Teory Prolaps Uteri

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Pelvic organ prolapse in women: Surgical repair of apical prolapse (uterine or vaginal
vault prolapse)
Author:
Kimberly Kenton, MD, MS, FACOG, FACS
Section Editor:
Linda Brubaker, MD, FACS, FACOG
Deputy Editor:
Kristen Eckler, MD, FACO
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Topic 8073 Version 31.0
Literature review current through: Dec 2016. | This topic last updated: Dec 19, 2016.
INTRODUCTION Apical prolapse is the descent of uterus, cervix, or vaginal vault. Pelvic
organ prolapse (POP) affects millions of women; approximately 200,000 inpatient surgical
procedures for prolapse are performed annually in the United States [1,2]. Eleven to 19
percent of women will undergo surgery for POP or incontinence by age 80 to 85 years, and
30 percent of these women will require an additional POP or incontinence surgery [3,4].
Anterior vaginal wall prolapse without concomitant apical prolapse is uncommon [5], and
apical prolapse repair should be included in the majority of pelvic reconstructive surgery
procedures.
Reconstructive procedures for prolapse of the vaginal apex are reviewed here. Evaluation of
women with POP, conservative management, and choosing a primary surgical procedure
are discussed separately. Obliterative procedures for POP (colpocleisis) are also discussed
separately. (See "Pelvic organ prolapse in women: An overview of the epidemiology, risk
factors, clinical manifestations, and management" and "Vaginal pessary treatment of
prolapse and incontinence" and "Pelvic organ prolapse in women: Choosing a primary
surgical procedure" and "Pelvic organ prolapse in women: Obliterative procedures
(colpocleisis)".)
TERMINOLOGY The International Continence Society defines apical vaginal prolapse as
any descent of the vaginal cuff scar or cervix, below a point which is 2 cm less than the total
vaginal length about the plane of the hymen [6]. The clinical significance of apical descent
that is not beyond the hymen is unclear, as half of asymptomatic women presenting for
routine gynecologic care have prolapse to the hymen [7]. Similarly, studies suggest that
prolapse becomes symptomatic when the leading edge protrudes beyond the vaginal
opening [8]. However, isolated anterior vaginal wall defects are uncommon. Therefore, if the
anterior vaginal wall protrudes beyond the hymen, the apex likely has inadequate support,
as well [5,9].
ANATOMY AND MECHANISMS OF INJURY Apical prolapse refers to the downward

displacement of the vaginal apex (figure 1). The vaginal apex is either the uterus and cervix
or, in women who have undergone subtotal or total hysterectomy, the cervix or vaginal cuff.
Support of the vaginal apex is primarily derived from the integrity of the uterosacral and
cardinal ligaments, the continuity of the endopelvic fascia, and a neuromuscularly intact
levator ani muscle (figure 2). The etiology of apical prolapse is likely related to connective
tissue, neural, and/or muscular defects in these normal supports.
It is rare to find isolated apical prolapse or isolated prolapse of the anterior or posterior
vaginal walls, since the defects in the connective tissue, neural pathways, and muscle are
not confined to one site [9,10].
The anatomy of the female pelvic floor is discussed in detail separately. (See "Pelvic organ
prolapse in women: An overview of the epidemiology, risk factors, clinical manifestations,
and management", section on 'Anatomy of pelvic support'.)
RISK FACTORS The risk factors for developing apical prolapse are generally the same
as for developing anterior or posterior vaginal wall prolapse. (See "Pelvic organ prolapse in
women: An overview of the epidemiology, risk factors, clinical manifestations, and
management", section on 'Risk factors'.)
The most common risk factors associated with apical prolapse are vaginal parity (number of
vaginal deliveries) and previous hysterectomy [11,12]. The risk of prolapse after
hysterectomy was illustrated in a case-control study in which 160,000 women who
underwent hysterectomy were significantly more likely than age-matched controls to require
subsequent pelvic floor repair (3.2 verus 2.0 percent) [13]. Women who have prolapse at the
time of hysterectomy have an even higher risk of subsequent surgery for pelvic organ
prolapse (POP). A case-control study of women who underwent hysterectomy reported that
the risk of subsequent POP repair was 5-fold in those who had a history of vaginal delivery,
8-fold in those who had prior surgery for POP or urinary incontinence, and almost 13-fold in
those who had grade 2 or higher prolapse at the time of hysterectomy [14]. Surgeons should
resuspend the vaginal apex when performing hysterectomy for nonprolapse indications to
minimize this risk.
CANDIDATES FOR APICAL PROLAPSE REPAIR Indications for apical prolapse repair
are generally the same as for other pelvic organ prolapse (POP) repair procedures, ie,
symptomatic prolapse in women who decline or fail conservative therapy and who can
tolerate surgery. Prolapse is not typically symptomatic until the vagina protrudes through the
hymen. (See "Pelvic organ prolapse in women: Choosing a primary surgical procedure",
section on 'Candidates for surgical treatment' and "Pelvic organ prolapse in women: An
overview of the epidemiology, risk factors, clinical manifestations, and management", section
on 'Clinical manifestations'.)
PREOPERATIVE EVALUATION AND PREPARATION In women planning surgical

repair of apical prolapse, surgeons should assess each vaginal compartment (apical,
anterior, and posterior) for the presence of support defects or prolapse. In addition, pelvic
organ prolapse (POP) often coexists with urinary and/or anal incontinence. During the
history and physical examination, the presence and severity of each of these disorders
should be assessed, as this information may alter surgical decision-making.
Aspects of preoperative evaluation and preparation that are specific to apical prolapse repair
are discussed in this section. General principles of evaluation of women undergoing POP
repair are discussed in detail separately. (See "Pelvic organ prolapse in women: Diagnostic
evaluation".)
Informed consent and patient goals Surgeons should discuss with each woman the
pelvic symptoms that are bothersome to her and their effects on her quality of life. This helps
to set realistic goals for reconstructive surgery and assess postoperative improvement.
Patient satisfaction after surgery for POP and urinary incontinence correlates highly with
achievement of self-described preoperative surgical goals, but poorly with objective outcome
measures [15-17].
Informed consent for repair of apical prolapse should include a discussion of the risk of
persistent or recurrent prolapse at the apex, anterior, or posterior vaginal walls. Since some
women develop stress urinary incontinence (SUI) following apical prolapse repair, surgeons
should also discuss the risk of developing incontinence, as well as the risks and benefits of
performing a prophylactic incontinence procedure versus deferring an incontinence
procedure until symptoms develop. (See 'Evaluation of urinary dysfunction' below.)
Other important items to discuss with women planning apical POP surgery include potential
postoperative changes in sexual function and mesh-related complications if mesh will be
used for the repair. In our practice, we counsel all women undergoing pelvic surgery that
there is a risk of postoperative dyspareunia. (See "Overview of transvaginal placement of
mesh for prolapse and stress urinary incontinence", section on 'Complications'.)
History The most common clinical manifestation of prolapse of the vaginal apex is a
bulge or protrusion from the vagina (picture 1). Protrusion of the vagina may result in vaginal
discharge and/or bleeding from ulceration. Other symptoms commonly reported by women
with apical prolapse are voiding difficulty and constipation; some women need to reduce the
prolapse using a finger in the vagina (ie, splint) to urinate or defecate.
Women with advanced anterior or posterior vaginal wall prolapse may have similar
symptoms and pelvic examination is needed to ascertain the site(s) and stage of prolapse.
Investigators demonstrated that restoration of the vaginal apex during prolapse examination
fixes anterior vaginal wall defects 50 percent of the time and posterior vaginal wall defects
30 percent of the time [18].
Physical examination A thorough speculum and bimanual pelvic examination are

performed. We perform apical prolapse assessment initially with the woman standing and
straining. Each vaginal compartment (apical, anterior, and posterior) should then be
examined with the women supine. The apical prolapse can be visualized during speculum
examination with the woman straining as the speculum is slowly withdrawn from the upper
third of the vagina. In some women with advanced apical prolapse, protrusion of the apex is
visible at or beyond the vaginal introitus before the speculum is inserted (picture 1).
Since isolated apical prolapse is rare, careful assessment of the anterior and posterior wall is
important [9].
The findings of the examination should be recorded using a quantitative and reproducible
method for recording POP. The system currently recommended by the International
Continence Society and the American Urogynecologic Society is the pelvic organ prolapse
quantitation (POP-Q) system (figure 3 and figure 4) [19]. (See "Pelvic organ prolapse in
women: Diagnostic evaluation", section on 'Speculum and bimanual examination'.)
Evaluation of urinary dysfunction Apical prolapse frequently coexists with urinary

incontinence or urinary retention, and women planning apical prolapse repair should be
evaluated for these conditions.
Urinary incontinence Women with symptoms of both POP and SUI are treated with a
combined prolapse repair and continence procedure. Women with POP but no SUI
symptoms are challenging because they can have stage II or greater apical prolapse and
remain continent despite loss of anterior vaginal and bladder/urethral support but then
become incontinent after POP repair. Studies have reported 13 to 65 percent of continent
women develop symptoms of stress incontinence after surgical correction of the prolapse
[7,20-22]. This likely occurs because the prolapse kinks and obstructs the urethra; this
obstruction is alleviated when the prolapse is repaired. This is referred to as "occult" or
"potential" stress incontinence. Women with stage I POP are unlikely to have urethral
obstruction and resultant occult stress incontinence [7,20-22].
To detect occult incontinence, we perform a preoperative evaluation for occult stress

incontinence during which the prolapse is reduced. Stress testing can be done via a basic
office evaluation with full-bladder cough stress test or urodynamic testing.
(See "Perioperative patient care issues in urogynecology", section on 'Urodynamic studies'.)
While we perform preoperative evaluation for occult SUI, we recognize that the ability of
preoperative prolapse reduction testing to predict postoperative urinary incontinence is
limited. In study of stress-continent women undergoing preoperative urodynamic testing prior
to sacrocolpopexy, nearly 4 percent of women had urodynamic stress incontinence when the
prolapse was not reduced, which increased to 27 percent of women with prolapse reduction
[23]. When all methods of prolapse reduction were combined, the positive and negative
predictive values of preoperative prolapse reduction stress testing were 37 and 80 percent,
respectively. While the positive predictive value of preoperative reduction stress tests is low,
it appears to be helpful in surgical planning. In a multicenter trial of continent women
undergoing vaginal prolapse repair who were randomly assigned to concomitant midurethral
sling or sham incision, women with a positive cough stress test had more benefit from
prophylactic sling than those without a positive stress test [24]. (See "Pelvic organ prolapse
and stress urinary incontinence in women: Combined surgical treatment", section on
'Detecting occult incontinence'.)
For continent women with stage II or greater POP who undergo abdominal sacral colpopexy,
high quality data indicate that bothersome stress incontinence is less likely to develop in
women who undergo a concomitant Burch colposuspension rather than sacral colpopexy
alone. While there are fewer data regarding prophylactic surgery for stress incontinence in
women undergoing transvaginal apical prolapse repair, it appears such preventive surgery is
safe and effective in this population. Combined surgery for POP and SUI is discussed in
detail separately. (See "Pelvic organ prolapse and stress urinary incontinence in women:
Combined surgical treatment", section on 'POP with no symptoms of SUI'.)
Urinary retention Urinary retention is evaluated by measuring a postvoid residual urine

volume (PVR) within 10 minutes after the patient has voided. In general, a PVR of less than
50 mL is considered adequate emptying, and a PVR greater than 200 mL is considered
inadequate. An elevated preoperative PVR normalizes after surgical correction of prolapse in
over 90 percent of women [25,26].
Evaluation of defecatory dysfunction Women with POP should be asked about

symptoms of defecatory dysfunction (eg, constipation, the need to place pressure on, or
splint, the posterior vaginal wall to defecate, anal incontinence). Such symptoms should be
evaluated prior to surgery, as appropriate. (See "Pelvic organ prolapse in women: An
overview of the epidemiology, risk factors, clinical manifestations, and management", section
on 'Defecatory symptoms' and "Fecal incontinence in adults: Etiology and evaluation".)
SURGICAL PLANNING When planning surgery for quality of life disorders, such as
apical prolapse, factors beyond simple anatomic outcomes are discussed by each woman
with her surgeon. Such factors include the woman's goals for surgery, concerns for symptom
recurrence and reoperation, ability to tolerate surgery, preferences regarding recovery time
and complication profile of each surgery, and concerns regarding sexual function (algorithm
1). Key issues for discussion include the choice of surgical route (abdominal open,
laparoscopic, robotic or vaginal) and the risks and benefits of that route, the need for repair
of other pelvic defects, and the presence of urinary incontinence. In addition, women
undergoing intraperitoneal surgery must further decide if they desire hysterectomy as part of
the repair, elective or risk-reducing bilateral salpingo-oophorectomy, or prophylactic
salpingectomy for ovarian cancer risk reduction. (See "Pelvic organ prolapse in women:
Choosing a primary surgical procedure", section on 'Concomitant
hysterectomy' and "Opportunistic salpingectomy for ovarian, fallopian tubal, and peritoneal
carcinoma risk reduction", section on 'Opportunistic salpingectomy'.)
Issues specific to planning repair of apical prolapse are discussed in this section. General
principles of surgical decision-making regarding pelvic organ prolapse (POP) (eg, obliterative
versus reconstructive surgery) are discussed separately. (See "Pelvic organ prolapse in
women: Choosing a primary surgical procedure", section on 'Candidates for surgical
treatment'.)
Abdominal versus vaginal approach To repair apical vaginal prolapse, the surgeon
must decide between abdominal or vaginal surgical routes. Data suggest that abdominal
surgery, typically with an open abdominal sacral colpopexy (ASC), provides better objective
anatomic outcomes than vaginal apical support procedures for most women [27,28].
However, vaginal procedures are a reasonable alternative because of similar rates of
postoperative prolapse symptoms, reoperation, and adverse events compared with ASC
[27,28]. The uterus or fallopian tubes can be removed by either route. While the majority of
studies on ASC outcomes used an open technique, laparoscopic and robot-assisted
approaches are now more commonly performed. Laparoscopic and robotic approaches
appear to offer the improved vaginal support associated with open procedures and the
shorter recovery of vaginal procedures. One trial of 112 women randomly assigned to
laparoscopic or open abdominal sacrocolpopexy reported no difference between the
procedures for recurrence of apical prolapse (none in either group), surgical complications,
or mesh exposures at a mean of 41 months of follow-up, although there were significantly
more anterior compartment recurrences in the laparoscopic group compared with the
abdominal group (18 versus 2 percent) [29]. None of the women with recurrent prolapse had
symptoms or required repeat surgery.
Women who benefit from abdominal repair ASC appears to provide improved
anatomic support without a large increase in morbidity compared with vaginal repairs.
Therefore, ASC may be more appropriate for women with risk factors for prolapse
recurrence, including young age, obesity, stage III or IV POP, prone to high-impact activities
or heavy lifting, and previous failed POP repair [30-33]. Rare risk factors for recurrent
prolapse are bladder exstrophy or spina bifida [34,35]. Other reasons to choose an
abdominal approach include insufficient vaginal length for transvaginal repair or other
indications for abdominal surgery (eg, ovarian cystectomy).
Women who benefit from vaginal repair Transvaginal apical repair benefits women
who do not want the risk associated with abdominal procedures; in addition, native tissue
vaginal repairs do not include use of mesh or graft materials often associated with foreign
body complications. Transvaginal surgery is performed in 80 to 90 percent of prolapse
surgeries in the United States [2,3,36]. This may be secondary to the minimally invasive
nature of vaginal surgery and the ease of addressing the anterior and posterior
compartments more easily at the time of vaginal surgery; however, outcome data after ASC
suggest that simply addressing the apex often corrects both anterior and posterior defects as
well. In addition, vaginal surgery has a shorter operative duration and recovery compared
with open abdominal sacral colpopexy. For these reasons, it is often selected by women with
increased surgical risk or who place a high priority on avoiding an abdominal incision. Lastly,
native tissue vaginal repair eliminates the risk factors for mesh-related complications
associated with abdominal support procedures or vaginal mesh procedures. The elimination
of mesh-related complications can be particularly important in women at higher risk of mesh
or graft erosion (eg, women who smoke or are immunosuppressed). (See "Management of
transvaginal mesh exposure and pain following pelvic surgery".)
Surgical comparators The majority of outcome data comes from studies comparing ASC
and sacrospinous ligament suspension (SSLS). Additional vaginal procedures can include
uterosacral ligament suspension and iliococcygeus suspension.
Anatomic outcome: ASC is associated with improved objective anatomic support

compared with vaginal prolapse repairs, mainly SSLS. In two systematic reviews and
meta-analyses that defined anatomic failure as Stage 2 prolapse, postoperative
anatomic success was more likely with ASC compared with vaginal repairs (failure rate
6 versus 20 percent, relative risk [RR] 0.29, 95% CI 0.09-0.97 [27] and odds ratio [OR]
for success 2.04, 95% CI 1.12-3.27 [28]). There was some, but not complete, overlap in
the studies selected by the two reviews.
Postoperative prolapse symptoms: While ASC may have improved objective anatomic
support, postoperative prolapse symptoms are similar for ASC compared with SSLS. A
meta-analysis of three trials reported a statistically insignificant trend toward lower risk
of postoperative prolapse symptoms for ASC compared with vaginal repairs (RR 0.53,
95% CI 0.25 to 1.09, n = 169 women) [27].
Reoperation rates: Reoperation rates appear similar between ASC and SSLS. One
meta-analysis reported a statistically insignificant lower reoperation rate for ASC
compared with SSLS (7 versus 16 percent, RR 1.46, 95% CI 0.19-1.11, n = 169). A
different meta-analysis reported no difference in reoperation rates between ASC with
mesh compared with a combined group of native tissue vaginal repairs, although the
data were limited by small sample size, short duration of follow-up, and a combination
of surgical procedures [28].
Complication rates: While a definitive conclusion regarding complication rates
between abdominal and vaginal repairs is limited by study heterogeneity, surgical
heterogeneity, and inconsistent reporting of adverse events, there does not appear to
be a difference in overall complication rates between the two approaches. In a meta-
analysis of 100 trials and studies (n = 13,466 women) that addressed the severity of
complications in ASC and native tissue transvaginal apical suspension procedures,
total complication rates were similar for abdominal compared with vaginal procedures
(complication rate 17.1 percent [CI 16.1-18.1] for abdominal procedures versus 15.3
percent [CI 14.7-16.3] for vaginal procedures) [37]. A systematic review and meta-
analysis of 79 studies reported that total complication rates were similar for the vaginal
and abdominal approaches, but bowel and mesh complications were more common
with ASC than the combined group of vaginal repairs [28].
Risk of mesh or suture complications: Native tissue vaginal prolapse repairs do not
use synthetic mesh, and therefore cannot have mesh-related complications. Suture
complications can occur with either procedure. A meta-analysis of trials and cohort
studies reported more mesh or suture complications after ASC than a combined group
of vaginal procedures (OR 3.26, 95% CI 1.62-6.56) [28]. (See "Overview of transvaginal
placement of mesh for prolapse and stress urinary incontinence", section on
'Complications'.)
Risk of postoperative dyspareunia: The conflicting results among trials and meta-
analyses suggest that a large difference in postoperative dyspareunia rates is unlikely.
As an example, in a meta-analysis of three randomized trials, postoperative
dyspareunia was less likely in women who underwent ASC compared with SSLS (RR
0.39, 95% CI 0.18-0.86, n = 106 women) [27]. In contrast, a different meta-analysis
reported no difference in dyspareunia in two trials and two cohort studies between the
surgical approaches [28], yet also included one trial that reported a decreased rate of
dyspareunia with ASC compared with vaginal repair [38].
Length of surgery: Comparison of surgical operating time between vaginal and
abdominal procedures varies based on type of abdominal approach (open,
laparoscopic, and robot-assisted). In a meta-analysis of three trials, ASC was
associated with longer operating time (an average of 21 minutes longer), longer
recovery time (an average of eight days longer), and greater expense [27]. In contrast,
a different meta-analysis of three trials and three cohort studies reported no difference
in hospital length of stay between the abdominal and vaginal approaches, but the data
were limited.
While the majority of studies have compared ASC with SSLS, other transvaginal apical
support procedures have been assessed as well. Studies comparing high uterosacral
ligament suspension [39] and iliococcygeus suspension [40] with ASC suggest similar
outcomes to the SSLS data. While the sample size and duration of follow-up are limited in
these studies, these procedures are established apical support surgeries and are reasonable
alternatives to SSLS in women who wish to avoid abdominal surgery or the risk of pudendal
nerve and vascular injury associated with SSLS. (See 'Uterosacral ligament
suspension' below and 'Iliococcygeus suspension' below.)
Concomitant repair of other sites of prolapse Apical prolapse almost always coexists
with other sites of POP (anterior or posterior). It is controversial whether repair of apical
prolapse is sufficient to support the anterior and posterior vaginal walls or if additional
procedures are required to address anterior and/or posterior prolapse. If the vaginal
muscularis is well suspended at the apex, many anterior and posterior defects will also
resolve; conversely, correction of anterior or posterior prolapse does not repair apical
descent. Anterior vaginal wall prolapse, in particular, is highly correlated with apical
prolapse. The approach to concomitant repair of multiple sites of prolapse varies by surgical
route and by site of prolapse. A detailed discussion of the concomitant repair of multiple sites
of prolapse can be found separately. (See "Pelvic organ prolapse in women: Choosing a
primary surgical procedure", section on 'Concomitant repair of apical and anterior or
posterior prolapse'.)
Concomitant surgery for stress urinary incontinence Many women with apical
prolapse have coexisting urinary incontinence, as noted above. (See 'Evaluation of urinary
dysfunction' above.)
Burch colposuspension performed concurrently with abdominal sacral colpopexy is

discussed below. (See 'Concomitant Burch colposuspension' below.)
Women with symptomatic urinary incontinence Women with symptoms of both POP
and stress incontinence are treated with a combined prolapse repair and continence
procedure. (See "Pelvic organ prolapse and stress urinary incontinence in women:
Combined surgical treatment", section on 'Symptomatic prolapse and incontinence'.)
Women at risk for occult urinary incontinence For women with stage II or greater POP
who are undergoing abdominal sacral colpopexy, high quality data support a concomitant
Burch colposuspension rather than sacral colpopexy alone. For continent women
undergoing transvaginal prolapse repair, the decision of whether to perform a concomitant
midurethral sling depends upon patient preference regarding the risk of developing stress
urinary incontinence (SUI) compared with the risk of perioperative complications.
Combined surgery for POP and stress incontinence is discussed in detail separately.
(See "Pelvic organ prolapse and stress urinary incontinence in women: Combined surgical
treatment", section on 'POP with no symptoms of SUI' and "Pelvic organ prolapse and stress
urinary incontinence in women: Combined surgical treatment", section on 'Summary and
recommendations'.)
EVALUATING APICAL PROLAPSE PROCEDURES Surgical outcomes of pelvic organ

prolapse (POP) treatments have ranged over the years from patients reports that they are
happy or cured to strict anatomic criteria for cure regardless of patient satisfaction.
Improvement in objectively measured outcomes after surgery do not always correspond to
patient satisfaction [15,16]. More recently, experts agree that outcomes literature should
include both a measure of subjective cure (based upon the patient's report of cure or
improvement) and a measure of objective cure using a validated POP measuring system. A
study looked at cure rates using a variety of anatomic and subjective definitions in a cohort
of women two years after abdominal sacral colpopexy [41]. Reported cure rates range
widely, from 19 percent to 97 percent, depending on the definition used with patient reports
of no bulge beyond the hymen being most associated patients own assessment of
improvement. These data should not be over-interpreted to mean objective outcomes are
not valuable, as the follow-up period in this study was short (only two years) and anatomic
outcomes tend to worsen over time.
ABDOMINAL SACRAL COLPOPEXY Abdominal repair of apical prolapse is performed

by securing the anterior and posterior vaginal walls via surgical mesh to the anterior
longitudinal sacral ligament just below the sacral promontory (figure 5). This reestablishes a
nearly horizontal vaginal axis [42]. The ventral abdominal wall and round ligaments should
never be used because of the high risk of recurrent prolapse.
Abdominal sacral colpopexy (attachment between the sacral promontory and the vagina
vault in women who have undergone total hysterectomy) is the most commonly performed
procedure. Uterine or cervix sparing procedures include: sacral hysteropexy (attachment
between the sacral promontory and the lower uterus) and sacral cervicopexy (attachment
between the sacral promontory and the cervix).
Typically, a hysterectomy is done at the time of apical pelvic organ prolapse (POP) repair in
women with uterovaginal prolapse. While no prospective comparative studies are available
to determine if outcomes are improved with concomitant hysterectomy, several small studies
suggest that POP outcomes are not worse and operating times are shorter with uterine
preservation [43-45]. A retrospective cohort study compared three groups (hysterectomy
plus sacral colpopexy, sacral hysteropexy, and hysterectomy plus uterosacral suspension)
and showed a six-fold increase in POP recurrence in the uterosacral suspension group [46].
Concomitant hysterectomy at the time of prolapse repair is discussed in detail separately.

(See "Pelvic organ prolapse in women: Choosing a primary surgical procedure", section on
'Concomitant hysterectomy'.)
Procedure Open abdominal sacral colpopexy is performed through a lower abdominal

incision, typically a Pfannenstiel, although there are increasing numbers of sacral
colpopexies being done laparoscopically or with robotic-assisted laparoscopic procedures
secondary to decreased recovery times and equivalent prolapse outcomes.
A commonly performed technique is to attach a permanent mesh to the posterior vagina to

the level of the rectal reflection and to the anterior vagina for a distance of 4 cm, or just
above the bladder trigone. It is acceptable to use a mesh fashioned into a Y configuration or
to use two separate strips of mesh. Alternatively, the posterior mesh may extend to the
perineal body, adding support to this area (sacral colpoperineopexy). Two rows of sutures
are then used to widely attach the mesh to the vagina to distribute the tension; the sutures
should approximate the mesh to the vaginal walls for a distance of several centimeters.
Permanent sutures are typically used to attach the mesh to the vagina and sacrum.
Secondary to concern about vaginal erosion of permanent sutures, some surgeons are
starting to use delayed absorbable sutures. In the Colpopexy and Urinary Reduction Efforts
(CARE) trial (a randomized trial that compared abdominal sacral colpopexy with and without
Burch colposuspension) of 322 women undergoing abdominal sacral colpopexy with
permanent sutures, only three participants had a vaginal erosion of the permanent suture in
the first two years after surgery [47]. The suture was simply removed in all three patients;
two healed without further problem, and the other was lost to follow-up. Given the lack of
high quality data supporting comparable anatomic and/or symptomatic outcomes with use of
delayed absorbable sutures and the minimal risks associated with permanent suture,
patients should be counseled appropriately if nonpermanent sutures are used.
Failure to attach the mesh anteriorly results in anterior vaginal wall recurrence rates of
almost 30 percent [48]. The optimal approach for posterior vaginal wall attachment is
unclear; however, simply attaching the mesh to the rectovaginal septum to maintain
continuity with the perineal body results in high success rates [49]. The mesh erosion rates
reported from abdominovaginal attachment of the mesh to the perineal body have varied
widely (7 to 40 percent) [50,51].
After exposing the presacral space, the free end of the mesh is attached to the anterior
longitudinal ligament just below the sacral promontory using two or three nonbraided
permanent sutures.
Avoiding presacral hemorrhage Laceration of the presacral venous plexus leads to

profuse hemorrhage. Careful dissection must be used near the sacrum. The sutures are
placed through the sacral (anterior longitudinal) ligament just below the sacral promontory
since placement lower on the sacrum, at the S3 to S4 level, is more likely to result in
presacral hemorrhage. Additionally, suture placement on the promontory may deviate the
vaginal axis too far forward or result in discitis.
Choosing a surgical mesh Simple suturing of the apical vaginal skin to the sacrum is
also regarded as insufficient fixation and likely to result in recurrent prolapse. The best type
of mesh and suture material remains controversial, but most surgeons agree that synthetic
nonabsorbable materials should be used. Synthetic mesh sacral colpopexy has consistently
outperformed the biologic graft materials (autologous, allogeneic, xenograft) in randomized
trials, but at the expense of higher mesh erosion rates [42,52,53]. In a systematic review of
65 studies (three were randomized trials), the average rate of synthetic mesh erosion was
3.4 percent, the lowest rate was for polypropylene (0.5 percent) compared with other types
of synthetic mesh, such as polyethylene or polytetrafluoroethylene (3.1 to 5.0 percent) [52].
On rare occasions, a surgeon may also face an intraoperative decision on whether to use
synthetic or biologic mesh in the face of a bowel injury or concomitant sigmoid resection with
reanastomosis for the treatment of rectal prolapse. Since it is often not advisable to place
synthetic nonabsorbable materials during procedures contaminated by bowel contents,
these choices should be determined by carefully weighing the risk and benefits for an
individual patient.
Surgical treatment of prolapse of the vaginal apex with vaginal mesh kits is increasingly
common, although outcome data are lacking [54]. Similar to anterior vaginal mesh
placement, use of apical vaginal mesh may be associated with significant complications
[37,55].
Outcome A systematic review of studies from 1966 to 2004 reported that anatomic
success rates after abdominal sacral colpopexy range from 76 to 100 percent with a 4
percent (range 0 to 18 percent) reoperation rate for prolapse [52].
The need for concomitant anterior or posterior vaginal wall repairs at the time of sacral
colpopexy is controversial. This topic is discussed in detail separately. (See "Pelvic organ
prolapse in women: Choosing a primary surgical procedure", section on 'Abdominal route'.)
One-year outcomes of the CARE trial showed that abdominal sacral colpopexy performed
with or without posterior vaginal wall repair resulted in statistically and clinically significant
improvements in bowel symptoms, including obstructive defecation and posterior vaginal
wall topography regardless of concomitant posterior repair [8]. Likewise, there was no
difference in anterior vaginal wall support in women who had a concomitant paravaginal
repair and those who did not. Another study of 149 women with advanced prolapse who
underwent sacral colpopexy without any concomitant repairs demonstrated excellent
anatomic outcomes one year after surgery [56].
Two-year outcomes of the CARE trial showed that 95 percent of women had support of the
vaginal apex within 2 cm of the total vaginal length and 3 percent had undergone
reoperation for prolapse [57]. Women reported significant improvement in pelvic floor
symptoms and sexual function using validated questionnaires. In addition, correction of
apical prolapse via abdominal sacral colpopexy with or without Burch colposuspension
significantly reduced bladder symptoms other than incontinence, both irritative (eg, urgency,
frequency, nocturia) and obstructive (eg, intermittent flow, straining to void, sensation of
incomplete emptying, poor stream) [58]. At one-year, participants reported a significant
decrease in obstructive defecatory symptoms, fecal incontinence and anorectal pain [8].
New onset fecal incontinence with activity, as well as pain prior to and with defecation, were
more likely to be reported by women who had a concomitant posterior repair procedure than
by those who did not.
Seven-year outcomes of the CARE trial showed that the estimated probabilities of treatment
failure for the urethropexy group and the no urethropexy group, respectively, were 0.27 and
0.22 for anatomic POP and 0.29 and 0.24 for symptomatic POP [59].
Mesh exposure/erosion probability at seven years was 10.5 percent; however, approximately
half of the synthetic mesh inserts were older multifilament products with known higher risk of
exposure. Long-term studies report that, at 10 to 14 years after abdominal sacral colpopexy,
2 to 26 percent of women had undergone reoperation for prolapse [60].
Complications The most frequently reported intraoperative and postoperative

complications of open abdominal sacral colpopexy include [52]:
Incisional problems - 4.6 percent

Blood transfusion - 4.4 percent
Ileus - 3.6 percent
Thromboembolic event - 3.3 percent
Cystotomy - 3.1 percent
Enterotomy - 1.6 percent
Studies consistently report that gastrointestinal complications, such as small bowel

obstruction or ileus, occur after approximately 0.1 to 5 percent of abdominal sacral
colpopexy procedures [52,61,62]. In the CARE trial, 4 of 322 women required reoperation for
small bowel obstruction and all were associated with incisional problems. No intraoperative
bowel injuries were reported [61].
Presacral hemorrhage is the most concerning intraoperative complication and can have life-
threatening consequences. Reconstructive surgeons should be prepared to manage
presacral hemorrhage and have bone wax, concave thumbtacks, and thrombin immediately
available. (See "Management of hemorrhage in gynecologic surgery" and "Management of
hemorrhage in gynecologic surgery", section on 'Presacral bleeding'.)
Mesh erosion rates vary depending on the type of mesh used. Synthetic nonabsorbable
mesh is typically used and, as noted above, a systemic review found that the average rate of
erosion for all types of synthetic mesh was 3.4 percent, with a rate of 0.5 percent for
polypropylene mesh [52]. (See 'Choosing a surgical mesh' above.)
Several studies report higher mesh erosion rates when sacral colpopexy is performed with
concomitant total hysterectomy, but this is not universally reported [47,63]. In a large
multicenter study of women undergoing abdominal sacral colpopexy, concomitant total
hysterectomy was more common in women who developed a mesh or suture erosion (60
percent versus 24 percent), resulting in a nearly five-fold increased risk of mesh erosion in
women with a concomitant hysterectomy [47]. Some data suggest that smoking and use of
ePTFE mesh (Gore-Tex) are also risk factors for mesh erosion following sacral colpopexy
[47,64].
Laparoscopic or robotic procedures Sacral colpopexy is traditionally performed

through a laparotomy; however, conventional and robot-assisted laparoscopic approaches
have gained popularity. In addition, single port laparoscopic procedures have been reported
[65]. (See "Robot-assisted laparoscopy" and "Abdominal access techniques used in
laparoscopic surgery", section on 'Single-incision surgery (SIS)'.)
Data suggest that the conventional laparoscopic and robot-assisted routes result in a shorter
hospital stay (eg, one to two versus three to four days), faster time to recovery, and less
postoperative pain than laparotomy, with comparable short-term efficacy [37,66-70]. Some
retrospective studies have also found a significant decrease in blood loss (eg, 60 to 150 mL
less) with laparoscopic procedures [66,68]. A disadvantage of laparoscopic procedures is a
longer operative duration (eg, one to two hours longer). In addition, robotic procedures are
more costly than laparotomy or conventional laparoscopy [71,72]. A United Kingdom
multicenter randomized equivalence trial compared open to laparoscopic sacral colpopexy.
At one year, there were no differences in anatomic or subjective pelvic floor outcomes;
however, blood loss, postoperative hemoglobin values, and hospital stay were better in the
laparoscopic arm [73]. Many surgeons have adopted a higher sacral fixation point when
performing laparoscopic and robotic procedures. Case reports of vertebral discitis [74] and
cadaveric and magnetic resonance imaging studies suggest that to avoid disc complications,
sutures should be placed inferior to the promontory to avoid the intravertebral disc [75,76].
Performing sacral colpopexy requires suturing, which is more difficult to do with conventional
than during robot-assisted laparoscopy. For this reason, some surgeons prefer robotic-
assisted laparoscopy. However, two randomized trials have found that robotic compared
with conventional laparoscopic sacral colpopexy has a longer operative duration (24 to 67
minutes longer) and higher costs, with similar complication rates and short-term outcomes
[77,78].
Although further studies are necessary to ascertain the role for robotic versus laparoscopic
sacral colpopexy, current data suggest that the laparoscopic route may be more cost
effective and confer some benefits to the patients.
CONCOMITANT BURCH COLPOSUSPENSION Burch colposuspension (also referred to

as retropubic urethropexy) is an effective procedure for the treatment and prevention of
stress urinary incontinence (SUI). This procedure had been widely used, but has now been
largely replaced by midurethral sling procedures. This is due to the increased operative
duration and risk of complications for a Burch procedure compared with a midurethral sling.
(See "Surgical management of stress urinary incontinence in women: Choosing a primary
surgical procedure", section on 'Midurethral slings versus other procedures'.)
In current practice, Burch colposuspension is typically performed mostly in combination with
an abdominal sacrocolpopexy in women with symptomatic SUI or as a prophylactic
procedure in women with advanced prolapse who are likely to develop SUI after sacral
colpopexy. The two procedures are both performed via an abdominal incision, and thus,
traditionally have been done together. However, some surgeons prefer to perform a
midurethral sling procedure even for women undergoing abdominal sacral colpopexy.
Combined prolapse and continence surgery and choice of a concomitant procedure are
discussed in detail separately. (See "Pelvic organ prolapse and stress urinary incontinence
in women: Combined surgical treatment" and "Surgical management of stress urinary
incontinence in women: Choosing a primary surgical procedure", section on 'Coexistant
anatomic or functional abnormality'.)
Indications and preoperative evaluation The Burch colposuspension is indicated for

women planning surgical treatment of SUI, and for women who prefer this procedure to other
types of surgery. Burch colposuspension is intended to support the bladder neck and
proximal urethra to prevent downward descent of these structures and to allow for urethral
compression; therefore, it is not an appropriate operative choice for women without urethral
hypermobility.
The preoperative evaluation of women prior to a Burch procedure is the same as for other
surgical treatments for SUI. (See "Surgical management of stress urinary incontinence in
women: Preoperative evaluation for a primary procedure".)
Outcome Burch colposuspension is an effective procedure for the treatment of SUI.

Randomized trial data show that the long-term success rate is comparable or slightly lower
than for midurethral slings (70 versus 63 percent in one trial [79]) or fascial slings (24 versus
31 percent in one trial [80,81]). The success rates reported in these trials represent a
rigorous composite measure of several endpoints (subjective and objective outcomes).
Patient satisfaction rates after both procedures are much higher, approaching 80 percent.
Many trials evaluating continence procedures exclude women who are undergoing
concomitant prolapse repair. The only trial to evaluate Burch procedures that included
concurrent prolapse repair procedures was the Stress Incontinence Surgical Treatment
Efficacy Trial (SISTEr) [80,81]. The SISTEr trial assigned 655 women at 9 United States
sites with SUI to undergo Burch colposuspension or a rectus fascial sling procedure. Forty-
eight percent of women in the Burch arm underwent concomitant prolapse repair, including
apical suspension and/or anterior and posterior repair. Using a stringent composite outcome,
overall success at 24 months was significantly lower after Burch colposuspension (38 versus
47 percent), although satisfaction was considerably higher at 78 percent (86 percent in sling
arm). By five years after surgery, overall continence rates decreased and remained
significantly lower in the Burch arm than in the sling arm (24 versus 31 percent). No high
quality data exist comparing Burch colposuspension to midurethral sling in women with
prolapse. Forty-eight percent of women assigned to Burch and 55 percent to sling underwent
concomitant prolapse surgery, including anterior repairs, vaginal and abdominal apical
suspension procedures, and hysterectomy. Continence outcomes did not differ based on
concomitant prolapse surgery. There was no clinically or statistically significant interaction
between concomitant surgery and incontinence outcomes in either arm [80].
Burch colposuspension is also safe and effective for the prevention of SUI in women
undergoing abdominal sacral colpopexy for apical prolapse. This was demonstrated in the
Colpopexy and Urinary Reduction Efforts (CARE) trial, which is described in detail
separately. (See "Pelvic organ prolapse and stress urinary incontinence in women:
Combined surgical treatment", section on 'Abdominal approach'.)
Procedure Burch colposuspension is most commonly performed through a low

transverse abdominal incision; it may also be performed laparoscopically.
Regardless of route of access, in a Burch colposuspension, the avascular retropubic space

is exposed bilaterally and the bladder mobilized from the pubic symphysis. With the
surgeons nondominant hand in the vagina elevating the anterior vaginal wall, two sutures
are placed near full-thickness through the anterior vagina on either side of the midurethra
(figure 6 and figure 7 and figure 8). Two additional sutures are placed through the vagina on
either side of the urethrovesical junction. All sutures are then placed through Coopers
ligament with the midurethral sutures medial on the ligament to the urethrovesical junction
sutures. The suture arms are tied above Coopers ligament so the urethrovesical junction is
supported; there should generally be an approximately 2 cm suture bridge between the
vagina and Coopers ligament to prevent over-correction of the urethrovesical junction and
urinary retention. Intraoperative cystoscopy should be performed after procedure to ensure
no sutures were placed into the bladder and bilateral brisk efflux of urine.
Laparoscopic route Burch colposuspension can be performed laparoscopically. There is

no difference in efficacy between the open and laparoscopic approaches to the Burch
procedure, but laparoscopic procedures have somewhat lower complication rates [82,83].
We suggest laparoscopic rather than open Burch colposuspension. However, routine use of
the laparoscopic Burch procedure is limited by the availability of surgeons with the
appropriate skills. Thus, open colposuspension should be performed if the surgeon is not
experienced in the laparoscopic technique for this procedure.
Open and laparoscopic Burch colposuspension were compared in a meta-analysis of 10

randomized trials [84]. Short-term subjective cure rates for laparoscopic compared with open
Burch colposuspension were similar (at 18-month follow-up: 78 versus 83 percent, RR 1.0,
95% CI 0.9-1.0) [84]. The lower rate of perioperative complications (eg, infection,
hemorrhage) for laparoscopic procedures just reached statistical significance (15 versus 18
percent, RR 0.74, 95% CI 0.58-0.96). Laparoscopic procedures were an average of 14
minutes longer. The main advantages of the laparoscopic approach were a shorter hospital
stay (an average of one day) and a faster return to normal activity (10 days sooner). The
long-term effectiveness of open Burch colposuspension ranges from 70 to 90 percent at 5 to
10 years following surgery [85-87].
Data also suggest similar outcomes after laparoscopic Burch compared with midurethral
sling procedures. One randomized trial reported incontinence rates of 58 and 48 percent four
to eight years after laparoscopic Burch colposuspension or midurethral sling [88].
When using this approach, some surgeons modify the technique to use mesh and tackers
rather than suturing, which can result in significant morbidity [89]. Given the paucity of
outcome data and morbidity using these modifications, we do not modify the procedure this
way in our practice.
Complications
Voiding dysfunction and urgency incontinence Historically, Burch colposuspension

was associated with high rates of de novo voiding dysfunction and urgency urinary
incontinence. However, well designed studies have reported low complication rates. In the
SISTEr randomized trial, postoperative urinary function complications included: prolonged
voiding dysfunction (2 percent) and new onset urgency incontinence (3 percent) [80]. In
another randomized trial, there was no significant difference in the rate of voiding
dysfunction in women who underwent Burch compared with a midurethral sling procedure
[90]. For Burch, the proportion of women who required catheterization at six-month follow-up
was 8 percent, which was higher than in the SISTEr trial, but this decreased with time. Two
years after surgery, 2.4 percent of women required intermittent self catheterization.
Urinary tract infection Postoperative urinary tract infection is the most commonly
reported adverse event following a Burch procedure, 32 to 50 percent in randomized trials
[80,90]. The incidence of cystitis or symptoms of urinary tract infection (with or without
positive culture) is highest in the first 6 months, but this issue persists in 2 to 9 percent of
women up to 24 months after surgery [91].
Apical prolapse Early reports suggested rates of enterocele of up to 17 percent following

Burch colposuspension [92,93]. This is thought to occur as a result of the more anterior
angulation of the vagina as a result of the procedure, allowing the posterior compartment to
become more subject to the pressure transmission of intraabdominal pressure. As an
example, in one study, nearly 5 percent of women with stage II prolapse required
reoperation rate for prolapse [90]. On physical examination, the rate of women with apical
prolapse increased from 21 percent preoperatively to 63 percent at 24 months; 18 percent of
the women with prolapse were symptomatic. Of course, this study did not include women
who underwent concomitant apical prolapse repair.
Other complications Additional adverse events reported in women who underwent the
Burch colposuspension include: incidental cystotomy (3 percent), surgical wound
complications requiring surgery (2.4 percent), recurrent cystitis leading to diagnostic
cystoscopy (1.5 percent), bleeding (1 percent), ureteral injury (1 percent), incidental
vaginotomy (0.5 percent), ureteral vaginal fistula (0.5 percent), erosion of suture into the
bladder (0.5 percent), and pyelonephritis (0.5 percent) [80].
Summary
Burch colposuspension is a safe, effective treatment for SUI in women with and
without concomitant pelvic organ prolapse (POP).
Open and laparoscopic Burch colposuspension result in similar subjective and
objective outcomes for the treatment of SUI in women.
Open and laparoscopic Burch colposuspension result in similar outcomes to
retropubic midurethral sling procedures.
Burch colposuspension should be considered for the prevention of SUI in stress
continent women undergoing abdominal sacral colpopexy.
VAGINAL PROCEDURES When the vaginal route is used, the vaginal apex is
suspended to a ligament in the pelvis, either the sacrospinous ligament, iliococcygeus
fascia, or the uterosacral ligament. Of these, only the sacrospinous is a true ligament. This is
typically performed in women who have undergone total hysterectomy, although cervix and
uterine sparing procedures are possible [94]. Vaginal procedures require a sufficient vaginal
length to reach the supporting ligament.
Sacrospinous ligament suspension (SSLS) was the most commonly used transvaginal
procedure for apical prolapse repair. However, more recently, uterosacral ligament
suspension (ULS) has gained popularity. The uterosacral technique was introduced in the
1920s, but in the half-century that followed, reconstructive surgeons seemed to shift focus
away from the uterosacral ligaments to more sturdy sites of fixation, such as the SSLS [95].
High rates of recurrent anterior vaginal wall prolapse are common after SSLS, so surgeons
attempted to find a more anatomic site to attach the apex to prevent defects in other
compartments. Uterosacral and iliococcygeus suspension are two such attempts.
In general, surgeons in the United States use a ULS when performing concomitant vaginal
hysterectomy, while SSLS is used more commonly for post-hysterectomy prolapse repair.
However, both procedures may be performed in women with a prior hysterectomy or at the
time of concomitant hysterectomy.
No high quality evidence is available to guide surgeons regarding uterine preservation at the
time of vaginal apical suspension procedures. A small, nonrandomized prospective trial
compared women undergoing sacrospinous cervicopexy with uterine preservation and those
undergoing SSLS with vaginal hysterectomy [96]. Uterine preservation was associated with
less blood loss and shorter operating times. Anatomic pelvic organ prolapse (POP)
outcomes and reoperation for POP were similar for both groups. Uterine conservation at the
time of prolapse repair is discussed in detail separately. (See "Pelvic organ prolapse in
women: Choosing a primary surgical procedure", section on 'Concomitant hysterectomy'.)
Sacrospinous ligament suspension SSLS (also referred to as sacrospinous ligament

fixation) is the most commonly studied transvaginal procedure for treating vaginal vault
prolapse.
Although SSLS may also improve anterior vaginal wall prolapse, it is less effective for this
indication. Thus, women with large anterior wall defects in addition to apical defects may
benefit from another type of prolapse repair, which better supports the anterior vagina or
concomitant anterior colporrhaphy. (See "Pelvic organ prolapse in women: Choosing a
primary surgical procedure", section on 'Concomitant repair of apical and anterior or
posterior prolapse'.)
SSLS is generally performed unilaterally. Most surgeons prefer the right side since the bowel
enters the rectum on the left side [97]. Some surgeons have proposed bilateral SSLS,
although the value of this modification has not been proven [98-100]. Use of the bilateral
technique depends upon adequate vaginal length and width.
Procedure Before starting the procedure, the patient is examined to ensure that the
vagina is long enough to reach the sacrospinous ligament. Women who do not have
sufficient vaginal length for SSLS may be candidates for abdominal sacral colpopexy.
The sacrospinous ligament extends from the ischial spines to the lower portion of the sacrum
and coccyx (figure 9 and figure 10). The coccygeus muscle follows the same path as the
sacrospinous ligament; together they are referred to as the coccygeus muscle-sacrospinous
ligament complex (figure 11). The ligament can be identified on pelvic examination by
palpating the ischial spine and tracing posteriorly and medially to the sacrum [101]. Marking
sutures are placed on the vaginal epithelium at the site where it will attach to the
sacrospinous ligament.
Several techniques are commonly used when performing a SSLS. In one modification, the
perirectal space is entered by opening the posterior vagina in the midline from the perineal
body to the apex. The vaginal epithelium is then separated from the underlying muscularis.
The dissection is continued to the level of the ischial spine. The rectovaginal space is
opened by gently pushing the rectum medially then perforating the rectal pillar (areolar tissue
that extends from the rectum to the arcus tendineus fascia pelvis and overlies the levator
muscle) (figure 12) [102].
Once the perirectal space is entered, the ischial spine can be palpated and the ligament
found medially. A long right angle retractor (eg, Briesky-Navratril) is placed on the ischial
spine to protect the pudendal neurovascular bundle and two others are used to retract the
bladder superiorly and the rectum medially.
With the ligament clearly visible, two to three sutures are placed through the ligament
approximately one and one-half finger-breadths medial to the ischial spine. Several
techniques and devices are available to assist placing the suture through the ligament (eg,
Miya hook, Deschamps ligature carrier, laparoscopic suturing devices) [97].
After securing the sutures to the ligament complex, each of the sutures is placed through the
muscularis on the undersurface of the posterior vaginal epithelium and tied by a pulley stitch,
while the free end of the suture is held. Traction on the free end of the suture draws the
vaginal apex directly onto the sacrospinous ligament and the suture is tied.
Another common modification of the SSLS is the "Michigan Modification" technique

[103,104]. In the Michigan Modification, all four vaginal walls are directly approximated to the
sacrospinous ligament (instead of just the posterior vaginal wall). The point on each vaginal
wall that reaches the ligament is identified and the intervening diamond of vaginal epithelium
is excised. The sutures are placed through the sacrospinous ligament, as described above,
then sewn through to both the anterior and posterior vagina and tied to the ligament. A long-
lasting absorbable suture is used. The goal of this modification is to decrease the risk of an
anterior vaginal wall recurrence; although it has not been evaluated in comparative studies
with standard SSLS, case series report high long-term satisfaction rates after the procedure.
A single site study reported that 76 percent of women were completely or very satisfied at
least five years after SSLS [104].
Avoiding nerve entrapment There are several techniques to decrease the risk of
entrapment of the sciatic nerve or its branches when the sutures are placed. One approach
is to perforate the sacrospinous ligament with the needle in a vertical rather than horizontal
orientation, thereby attempting to place the suture parallel to the course of these nerves.
Also, since these nerves did not travel in the lateral third segment of the sacrospinous
ligament, placement of the fixation sutures within this region is another approach to
decrease the risk of nerve injury. Regional anesthesia of prolonged duration should not be
used postoperatively in women undergoing SSLS, since this may mask the symptoms of
nerve entrapment. (See 'Complications' below.)
Treating hemorrhage Significant hemorrhage has been reported in 0.2 to 2 percent of

SSLS procedures [105,106]. Controlling hemorrhage is challenging because of the small
space, lack of visualization, and close approximation of vessels and nerves. Techniques to
control bleeding include pressure, topical hemostatic agents, direct repair, vaginal packing,
and embolization. (See "Management of hemorrhage in gynecologic surgery".)
Based on cadaveric study, vessels at risk for injury include the superior gluteal, inferior
gluteal, internal pudendal, vertebral, middle sacral, lateral sacral, and circumflex femoral
[107]. Among these vessels, the inferior gluteal artery and its coccygeal branch appear to be
the arteries at greatest risk for injury [107,108]. Bleeding encountered during SSLS can
typically be managed conservatively with surgical clips, pressure, and/or hemostatic agents.
A laparoscopic clip applier can facilitate visualization in this deep space when a discrete
vessel is identified. Alternatively, use of hemostatic agents and packing for 5 to 10 minutes
will control most bleeding. Computed tomography angiography and vessel embolization can
be performed when bleeding cannot be controlled with more conservative measures
[106,109-111]. Exploratory laparotomy is rarely indicated secondary to inability to access this
space from an abdominal approach.
Outcome In a literature review of mostly observational studies, cure rates of prolapse-

related symptoms ranged from 70 to 98 percent (only four studies reported subjective
results) and the range of objective cure rates was 67 to 97 percent [97]. Recurrence of apical
prolapse after SSLS has been reported in 2 to 19 percent of women and of anterior vaginal
wall prolapse in 6 to 29 percent [103,105,112-120]. Therefore, as noted above, women with
large anterior wall defects in addition to apical descent may benefit from an additional type of
prolapse repair, which more directly addresses support of the anterior vagina. A study that
followed women for 2 to 15 years reported that 16 percent had prolapse symptoms [121].
Regarding bowel symptoms, relief of constipation was reported in several studies [97]. Data
regarding fecal incontinence were inconsistent, with some studies reporting improvement in
patients with preoperative symptoms, and others reporting de novo incontinence in some
patients.
Complications Serious complications are uncommon following SSLS. A literature review
of mostly observational studies that included 1922 SSLS procedures reported the following
complication rates [97]:
Cystitis 4.5 percent

Fever, secondary wound healing, abscess, or septicemia 4.1 percent
Ureteral kinking, problems with urination 2.9 percent
Pain (unclassified, gluteal, or bladder) 2.0 percent
Hemorrhage/blood transfusion 1.9 percent
Nerve damage (eg, sciatic nerve) 1.8 percent
Injury to pelvic organs 0.8 percent
Pelvic or vaginal vault hematoma 0.4 percent
Infectious complications are the most common type of adverse event, and are generally mild
(eg, cystitis).
Lower urinary tract complications involving ureteral impingement or injury may also occur;
cystotomy is infrequent [105]. Enterotomy and postoperative bowel complications are rare,
as the procedure is meant to be extraperitoneal. A discussion of lower urinary tract injury in
gynecologic surgery can be found separately. (See "Urinary tract injury in gynecologic
surgery: Identification and management".)
Hemorrhage during SSLS is most commonly due to laceration of the inferior gluteal or
pudendal vessels [107]. Pudendal hemorrhage is best treated by tightly packing the
ischiorectal fossa and waiting for hemostasis. Further discussion of hemorrhage during
gynecologic surgery can be found separately. (See "Management of hemorrhage in
gynecologic surgery".)
Postoperative pain or nerve dysfunction is likely due to injury to the branches of the sciatic
nerve that cross the sacrospinous ligament, based on anatomic studies in cadavers [122]. If
the sciatic nerve is entrapped in the suture, the classic triad of nerves entrapment will
present (paresthesias, pain, temporary relief with injection of local anesthetic). The patient
typically awakens with severe buttock pain radiating down the posterior leg. Delay in
diagnosis and treatment can result in permanent neuropathy; therefore, as noted above,
regional anesthesia of prolonged duration should not be used for this type of surgery. Upon
diagnosis of nerve entrapment, the patient should be taken back to the operating room
immediately to have the sutures removed.
The effect of SSLS on sexual function has not been well studied. Many studies have not
evaluated this outcome and some women who undergo apical prolapse repair are not
sexually active [97]. The rate of dyspareunia was 36 percent in pooled data from three
randomized trials in which SSLS was compared with abdominal sacral colpopexy [27].
(See 'Abdominal versus vaginal approach' above.) In contrast, observational studies have
reported dyspareunia in 3 to 10 percent of women who underwent SSLS [97].
Uterosacral ligament suspension ULS has increased in popularity. The uterosacral

ligaments are thought to be one of the main connective tissue supports for the upper vagina.
Procedure This procedure is typically performed transvaginally, but it can also be done
laparoscopically. The uterosacral ligaments are made of smooth muscle, connective tissue,
and nerves. They originate from the S1 to S4 vertebrae to insert near the cervix (figure 13).
The key to successful ULS is simultaneous correction of all defects in the apical endopelvic
fascia. The anterior and posterior vaginal muscularis [123] near the apex should be directly
approximated to ensure the continuity of the vaginal muscularis.
In the most commonly performed ULS technique, the anterior and posterior vaginal walls are
opened in the midline; the enterocele sac is identified, if present [124]. The peritoneal cavity
is entered and the uterosacral ligaments identified. An Allis clamp can be used to tent the
uterosacral ligament, making it easier to identify. The rectum is retracted medially.
Two or three permanent sutures are passed through the uterosacral ligament on each side.
These are placed 1.5 centimeters medial and 1.5 centimeters posterior to the ischial spine.
The sutures are numbered sequentially with labeled Kelly clamps, one through six, to
facilitate vaginal placement. In serial fashion, one arm of each suture is passed through the
anterior muscularis surrounding the vaginal apex and the other through the posterior
endopelvic fascia. The sutures thereby cross the width of the vaginal apex. All sutures are
then tied, re-approximating the anterior and posterior vaginal muscularis, closing any
potential enterocele defect, and elevating the vaginal apex toward the sacrum.
Retrospective chart review of 248 procedures found that 1 percent with permanent sutures
had loss of support beyond the hymen versus 6 percent in delayed absorbable group [125].
Avoiding or detecting ureteral injury The average distance from the lateral aspect of
the suspension sutures to the medial border of the ureters was 14 mm in a cadaver study
[126]. Cystoscopy should be performed after tying the sutures due to a significant rate of
ureteral kinking during this procedure.
Avoiding nerve entrapment Cadaveric studies suggest a higher risk of sacral nerve
entrapment when uterosacral sutures are placed using a deep, dorsal, posterior technique
and suggest that sacral nerve injury may be minimized by tenting the ligament ventrally prior
to placing sutures [127].
Outcome A meta-analysis of 10 observational studies evaluated ULS in 930 women; a

successful anatomic outcome was defined as POP-Q stage 0 or 1 [128]. The rates of a
successful outcome for each compartment were: apical (98 percent), anterior (81 percent),
and posterior (87 percent). Meta-analysis of subjective outcomes was not possible due to
methodologic differences across studies; relief of prolapse symptoms was reported by 82 to
100 percent of patients (this outcome was only reported by five studies). Reoperation for
symptomatic prolapse was reported in 9 percent of women (reported by four studies). There
were few reports of significant improvement in bowel symptoms.
Complications Complications of ULS are uncommon. The meta-analysis described in

the preceding section reported the following complications rates [128]:
Ureteral obstruction 1.8 percent

Blood transfusion 1.3 percent
Pelvic organ injury 0.4 percent
Ureteral obstruction is the most common complication. Cystoscopy should be done routinely
at the completion of each case to prevent delayed recognition of ureteral injury. Ureteral
kinking from the uterosacral suture is found during routine intraoperative cystoscopy in up to
11 percent of cases [129,130]. If both ureters do not efflux briskly, the most lateral suture
(closest to the ureter) on that side should be removed. Typically, removing this suture is
sufficient to restore brisk ureteral efflux without further sequelae, although ureteral injury
requiring ureteroneocystostomy has been reported. (See "Diagnostic cystourethroscopy for
gynecologic conditions", section on 'Indications'.)
The sacral nerves can be ligated if ULS sutures are placed lateral to the ligament fibers or
too deep into the pelvic sidewall [126,131,132]. In a retrospective case series, 7 of 182
women who had undergone a ULS developed sensory neuropathy and pain in the S2 to S3
dermatomes immediately postoperatively [132]. Three of these women had reduction of pain
when suspension sutures were removed within four days after surgery.
Iliococcygeus suspension Iliococcygeus suspension is similar to the SSLS, but uses

the iliococcygeus fascia over the levator plate instead of the sacrospinous ligament.
Proposed advantages of the iliococcygeus suspension compared with SSLS are lower risks
of anterior vaginal wall recurrence and injury to the pudendal neurovascular bundle, but
these benefits remain unproven. There are few data regarding this procedure. In a case-
control study of 128 women, one- to two-year follow-up, subjective success rates were
similar for iliococcygeus suspension and SSLS (91 versus 94 percent), but objective success
occurred significantly more frequently in women who underwent SSLS (53 versus 67
percent) [133]. Perioperative complications were similar for the two procedures. Some data
suggest that vaginal length may be longer following iliococcygeus suspension compared with
SSLS [134].
Vaginal mesh kits One systematic review of articles reporting outcomes of vaginal mesh
procedures for apical prolapse concluded that vaginal mesh seemed to effectively cure
apical POP; however, long-term anatomic and functional data were needed, as well as
comparative studies to traditional POP repairs [55]. High complication rates were found with
apical mesh procedures (up to 17.6 percent) with mesh erosion and dyspareunia most
common. In contrast, authors of another systematic review of vaginal mesh procedures for
POP concluded that there were insufficient data to determine efficacy of vaginal mesh
procedures for apical POP [54]. This systematic review also found high complication rates
associated with vaginal mesh placement, including graft erosion in up to 30 percent, urinary
tract infections in up to 19 percent, and visceral injury in up to 3 percent. A randomized trial
compared a total vaginal mesh procedure (Prolift; this device has now been removed from
the market) with laparoscopic sacral colpopexy [135]. At two-year follow-up, women in the
sacral colpopexy group had a significantly higher objective success rate (77 versus 43
percent) and a lower reoperation rate (5 versus 22 percent). This study was limited by
methodologic issues. Safety issues regarding transvaginal placement of mesh or biografts
are discussed in detail separately. (See "Overview of transvaginal placement of mesh for
prolapse and stress urinary incontinence".)
Comparing among vaginal procedures The principal choice is between SSLS and ULS
for surgeons performing native tissue transvaginal apical prolapse repair. ULS potentially
improves anterior vaginal wall support compared to SSLS. On the other hand, the risk of
ureteral injury and need for cystoscopy for ULS are disadvantages for this procedure
compared with SSLS.
Randomized trial data suggest that the efficacy of ULS and SSLS are comparable for
treating apical prolapse; however, the risks and benefits of the procedures differ slightly. The
Operations and Pelvic Muscle Training in the Management of Apical Support Loss
(OPTIMAL) randomized trial compared ULS with SSLS in 374 women with POPQ stage 2 to
4 apical vaginal prolapse; all participants also had stress urinary incontinence and
underwent a concomitant retropubic midurethral sling procedure [136]. The primary surgical
outcome was a composite measure of surgical success, defined as the absence of all of the
following: (1) vaginal apical descent to more than one-third of the vaginal length; (2) anterior
or posterior vaginal wall descent beyond the hymen; (3) bothersome vaginal bulge
symptoms; and (4) re-treatment of prolapse by either surgery or pessary. Two years after
surgery, 59.2 percent of ULS and 60.5 percent SSLS met this definition of success (odds
ratio [OR] 0.9, 95% CI 0.6-1.5). There were no significant differences between ULS and
SSLS in most perioperative outcomes, including blood loss and severe intraoperative or
postoperative adverse events. However, women who underwent ULS had a significantly
lower rate of neurologic pain requiring intervention (6.9 versus 12.4 percent; OR 0.5, 95% CI
0.2-1.0). Pain also persisted to the four- to six-week postoperative visit in fewer women
following ULS (0.5 versus 4.3 percent). Ureteral obstruction occurred in six women in the
ULS group (3.2 percent) and none in the SSLS group; however, most cases were detected
and treated intraoperatively. At two-year follow-up, there was no significant difference in the
primary outcome between the ULS and SSLS groups (surgical success 59.2 versus 60.5
percent; OR 0.9, 95% CI 0.6-1.5). In a planned secondary analysis of the OPTIMAL trial,
there were no clinically meaningful or statistically significant differences between the SSLS
and ULS groups for the outcomes of quality of life, sexual function, de novo dyspareunia,
and body image [137].
It is important to note that the OPTIMAL trial also compared perioperative behavioral therapy
with pelvic floor muscle training with usual care. In a subgroup analysis of the usual care
group, at two-year follow-up, ULS had a significantly lower rate of apical descent than SSLS
(8.6 versus 20.8 percent; OR 0.3, 95% CI 0.1-0.9). Among women who received usual care,
bothersome vaginal bulge symptoms were also lower in the ULS group (15.4 versus 21.1
percent), although the statistical significance was not reported. Rates of re-treatment were
not reported for this subgroup analysis. This raises the question of whether ULS is the
superior procedure for most women, since most women receive usual care. The pelvic floor
muscle training aspect of the trial is discussed in detail below. (See 'Pelvic floor muscle
training' below.)
A meta-analysis of observational studies suggests ULS results in excellent apical outcomes;

however, anterior success (stage 0 or I) rates were only 67 percent in women with
preoperative stage III prolapse [128].
Given the available data, outcomes appear similar for ULS and SSLS. However, risks and
benefits differ slightly, so patients should be counseled regarding a slightly higher risk of
persistent neurologic pain that may require reintervention after SSLS compared with the
increased risk for ureteral obstruction with ULS.
POSTOPERATIVE CARE Postoperative care is similar for both vaginal and abdominal
approaches; however, recovery after abdominal sacral colpopexy may be slower than
transvaginal procedures due to the abdominal incision. The postoperative course will also
vary according to whether concomitant procedures were performed (eg, hysterectomy,
surgery for stress urinary incontinence).
We give patients standard instructions regarding postoperative pain control, bleeding, signs
of infection, and gastrointestinal function. We advise no sexual intercourse for six weeks to
avoid disruption of the repair.
We see patients at two weeks postoperatively for routine follow-up. We perform a wound
check and speculum examination. Few data are available to guide postoperative care and
most recommendations are based on the surgeon's experience and preferences.
Routine discharge instructions can be found separately. (See "Patient education: Care after
gynecologic surgery (Beyond the Basics)".)
Pelvic floor muscle training Pelvic floor muscle training is often used as an initial
treatment for pelvic organ prolapse (POP) or stress urinary incontinence (SUI). Many
clinicians also advise patients to perform these exercises following pelvic floor reconstructive
surgery. However, there is not high quality evidence to support the efficacy of perioperative
use. This was investigated in the Operations and Pelvic Muscle Training in the Management
of Apical Support Loss (OPTIMAL) randomized trial (n = 374) that compared sacrospinous
ligament suspension (SSLS) with uterosacral ligament suspension (ULS), as well as
perioperative behavioral therapy with pelvic floor muscle training (BPMT) with usual care;
behavioral therapy included education on behavioral strategies to reduce urinary and
colorectal symptoms [136]. All participants also had stress urinary incontinence and
underwent a concomitant retropubic midurethral sling procedure. BPMT compared with
usual care did not result in a significant difference in urinary symptoms at six months or
prolapse outcomes at two years.
The surgical outcomes of the trial are discussed in detail above. (See 'Comparing among
vaginal procedures' above.)
SUMMARY AND RECOMMENDATIONS
Apical prolapse is the descent of uterus, cervix, or vaginal vault (figure 1). Common
symptoms of apical prolapse are a vaginal bulge, difficulty voiding, or constipation.
(See 'Anatomy and mechanisms of injury' above.)
Surgical candidates for apical prolapse include symptomatic women who have failed
or declined conservative management. Prolapse is typically a chronic problem, and
women often prefer surgery to conservative therapy since successful surgery does not
require ongoing maintenance to control symptoms. (See 'Candidates for apical prolapse
repair' above.)
Apical prolapse repair via open abdominal sacral colpopexy is more effective at
restoring vaginal topography than traditional vaginal repairs, although subjective
outcomes are similar after the two types of procedures. We suggest abdominal sacral
colpopexy rather than transvaginal repair for most women undergoing apical prolapse
repair (Grade 2C). (See 'Abdominal versus vaginal approach' above.)
Laparoscopic sacrocolpopexy is as effective as open sacrocolpopexy, but results in
decreased blood loss and shorter hospital stays. (See 'Laparoscopic or robotic
procedures' above.)
For women with apical prolapse undergoing abdominal sacral colpopexy, we
recommend synthetic mesh over biografts (Grade 1B). Synthetic mesh use in sacral
colpopexy reduces the risk of recurrent apical prolapse. (See "Overview of transvaginal
placement of mesh for prolapse and stress urinary incontinence".)
A vaginal surgical approach is a reasonable alternative to an abdominal approach for
women who cannot tolerate abdominal surgery, have no risk factors for prolapse
recurrence (eg, young age, obesity, stage III or IV POP, previous failed POP repair),
are having concomitant vaginal surgery, have risk factors for mesh-related
complications (eg, concomitant hysterectomy, smoking, immunosuppression, obesity),
or who place a high priority on a short recovery period or avoiding an abdominal
incision. (See 'Abdominal versus vaginal approach' above and 'Comparing among
vaginal procedures' above.)
Transvaginal apical repair procedures include sacrospinous ligament suspension
(SSLS) and uterosacral ligament suspension (ULS). The efficacy of these two
procedures appears comparable, but each procedure is associated with different risks
of complications. (See 'Comparing among vaginal procedures' above.)
For women undergoing repair of apical prolapse, a concomitant continence procedure
often performed to treat or prevent stress urinary incontinence. Midurethral slings are
the preferred concomitant procedure if a vaginal route is used for prolapse repair; some
surgeons also place a midurethral sling at the time of abdominal sacral colpopexy.
(See 'Concomitant surgery for stress urinary incontinence' above.)
For women undergoing Burch colposuspension, we suggest a laparoscopic rather
than open approach (Grade 2A). Open colposuspension should be performed if the
surgeon is not experience in the laparoscopic technique for this procedure.
(See 'Concomitant Burch colposuspension' above.)
literatur saat ini melalui: 2016. Desember | Topik ini terakhir diperbarui: 19 Desember 2016.
PENDAHULUAN - apikal prolaps adalah keturunan dari rahim, leher rahim, atau kubah vagina.
prolaps organ panggul (POP) mempengaruhi jutaan wanita; sekitar 200.000 prosedur bedah rawat
inap untuk prolaps dilakukan setiap tahun di Amerika Serikat [1,2]. Sebelas sampai 19 persen wanita
akan menjalani operasi untuk POP atau inkontinensia pada usia 80 sampai 85 tahun, dan 30 persen
dari wanita ini akan memerlukan POP atau inkontinensia tambahan operasi [3,4]. Anterior prolaps
dinding vagina tanpa prolaps apikal bersamaan jarang [5], dan perbaikan prolaps apikal harus
dimasukkan dalam mayoritas prosedur bedah rekonstruksi panggul.
prosedur rekonstruksi untuk prolaps puncak vagina ditinjau di sini. Evaluasi wanita dengan POP,
manajemen konservatif, dan memilih prosedur bedah primer dibahas secara terpisah. prosedur
obliterative untuk POP (colpocleisis) juga dibahas secara terpisah. (Lihat "prolaps pelvis organ pada
wanita: Sebuah gambaran epidemiologi, faktor-faktor risiko, manifestasi klinis, dan manajemen" dan
"pengobatan vagina alat pencegah kehamilan prolaps dan inkontinensia" dan "prolaps organ
panggul pada wanita: Memilih prosedur bedah primer" dan " prolaps panggul organ pada wanita:
prosedur obliterative (colpocleisis) ").
ISTILAH - The International Kontinensia Masyarakat mendefinisikan prolaps vagina apikal sebagai
salah keturunan dari bekas luka manset vagina atau leher rahim, di bawah titik yang 2 cm kurang
dari total panjang vagina tentang pesawat dari selaput dara [6]. Signifikansi klinis keturunan apikal
yang tidak melampaui selaput dara tidak jelas, karena setengah dari wanita tanpa gejala yang datang
untuk perawatan ginekologi rutin harus prolaps ke selaput dara [7]. Demikian pula, studi
menunjukkan bahwa prolaps menjadi gejala ketika terdepan menonjol di luar lubang vagina [8].
Namun, cacat dinding vagina anterior terisolasi jarang terjadi. Oleh karena itu, jika dinding vagina
anterior menonjol di luar selaput dara, puncak cenderung memiliki dukungan yang tidak memadai,
serta [5,9].
ANATOMI DAN MEKANISME CEDERA - apikal prolaps mengacu pada perpindahan ke bawah puncak
vagina (gambar 1). Puncak vagina adalah salah rahim dan leher rahim atau, pada wanita yang telah
mengalami subtotal atau total histerektomi, leher rahim atau manset vagina.
Dukungan dari puncak vagina terutama berasal dari integritas uterosakrum dan kardinal ligamen,
kelangsungan fasia endopelvis, dan utuh otot levator ani neuromuscularly (gambar 2). Etiologi dari
prolaps apikal kemungkinan terkait dengan jaringan ikat, saraf, dan / atau cacat otot di ini
mendukung normal.
Sangat jarang untuk menemukan prolaps apikal terisolasi atau prolaps terisolasi dari anterior atau
dinding vagina posterior, karena cacat pada jaringan ikat, jalur saraf, dan otot tidak terbatas pada
satu situs [9,10].
Anatomi panggul perempuan dibahas secara rinci secara terpisah. (Lihat "prolaps pelvis organ pada
wanita: Sebuah gambaran epidemiologi, faktor-faktor risiko, manifestasi klinis, dan manajemen".,
Bagian tentang 'Anatomi dukungan panggul')
FAKTOR RISIKO - Faktor risiko untuk mengembangkan prolaps apikal umumnya sama seperti untuk
mengembangkan anterior atau posterior prolaps dinding vagina. (Lihat "prolaps pelvis organ pada
wanita: Sebuah gambaran epidemiologi, faktor-faktor risiko, manifestasi klinis, dan manajemen".,
Bagian tentang 'Faktor risiko')
faktor risiko yang paling umum yang terkait dengan prolaps apikal adalah paritas vagina (jumlah
pengiriman vagina) dan histerektomi sebelumnya [11,12]. Risiko prolaps setelah histerektomi
digambarkan dalam studi kasus-kontrol di mana 160.000 wanita yang menjalani histerektomi secara
bermakna lebih mungkin dibandingkan kontrol seusianya memerlukan berikutnya panggul perbaikan
lantai (3,2 verus 2,0 persen) [13]. Wanita yang memiliki prolaps pada saat histerektomi memiliki
risiko lebih tinggi dari operasi berikutnya untuk prolaps organ panggul (POP). Sebuah studi kasus-
kontrol perempuan yang menjalani histerektomi melaporkan bahwa risiko perbaikan POP berikutnya
adalah 5 kali lipat pada mereka yang memiliki riwayat persalinan pervaginam, 8-kali lipat pada
mereka yang menjalani operasi sebelumnya untuk POP atau inkontinensia urin, dan hampir 13
ganda pada mereka yang memiliki grade 2 atau prolaps lebih tinggi pada saat histerektomi [14]. Ahli
bedah harus resuspend puncak vagina saat melakukan histerektomi untuk indikasi nonprolapse
untuk meminimalkan risiko ini.
CALON apikal prolaps PERBAIKAN - Indikasi untuk perbaikan prolaps apikal umumnya sama dengan
prosedur lainnya prolaps organ panggul (POP) perbaikan, yaitu, prolaps gejala pada wanita yang
menurun atau gagal terapi konservatif dan yang dapat mentoleransi pembedahan. Prolaps tidak
biasanya gejala sampai vagina menonjol melalui selaput dara. (Lihat "prolaps pelvis organ pada
wanita: Memilih prosedur bedah utama", bagian tentang 'Calon perawatan bedah' dan "prolaps
pelvis organ pada wanita: Sebuah gambaran epidemiologi, faktor-faktor risiko, pria klinis
Perut dibandingkan pendekatan vagina - Untuk memperbaiki prolaps vagina apikal, ahli bedah harus
memutuskan antara rute bedah perut atau vagina. Data menunjukkan bahwa operasi perut,
biasanya dengan terbuka perut colpopexy sakral (ASC), memberikan hasil anatomi tujuan yang lebih
baik daripada prosedur dukungan apikal vagina bagi kebanyakan wanita [27,28]. Namun, prosedur
vagina adalah alternatif yang masuk akal karena tingkat gejala yang serupa pasca operasi prolaps,
operasi ulang, dan efek samping dibandingkan dengan ASC [27,28]. Rahim atau tuba tabung dapat
dihilangkan dengan baik rute. Sementara mayoritas studi pada hasil ASC digunakan teknik terbuka,
laparoskopi dan pendekatan robot-dibantu sekarang lebih sering dilakukan. Laparoskopi dan
pendekatan robot muncul untuk menawarkan dukungan vagina ditingkatkan terkait dengan
prosedur yang terbuka dan pemulihan lebih pendek dari prosedur vagina. Satu percobaan dari 112
wanita secara acak ditugaskan untuk sacrocolpopexy perut laparoskopi atau terbuka melaporkan
tidak ada perbedaan antara prosedur untuk kekambuhan prolaps apikal (tidak ada dalam kedua
kelompok), komplikasi bedah, atau eksposur jala pada rata-rata 41 bulan masa tindak lanjut,
meskipun ada yang kambuh kompartemen signifikan lebih anterior pada kelompok laparoskopi
dibandingkan dengan kelompok perut (18 berbanding 2 persen) [29]. Tak satu pun dari wanita
dengan prolaps berulang memiliki gejala atau pembedahan ulang diperlukan.
Wanita yang mendapatkan manfaat dari perbaikan perut - ASC muncul untuk memberikan dukungan
anatomi ditingkatkan tanpa peningkatan besar dalam morbiditas dibandingkan dengan perbaikan
vagina. Oleh karena itu, ASC mungkin lebih tepat untuk wanita dengan faktor risiko kekambuhan
prolaps, termasuk usia muda, obesitas, stadium III atau POP IV, rentan terhadap kegiatan yang
berdampak tinggi atau angkat berat, dan sebelumnya gagal perbaikan POP [30-33]. faktor risiko
jarang prolaps berulang adalah kandung kemih ekstrofi atau spina bifida [34,35]. Alasan lain untuk
memilih pendekatan abdominal termasuk panjang vagina tidak cukup untuk perbaikan transvaginal
atau indikasi lainnya untuk operasi perut (misalnya, ovarium kistektomi).
Wanita yang mendapatkan manfaat dari perbaikan vagina - transvaginal perbaikan apikal manfaat
wanita yang tidak ingin risiko yang terkait dengan prosedur perut; di samping itu, jaringan asli
perbaikan vagina tidak termasuk penggunaan mesh atau cangkok bahan sering dikaitkan dengan
komplikasi benda asing. operasi transvaginal dilakukan di 80 sampai 90 persen dari operasi prolaps
di Amerika Serikat [2,3,36]. Ini mungkin menjadi sekunder untuk sifat minimal invasif operasi vagina
dan kemudahan menyikapi anterior dan posterior kompartemen lebih mudah pada saat operasi
vagina; Namun, data hasil setelah ASC menunjukkan bahwa hanya menangani puncak sering
mengoreksi baik anterior dan posterior cacat juga. Selain itu, operasi vagina memiliki durasi operasi
lebih singkat dan pemulihan dibandingkan dengan terbuka colpopexy sakral perut. Untuk alasan ini,
sering dipilih oleh wanita dengan peningkatan risiko bedah atau yang menempatkan prioritas tinggi
pada menghindari sayatan perut. Terakhir, jaringan asli perbaikan vagina menghilangkan faktor
risiko terkait jala komplikasi yang terkait dengan prosedur dukungan abdominal atau prosedur jala
vagina. Penghapusan komplikasi terkait jala dapat sangat penting pada wanita berisiko lebih tinggi
mesh atau cangkok erosi (misalnya, wanita yang merokok atau imunosupresi). (Lihat "Manajemen
paparan jala transvaginal dan nyeri setelah operasi panggul".)
pembanding bedah - Mayoritas data hasil berasal dari studi yang membandingkan ASC dan
sacrospinous ligamen suspensi (SSLs). prosedur vagina tambahan dapat mencakup uterosakrum
suspensi ligamen dan suspensi iliococcygeus.
hasil anatomi: ASC dikaitkan dengan peningkatan dukungan anatomi tujuan dibandingkan dengan
perbaikan prolaps vagina, terutama SSLs. Dalam dua tinjauan sistematis dan meta-analisis bahwa
kegagalan anatomi didefinisikan sebagai Tahap 2 prolaps, keberhasilan anatomi pasca operasi
lebih mungkin dengan ASC dibandingkan dengan perbaikan vagina (tingkat kegagalan 6 berbanding
20 persen, risiko relatif [RR] 0,29, 95% CI 0.09- 0.97 [27] dan rasio odds [OR] untuk sukses 2,04, 95%
CI 1,12-3,27 [28]). Ada beberapa, tapi tidak lengkap, tumpang tindih dalam studi yang dipilih oleh
dua ulasan.
gejala pasca operasi prolaps: Sementara ASC mungkin telah meningkatkan dukungan anatomi
objektif, gejala prolaps pasca operasi serupa untuk ASC dibandingkan dengan SSLs. Sebuah meta-
analisis dari tiga percobaan melaporkan tren statistik tidak signifikan terhadap risiko yang lebih
rendah dari gejala prolaps pasca operasi untuk ASC dibandingkan dengan perbaikan vagina (RR 0,53,
95% CI 0,25-1,09, n = 169 wanita) [27].
tarif reoperation: tarif operasi ulang muncul mirip antara ASC dan SSLs. Satu meta-analisis
melaporkan tingkat reoperation lebih rendah secara statistik tidak signifikan untuk ASC dibandingkan
dengan SSLs (7 vs 16 persen, RR 1,46, 95% CI 0,19-1,11, n = 169). Sebuah meta-analisis yang berbeda
melaporkan tidak ada perbedaan dalam tingkat reoperation antara ASC dengan jala dibandingkan
dengan kelompok gabungan dari va jaringan asli
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Topic 8073 Version 31.0

ANATOMY AND MECHANISMS OF INJURY Apical prolapse refers to the downward

PREOPERATIVE EVALUATION AND PREPARATION In women planning surgical

Physical examination A thorough speculum and bimanual pelvic examination are

Evaluation of urinary dysfunction Apical prolapse frequently coexists with urinary

To detect occult incontinence, we perform a preoperative evaluation for occult stress

Urinary retention Urinary retention is evaluated by measuring a postvoid residual urine

Evaluation of defecatory dysfunction Women with POP should be asked about

Anatomic outcome: ASC is associated with improved objective anatomic support

Burch colposuspension performed concurrently with abdominal sacral colpopexy is

EVALUATING APICAL PROLAPSE PROCEDURES Surgical outcomes of pelvic organ

ABDOMINAL SACRAL COLPOPEXY Abdominal repair of apical prolapse is performed

Concomitant hysterectomy at the time of prolapse repair is discussed in detail separately.

Procedure Open abdominal sacral colpopexy is performed through a lower abdominal

A commonly performed technique is to attach a permanent mesh to the posterior vagina to

Avoiding presacral hemorrhage Laceration of the presacral venous plexus leads to

Complications The most frequently reported intraoperative and postoperative

Incisional problems - 4.6 percent

Studies consistently report that gastrointestinal complications, such as small bowel

Laparoscopic or robotic procedures Sacral colpopexy is traditionally performed

CONCOMITANT BURCH COLPOSUSPENSION Burch colposuspension (also referred to

Indications and preoperative evaluation The Burch colposuspension is indicated for

Outcome Burch colposuspension is an effective procedure for the treatment of SUI.

Procedure Burch colposuspension is most commonly performed through a low

Regardless of route of access, in a Burch colposuspension, the avascular retropubic space

Laparoscopic route Burch colposuspension can be performed laparoscopically. There is

Open and laparoscopic Burch colposuspension were compared in a meta-analysis of 10

Voiding dysfunction and urgency incontinence Historically, Burch colposuspension

Apical prolapse Early reports suggested rates of enterocele of up to 17 percent following

Sacrospinous ligament suspension SSLS (also referred to as sacrospinous ligament

Another common modification of the SSLS is the "Michigan Modification" technique

Treating hemorrhage Significant hemorrhage has been reported in 0.2 to 2 percent of

Outcome In a literature review of mostly observational studies, cure rates of prolapse-

Cystitis 4.5 percent

Uterosacral ligament suspension ULS has increased in popularity. The uterosacral

Outcome A meta-analysis of 10 observational studies evaluated ULS in 930 women; a

Complications Complications of ULS are uncommon. The meta-analysis described in

Ureteral obstruction 1.8 percent

Iliococcygeus suspension Iliococcygeus suspension is similar to the SSLS, but uses

A meta-analysis of observational studies suggests ULS results in excellent apical outcomes;

SUMMARY AND RECOMMENDATIONS

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