Apical
prolapse is a disorder that affects scores of women; this article will detail a
variety of surgical procedures which have been used in the past and are
currently used in the treatment of apical prolapse. Based on an article in
Current Urology Reports titled Surgery
for Pelvic Organ Prolapse: A Historical Perspective by Barbalat and
Tunuguntla (2012 13: 256-261) nearly twenty percent of all women will undergo
some type of surgical procedure for treatment of apical prolapse which occurs
when the uterus, cervix or vaginal floor descends, causing a variety of medical
problems. Pelvic organ prolapse is a disorder which would rarely lead to death
however the quality of life for the woman who experiences this disorder can be
significantly diminished.
How Pelvic Organ Prolapse Affects a
Woman’s Life
Sexual
activity may be severely curtailed due to pelvic organ prolapse which can cause
extremely painful intercourse. According to Web MD, further symptoms of pelvic
organ prolapse may include lower backache, a pulling in the groin area, a
constant feeling of pelvic pressure or feeling as though something is falling
from the vagina, urinary incontinence, vaginal spotting or bleeding and bowel
movement problems. Women who are very active may find their symptoms worsen
when they engage in jumping or lifting while symptoms are relieved when the
patient lies down.
Types of Repair for Apical Prolapse
The
Obstetrics and Gynecology Board Review Manual details the incidence of pelvic
organ prolapse and the treatments for apical prolapse, stating that “as the average life span of the population increases,
problems related to pelvic support defects are seen with increasing frequency
ni women. The associated symptoms, although not a cause of mortality, have a
significant impact on the quality of a patient’s everyday life.” When the uterus, cervix or vaginal vault
descends, it is known as apical prolapse. The term for pelvic support defects
is dependent upon the specific organ being affected. Bladder herniations are
known as cystoceles, while protrusions of the rectal area are called
rectoceles.
According
to Barbalat and Tunuguntla there are several transvaginal techniques used in
the repair of apical prolapse: sacrospinous vault suspension, iliococcygeus
suspension and uterosacral vault suspension. The sacrospinous ligament is
attached to the vaginal apex, either unilaterally or bilaterally in a
sacrospinous vault suspension while iliococcygeous suspensions are always
performed in a bilateral manner. The uterosacral suspension can be performed
either vaginally or abdominally.
Historical Perspective on Uterine
Prolapse Treatment
The
first vaginal hysterectomy performed as a treatment for uterine prolapse was
done by Samuel Choppin in 1861. This particular procedure was later reported in
a publication from the Mayo Clinic. The article in Current Urology Reports
notes that two Charing Cross Hospital physicians from London contributed
considerable knowledge regarding surgical repair techniques for apical defects.
These doctors understood for the first time in history that although many
surgeons performed a hysterectomy to correct prolapse, there was no guarantee
it would accomplish that goal and that prolapse could actually be the result of an abdominal or vaginal
hysterectomy.
Vaginal Repair of the Prolapse Using the
Sacrospinous Ligament
Barbalat
& Tunuguntla describe how using a procedure known as the sacrospinous
ligament suspension fixation, vaginal vault prolapse can be repaired in a less
invasive operation, however it has been deemed to be only moderately
successful. Because there are newer, less invasive vaginal approaches today,
the sacrospinous ligament suspension fixation has a limited role in surgery to
correct vaginal vault prolapse. Traditionally the ligament is attached to the
vaginal vault via sutures on one side however this pulling of the top of the
vagina to one side is not particularly secure as the sutures can pull away from
the skin of the vagina. The Amreich-Richter procedure uses the sacrospinous
ligament in the repair of vaginal prolapse and this procedure is still commonly
used in Europe. Other than modifications in the surgical instruments used to
perform the surgery – which give surgeons a more predictable outcome - little
has changed in this particular surgery.
Accepted Treatment for Apical Prolapse
A
surgical procedure used in the treatment of vaginal prolapse which attaches one
end of a synthetic mesh product to the top of the vagina and the other end to
the upper tail bone is called a sacral colpopexy. This surgery is widely
considered the gold standard in treating apical prolapse according to Current
Urology Reports. Surgeons in 1958 and 1962 gave a detailed description of using
a graft to bridge the gap from the cuff of the vagina to the sacrum. When
synthetic mesh was first used in the treatment of apical prolapse it was
generally either polyethylene or Gore-Tex. The polypropylene mesh historically
has performed better than biologic grafts when used abdominally in a sacral
colpopexy surgical procedure.
Minimally Invasive Abdominal Sacral
Colpopexy
In
today’s surgical world, robotic-assisted laparoscopy is typically used in
abdominal sacrocolpopexy surgeries due to the fact that this particularly
surgery is considered very challenging for many surgeons and the new technology
can shorten the surgical learning curve. Barbalat & Tunuguntla stated that
“laparascopic surgery is sometimes technically challenging and operative times
are much longer, especially for those with no formal laparoscopic
training.” Post-operative complications
which are generally associated with the procedure have also been found to be
minimized when robotic assistance is implemented.
Procedures for Enterocele Repair
An
article in PubMed.com states that an “Enterocele
is defined as a herniation of the peritoneal sac between the vagina and the
rectum. This hernial sac contains either sigmoid colon or small bowel. It is
well known that enteroceles are associated with symptoms of pelvic discomfort.”
Enteroceles can cause a woman significant amounts of pain and requires an
operation to excise it from the rectum and vagina. The wounds left from the
excision are closed with sutures then the uterosacral ligaments are shortened and
attached to the posterior vaginal wall. The article in Current Urology Reports
details four basic procedures for the repair of enteroceles. Bringing the
ligaments together in the midline is known as the McCall culdoplasty technique while excising a triangular portion of
the peritoneum and excess vaginal vault wall and closing in the middle is
called the Torpin technique. The Moschowitz procedure places sutures in a
similar fashion as the transvaginal enterocele repair and is performed
abdominally. Finally, the Halban
enterocele repair sutures the peritoneum to the posterior vaginal wall via
rows of sutures.
The Colpocleisis Procedure
An
article in Women’s Health Specialists details a procedure known as the
colpocleisis for the treatment of apical prolapse stating “Colpocleisis is advantageous for a woman who would otherwise be unable
to tolerate a long, extensive surgical procedure. The surgery is easy to
perform, takes a relatively short amount of time, requires only regional or
local anesthesia, and
has a fairly quick recovery time.” Barbalat and
Tunuguntla state that “Apical prolapse
also has been managed with obliterative procedures in poor-risk patients, in
women with symptoms of POP that do not desire the presence of a vagina or those
who have failed multiple prior prolapse repairs.”
This
particular procedure is considered most effective among women who are older and
are not as adamant about preserving their vagina in order to engage in sexual
activity. The surgical procedure offers few risks and can address urinary
incontinence during the same surgery through the use of a synthetic sling.
Patient satisfaction for this surgery is high—as much as 90%. A partial
colpocleisis was actually performed in 1877 which implemented a closure of the
front and back vaginal walls, leaving the uterus in place. Over the years
modifications were made to the procedure to reduce both the recurrence of
prolapse as well as reducing incontinence. This article discussed the various
procedures for apical prolapse repair.
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