The ideal procedure for pelvic organ prolapse (POP) repair would be associated with a low chance of long-term anatomic recurrence in the corrected compartment and should not predispose the patient to de novo stress urinary incontinence (SUI) or POP in other compartments. The procedure should also improve the woman’s quality of life and subjective symptoms of pelvic floor dysfunction, it should be safe, and not be associated with significant immediate and long-term morbidity. Each procedure for POP repair has strong advantages and potential detractors. This article discusses anterior and posterior compartment POP repairs.
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Pelvic organ prolapse is a prevalent, costly, and bothersome condition.
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Traditional (plication-type) prolapse repairs may be associated with high degrees of anatomic recurrence, but quality of life and symptoms may improve.
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Prolapse repairs augmented with synthetic mesh provide a higher anatomic cure rate, but may be associated with extrusion and erosion.
Introduction and epidemiology of pelvic prolapse
An analysis of women who participated in the 2005 to 2006 National Health and Nutrition Examination Survey revealed the weighted overall prevalence of pelvic organ prolapse (POP) to be 2.9%, with the prevalence increasing with age, from 1.6% in women 20 to 39 years of age to 4.1% in women aged 80 years or older. The lifetime risk of undergoing a single operation for prolapse or incontinence by age 80 years has been estimated to be as high as 11.1%, with risk factors being older age, postmenopausal status, multiparity, and obesity. Some US Census Bureau projections estimate that as many as 9.2 million women in the United States will have prolapse by the year 2050, and, as may be expected, the demand for services to care for pelvic floor disorders is also estimated to increase by 45% by the year 2030.
The cost of treating POP is also significant, because the direct costs of prolapse surgery were estimated to be $1012 million (in 1997). Furthermore, women with POP have an impaired quality of life (QoL), are more likely to be self-conscious and less likely to feel physically and sexually attractive than normal controls. Taking these factors into account, it is easy to see that the demand for durable and safe surgical options will continue to increase. The main controversy in the realm of POP repair is the role of traditional (plication-type) repairs and augmented repairs, especially with the addition of synthetic mesh. The recent warnings by the US Food and Drug Administration (FDA) regarding the complications of transvaginal mesh implantation for POP repair have raised valid concerns regarding these procedures for pelvic floor reconstruction. Some questions may remain unanswered; however, several conclusions may be drawn regarding the role of different types of POP repair in 2012. Because the role of synthetic mesh in the repair of vaginal vault prolapse with abdominal sacrocolpopexy is beyond the scope of this article, only anterior and posterior compartment POP repairs are discussed.
Brief anatomy of pelvic prolapse
Normal Anatomy
A 3-level system is useful when considering normal vaginal support cephalad to caudad, with levels I and II providing the key support in POP, and level III support responsible for urethral hypermobility and perineal defects, in the anterior and posterior compartments, respectively. The cardinal ligaments anchor the upper vagina and cervix to the pelvic sidewall (level I) and, in the midvagina, the vesicopelvic ligament/pubocervical fascia support the bladder base and the anterior vaginal wall through its attachment to the arcus tendineus fasciae pelvis (ATFP) laterally (level II).
In the posterior compartment, level II support is provided by the direct attachment of the posterior vaginal wall laterally to the levator ani fascia. The vagina is separated from the rectum by the rectovaginal fascia, which is attached laterally to the ATFP in the proximal two-thirds of the vagina and fused proximally with the uterosacral ligaments laterally and the pericervical ring centrally.
Anatomic Variations
Weakness in the pubocervical fascia in the setting of an intact lateral attachment of the vesicopelvic ligament to the ATFP produces a central cystocele, whereas a lateral cystocele results from an intact pubocervical fascia and disrupted attachment of the vesicopelvic ligament to the ATFP. Central defects are often associated with loss of level I support at the cardinal ligaments and patients often have a concomitant enterocele. Traditional repair of a central cystocele involves the plication of the pubocervical fascia in the midline (anterior colporrhaphy), whereas a lateral cystocele is repaired with reattachment of the vesicopelvic ligament to the pelvic sidewall (paravaginal repair). Attachment of a mesh graft to the ATFP or obturator internus fascia has the potential to address central and lateral defects simultaneously.
A rectocele may be central, lateral, or combined, and may be addressed with plication of the rectovaginal septum (posterior colporrhaphy). A site-specific rectocele repair involves the repair of discrete rents in the rectovaginal fascia instead of a midline plication. A mesh graft that spans sidewall to sidewall may address all variations of rectoceles.
Brief anatomy of pelvic prolapse
Normal Anatomy
A 3-level system is useful when considering normal vaginal support cephalad to caudad, with levels I and II providing the key support in POP, and level III support responsible for urethral hypermobility and perineal defects, in the anterior and posterior compartments, respectively. The cardinal ligaments anchor the upper vagina and cervix to the pelvic sidewall (level I) and, in the midvagina, the vesicopelvic ligament/pubocervical fascia support the bladder base and the anterior vaginal wall through its attachment to the arcus tendineus fasciae pelvis (ATFP) laterally (level II).
In the posterior compartment, level II support is provided by the direct attachment of the posterior vaginal wall laterally to the levator ani fascia. The vagina is separated from the rectum by the rectovaginal fascia, which is attached laterally to the ATFP in the proximal two-thirds of the vagina and fused proximally with the uterosacral ligaments laterally and the pericervical ring centrally.
Anatomic Variations
Weakness in the pubocervical fascia in the setting of an intact lateral attachment of the vesicopelvic ligament to the ATFP produces a central cystocele, whereas a lateral cystocele results from an intact pubocervical fascia and disrupted attachment of the vesicopelvic ligament to the ATFP. Central defects are often associated with loss of level I support at the cardinal ligaments and patients often have a concomitant enterocele. Traditional repair of a central cystocele involves the plication of the pubocervical fascia in the midline (anterior colporrhaphy), whereas a lateral cystocele is repaired with reattachment of the vesicopelvic ligament to the pelvic sidewall (paravaginal repair). Attachment of a mesh graft to the ATFP or obturator internus fascia has the potential to address central and lateral defects simultaneously.
A rectocele may be central, lateral, or combined, and may be addressed with plication of the rectovaginal septum (posterior colporrhaphy). A site-specific rectocele repair involves the repair of discrete rents in the rectovaginal fascia instead of a midline plication. A mesh graft that spans sidewall to sidewall may address all variations of rectoceles.
Interposition grafting for pelvic prolapse
Background and Anatomy
As pelvic surgeons have gradually noticed similarities between POP and hernias of the abdominal wall, interposition grafting has become an increasingly attractive method to replace or augment standard POP repairs. Advantages of graft augmentation are that both central and lateral compartment defects can be repaired simultaneously and a graft may be anchored to an apical landmark, or placed suburethrally, to provide concomitant level I and level III support, respectively. Cadaver allografts, xenografts, and synthetic meshes, both absorbable and nonabsorbable, have been used for interposition grafting in both the anterior and posterior compartments.
Owing to the unpredictable long-term outcomes with biologic grafts, permanent synthetic meshes have largely supplanted other materials for interposition grafting. Julian first sutured a polypropylene (Marlex) graft to the obturator/levator fascia to address an anterior compartment defect and reported no anatomic recurrence at 2 years of follow-up. Because synthetic meshes may differ significantly by weave, fiber type, pore size, weight, and stiffness, outcomes may differ substantially with each material. As with midurethral slings (MUS), macroporous, monofilament, polypropylene mesh has the most favorable biocompatibility profile of all the current synthetics. The absence of interstitial pores allows native collagen ingrowth and the large pores allow entry to macrophages and other immune mediators.
Transvaginal Mesh Kits
Owing to the popularity and success of the all-inclusive MUS kits, interest in POP kits has peaked in the last decade. These kits combine mesh for repair of an anterior or posterior compartment defect, trocars for tunneling mesh arms subcutaneously, and suture capturing or anchoring devices to provide simultaneous apical support. The concept behind the kits is to provide a route for a minimally invasive, mesh-augmented, transvaginal POP repair using easily identified landmarks.
The first kit, the posterior intravaginal slingplasty (PIVS; US Surgical, Tyco Healthcare Group, Norwalk, CT, USA), achieved level I support by tunneling a nylon tape through the ischiorectal fossa into an incision in the posterior vaginal fornix. The tunnelers exited through the iliococcygeus muscle near the ischial spines and the deployed tape was sutured to the vaginal vault. Several other commercially manufactured POP kits have been introduced and, although a detailed discussion of specific kit properties is beyond the scope of this article, a comparison of mesh kits is available elsewhere. All of the currently available kits are constructed from type I, macroporous, monofilament polypropylene.
For anterior compartment repair, 2 sets of trocars are typically advanced percutaneously through each obturator foramen into a vaginal incision. The superior trocars exit near the bladder neck, whereas the inferior trocars exit near the ischial spine. Mesh arms are advanced through the skin with the trocars until the body of the mesh is seated under the bladder base in a tension-free position. For posterior compartment repair, 1 set of trocars is passed through bilateral perianal incisions to exit near the ischial spine and the proximal part of the mesh is positioned as described earlier. In the second generation of kit procedures, surgical dissection is performed solely through the vagina under direct vision and there is no percutaneous mesh advancement. In addition, suture passers or specialized trocars attach mesh arms to the sacrospinous ligament for repair of a concomitant apical defect.
Outcomes of pelvic prolapse repair
The debate over the optimal method to repair POP exists mainly because traditional repairs are perceived to lack durability. In an analysis of the Kaiser Permanente Northwest database, Olson and colleagues found that 29.2% of nearly 400 women underwent reoperation for incontinence or POP and the time intervals between procedures decreased with each subsequent repair. Clark and colleagues determined that the risk of reoperation increased from 12% to 17% in those women who had already failed a previous procedure for SUI or POP. Although 60% underwent reoperation at the same anatomic site, 32.5% of the women developed an occult support defect and underwent reoperation at a different site.
Standard POP Repairs
The reports of success after standard anterior colporrhaphy have been inconsistent. Although some reports cite ∼5% long-term recurrence, most studies quote anterior compartment recurrence rates that approach 50%. Although no long-term prospective trials are available, anatomic cure rates after isolated rectocele repair are high and typically exceed 85%. Published outcomes are often difficult to compare because of variations in patient population, surgical technique, definitions of success, and indications for repair. Furthermore, outcomes of POP repair may be confounded by concomitant repairs in other compartments and, as such, should be interpreted cautiously.
Interposition Grafts and Kit Repairs
Despite variations in technique and definitions of success, short-term anatomic cure rates after interposition grafting with most materials have approached 90%. However, the cure rates with biologic grafts seem to decline with longer periods of follow-up, mirroring the surgical experience after biologic slings. The anatomic outcomes after transvaginal kit repairs have likewise been promising in the short term. A recent meta-analysis encompassing 30 studies with 2653 patients calculated the objective success rates to be 87% to 95% for several different commercial POP kits.
Comparative studies
Standard Versus Augmented POP Repairs
Studies comparing standard transvaginal POP repairs and those using synthetic or xenograft-derived interposition grafts are summarized in Table 1 . Several meta-analyses and systematic reviews have evaluated these outcomes. In a 2010 Cochrane Database review, anterior colporrhaphy was associated with more recurrent cystoceles than standard repairs augmented with polyglactin mesh or porcine dermis inlay, polypropylene mesh as an overlay, or armed transobturator mesh. The review also emphasized that, although some data were limited, there were no differences in subjective outcomes, QoL data, de novo dyspareunia, SUI, and reoperation rates for prolapse or incontinence between the augmented and standard procedures. Furthermore, because there are fewer evidence-based outcomes comparing the outcomes after standard posterior colporrhaphy and graft-augmented repair, the review found little evidence supporting interposition grafting in the posterior compartment. An additional meta-analysis encompassing 49 studies and more than 4500 women determined that nonabsorbable synthetic mesh had a significantly lower objective anterior compartment recurrence rate (8.8%) than absorbable synthetic mesh (23.1%) and biologic graft (17.9%).
| Author | Location (N) | Graft (N) | F/U (mo) | Objective Recurrence (%) | Symptomatic Recurrence (%) | Postoperative Complications (%) | |
|---|---|---|---|---|---|---|---|
| Extrusion (Graft) | Dyspareunia | ||||||
| Standard Anterior/Posterior Colporrhaphy vs Absorbable Synthetic Mesh-Augmented Repair | |||||||
| Weber (RCT) | Anterior (35) | Vicryl (35) | 23 median | 70/58 | 0/9 | N/A | N/A |
| Sand (RCT) | A&P (70) | Vicryl (73) | 12 | 10/9 | N/A | N/A | N/A |
| Standard Anterior/Posterior Colporrhaphy vs Nonabsorbable Synthetic Mesh-Augmented Repair (Including Kits) | |||||||
| Hiltunen Niemenen (RCT) | Anterior (97) | PP (104) | 12 | 39/7 | 18/5 | 17.3 | Dyspareunia score lower in PP group |
| Sivaslioglu (RCT) | Anterior (45) | PP (45) | 12 mean | 28/9 | P-QoL similar | 6.9 | 0/4.6 |
| Nguyen (RCT) | Anterior (38) | PP + AC (37) | 12 | 45/13 | PFDI/PFIQ similar | 5 | 16/9 |
| Carey (RCT) | A&P (70) | PP + A&P (69) | 12 | 34/19 | PSI-QoL similar | 5.6 | 15.2/16.7 |
| Niemenen (RCT) | Anterior (97) | PP (105) | 36 | 41/13 | 65/69 | 19 | 8.2/3.8 |
| Altman (RCT) | Anterior (189) | Prolift (200) | 12 | 66/39 | 38/25 | 3.2 | 2/7.3 |
| Sokol (RCT) | AC + VVS (33) | Prolift (32) | 12 | 70/63 | 9/4 | 15.6 | 18.8/6.7 |
| Standard Anterior/Posterior Colporrhaphy vs Xenograft-Augmented Repair | |||||||
| Gandhi (RCT) | Anterior (78) | Tutoplast + AC (76) | 13 median | 29/21 | 31/22 | N/A | N/A |
| Paraiso (RCT) | Posterior (33) | Bovine pericardium (29) | 17.5 mean | 14/22/46 | 16/12/21 | N/A | 20/14/6 |
| SSPC (37) | |||||||
| Meschia (RCT) | Anterior (103) | Pelvicol (98) | 12 | 19/7 | 13/9 | 1 | N/A |
| Botros | Anterior (89) | Cadaver dermis (102) | >15 mean | 23/10 | N/A | 0 | 19/14 |
| Guerette (RCT) | Anterior (26) | Bovine pericardium (33) | 24 | 37/24 | N/A | N/A | 20/15 |
| Hviid (RCT) | Anterior (31) | Pelvicol (30) | 12 | 15/7 | 3/3 | 3.3 | N/A |
| Dahlgren (RCT) | Anterior/posterior (60) | Pelvicol (65) | 36 | 57/62 (A) 40/17 (P) | 15/16 | 4.4 | N/A |
| Handel | Anterior (18) | PD (56) | 13.5 mean | 6/36/4 | N/A | -/21/4 | N/A |
| PP (25) | |||||||
| Menefee (RCT) | Anterior (32) | PD (31) | 12/24 | 58/46/18 | 13/12/4 (composite) | -/4/14 | 9/6/6 |
| PP (36) | |||||||
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