Corrective Surgical Procedures for Apical Prolapse

This article will discuss the various surgical procedures currently used in the treatment of apical prolapse. Apical prolapse is the descent of uterus, cervix or vaginal vault and affects millions of women worldwide. By the age of 80 to 85 years, as many as 19 percent of women will have undergone a surgical procedure to correct pelvic organ prolapse or stress urinary incontinence.

According to an article in the Obstetrics and Gynecology Board Review Manual titled Diagnosis and Treatment of Vaginal Apical Prolapse, “As the average life span of the population increases, problems related to pelvic support defects are seen with increasing frequency in women.”

Consequences of Pelvic Organ Prolapse

While pelvic organ prolapse will not cause death, it can certainly have a significant impact on the patient’s quality of life, including sexual activities. Descriptions of defects in the pelvic support system are typically based on the affected organ. A herniation of the bladder is known as a cystocele, while a rectocele is a protrusion of the rectum. According to a Current Urology Reports titled Surgery for Pelvic Organ Prolapse: A Historical Perspective by Barbalat and Tunuguntla (2012 13: 256-261) “Transvaginal techniques to correct apical prolapse include sacrospinous vault suspension, iliococcygeus suspension and uterosacral vault suspension.” The sacrospinous vault suspension, according to the same article, is performed unilaterally or bilaterally through the suspension of the vaginal apex to the sacrospinous ligament.

The iliococcygeus suspension is always performed bilaterally while the uterosacral suspension is performed vaginally or abdominally.  Although a far cry from current surgical procedures, the first vaginal hysterectomy performed to treat a uterine prolapse was done in 1861 by Samuel Choppin and later reported in a Mayo Clinic publication. Two doctors who practiced in the Charing Cross Hospital in London made significant contributions in the surgical repair techniques of apical defects and recognized that prolapse was sometimes a by-product of abdominal or vaginal hysterectomy and that a hysterectomy was not guaranteed to correct the prolapse.

The Sacrospinous Ligament Repair

The Current Urology Reports article details how by using the sacrospinous ligament doctors Sederl and Richter attempted a vaginal repair of the prolapse—a technique which is still widely used in Europe and is known as the Amreich-Richter procedure. To this day, very little has changed in this particular surgical procedure other than certain modifications to instruments. One surgical instrument known as the Miya Hook, another called the Shutt needle driver and a third known as the Laurus needle driver were introduced in 1987, 1993 and 1997, making the surgery easier for the surgeon with a more predictable outcome.

The Gold Standard for Treatment of Apical Prolapse

The sacral colpopexy (a surgical procedure to treat 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 or lower spine) is the abdominal counterpart of the vaginal vault prolapse and is considered the gold standard treatment for apical prolapse according to the Current Urology Reports article. The gap from the vaginal cuff to the sacrum is bridged using a graft as described by surgeons in 1958 and 1962. Early cases describe the use of polyethylene and Gore-Tex synthetic meshes for reconstruction for pelvic organ prolapse. Reviews of sacral colpopexy surgeries found that the polypropylene mesh performed better than certain biological grafts when used in abdominal sacral colpopexy including skin taken from the patient, from a cadaver and a cerebral dura mater allograft in 2002.  The International Center for Laparoscopic Urogynecology states “By performing the sacral colpopexy laparoscopically, our physicians are able to reposition the vagina to its anatomic position in a minimally invasive manner. Most surgeons perform this procedure through a large incision thus contributing to a longer recovery time. Our laparoscopic approach also allows us to incorporate additional laparoscopic procedures if needed.”

Abdominal Sacral Colpopexy with Minimal Invasion

Endoscopic technology has made great strides in the past two decades, leading up to robotic-assisted laparoscopy used in abdominal sacrocolpopexy. The hope in improving these technologies was that pelvic visualization would be greatly enhanced. According to Barbalat and Tunuguntla, “Laparoscopic surgery is sometimes technically challenging and operative times are much longer especially for those with no formal laparoscopic training.” The robot-assisted technology was meant to shorten the learning curve for surgeons as well as minimize post-op complications typically associated with the procedure.

Repair of Enteroceles

When the loops of the small intestine dip into the pelvis, then bulge into the vagina during straining, an enterocele can occur, causing significant pain. Once the enterocele is identified, it is excised from the rectum and vagina with the wounds closed by sutures. The uterosacral ligaments are then shortened and reattached to the rear wall of the vagina. As detailed more fully in the Current Urology Reports there are four basic procedures for this surgery: The McCall culdoplasty brings the ligaments together in the midline, the Torpin technique excises a triangular part of the peritoneum and excessive vaginal vault wall closed in the middle, the Moschowitz procedure is an abdominal surgery in which sutures are placed in similar fashion to the transvaginal enterocele repair and the Halban enterocele repair closes the “cul-de-sac” by suturing the peritoneum to the posterior vaginal wall through several rows of sutures.

The Colpocleisis as an Obliterative Procedure for Apical Prolapse

Colpocleisis is an effective treatment for pelvic organ prolapse in those women who are older and do not want to preserve their vagina for sexual intercourse or for those who have had multiple failed prolapse repairs. This procedure can provide good results with little risk of death and stress urinary incontinence can also be addressed during the surgery through the use of a synthetic sling. Overall patient satisfaction for this particular surgery is over 90%. While a partial colpocleisis was performed in 1877 by Le Fort which included a closure of the front and back walls of the vagina, leaving the uterus in place, various modifications to the procedure were made through the years to reduce recurrence as well as occurrence of incontinence. This article addressed the various procedures for repair of apical prolapse.

 Pelvic Organ Prolapse|vaginal prolapse