspension is less likely to be successful than a tight fascial sling or artificial sphincter.

Indications for retropubic suspension.

Careful assessment of the patient is essential ( Fig. 17.12 ). A retropubic suspension is indicated when (1) a patient is undergoing laparotomy for concomitant abdominal surgery that cannot be performed vaginally and (2) there is limited vaginal access.