Approach to Pelvic Organ Prolapse

Abstract

Pelvic organ prolapse is highly prevalent condition, for which up to one in nine women will receive a surgery in their lifetimes. Surgical repair options include those with native tissue, mesh, or biograft, though ongoing scrutiny and FDA regulation of mesh may limit those options in the future. Refinements of surgical technique have evolved with improved understanding of pelvic anatomy and results of clinical trials. The choice of technique depends upon a patient’s anatomy, physician’s experience and comfort, and shared decision making with the patient.

Commentary by Benjamin M. Brucker, Division of Female Pelvic Medicine and Reconstructive Surgery and Neurourology, New York University Langone Health, Department of Urology and Obstetrics and Gynecology, New York, NY, USA

Commentary

• Benjamin M. Brucker 

Pelvic organ prolapse is a very common condition. Cross-sectional data suggest that 25% of women have significant anatomical prolapse, with the leading edge of the prolapse at the hymenal ring or below [99]. Not all women with pelvic organ prolapse will require a surgical intervention, but it is estimated that at least 10% of the female population will eventually undergo surgical correction, presumably because of bothersome symptoms or derangements of normal pelvic floor/organ functions. As the population of the United States ages, and women remain more active later in life, the importance of understanding how to manage women with pelvic organ prolapse is more pertinent than ever before [100]. The authors of this chapter do a fantastic job laying out the surgical approaches to treating women with pelvic organ prolapse. This chapter touches on the myriad approaches that surgeons use to treat pelvic organ prolapse. The data pertaining to these options are clearly summarized and presented in an easy-to-understand format (i.e., Table 15.1).

When choosing from the various approaches to surgical correction of pelvic organ prolapse, one critical question patients and clinicians ask is “how successful is this surgery?” The stage is set for analyzing the data presented when the authors explain the range of definitions of “success” that are commonly used in publications. As we read the data and compare the approaches, we must remind ourselves of the importance of considering what definition is being used in a given series. It is also important to look at studies with consideration of length of follow-up, taking into account the underlying disease process of pelvic organ prolapse. Additionally, understanding any bias each study may have, inherent to the study design and/or patient population, is critical. Finally, other factors, such as rates and severity of complications and the availability of patient-reported outcomes, add branches to our expanding decision tree. The complexity of the comparison does not end there. As members of a healthcare community, we need to consider cost of treatment choices [101]. Further, as providers sitting in front of an individual patient, we add unique patient factors (i.e., past medical history or family history) that might steer the decisions to a particular type of repair and away from another.

This chapter on the surgical treatment of pelvic organ prolapse is up-to-date, as it reviews the FDA notifications and subsequent withdrawal of vaginally placed mesh for the treatment of pelvic organ prolapse from the US market. The data on autologous grafts and biological materials are also reviewed. The results seem to suggest that there is room to improve and develop materials and/or modify techniques or teaching so that surgical outcomes can continue to improve. One graft that surgeons have continued to rely on is abdominally placed mesh. Even prior to the withdrawal of vaginally placed mesh, abdominally placed mesh, at the time of sacrocolpopexy, had been used with increasing frequency [102]. The authors highlighted rates of sacrocolpopexy mesh “erosions,” occurring in up to 10% of patients. We will see over time, as technique utilization changes, how prevalence of complications changes, for better or for worse.

As medical professionals, we try to make decisions using the highest-quality data available. Large randomized comparative studies are costly. Further, treatment durability data require long periods of time to mature. Techniques, tools, and materials are constantly changing. This means that we are often left to make clinical decision with data that has inherent limitations. Newer goals of surgical correction emerge such as uterine preservation [103]. We will see techniques described and investigated to achieve these goals [104,105,106]. If the interest in uterine preservation grows, we will require more data on appropriate preoperative screening/risk assessment along with long-term outcome data to counsel our patients appropriately.

We are lucky to have comprehensive reviews like this chapter to lay out what we know, and see what questions remain unanswered. The diversity of treatment options makes counseling extremely complex, but if we aim to utilize shared decision making, the data generated by this cycle of questions and answers allow the patient to contribute to selection of the surgical approach that works best for their case.