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Management of Apical Pelvic Organ Prolapse

  • Alexandriah N. Alas
  • Jennifer T. AngerEmail author
Female Urology (K Kobashi, Section Editor)
Part of the following topical collections:
  1. Topical Collection on Female Urology

Abstract

Pelvic organ prolapse is a prevalent condition, with up to 12 % of women requiring surgery in their lifetime. This manuscript reviews the treatment options for apical prolapse, specifically. Both conservative and surgical management options are acceptable and should be based on patient preferences. Pessaries are the most commonly used conservative management options. Guided pelvic floor muscle training is more beneficial than self-taught Kegel exercises, though may not be effective for high stage or apical prolapse. Surgical treatment options include abdominal and vaginal approaches, the latter of which can be performed open, laparoscopically, and robotically. A systematic review has demonstrated that sacrocolpopexy has better long-term success for treatment of apical prolapse than vaginal techniques, but vaginal surgery can be considered an acceptable alternative. Recent data has demonstrated equal efficacy between uterosacral ligament suspension and sacrospinous ligament suspension at 1 year. To date, two randomized controlled trials have demonstrated equal efficacy between robotic and laparoscopic sacrocolpopexy. Though abdominal approaches may have increased long-term durability, when counseling their patients, surgeons should consider longer operating times and increased pain and cost with these procedures compared to vaginal surgery.

Key Points

• Pelvic floor physical therapy (PFPT) with a physical therapist is the best approach to conservative management of apical prolapse [10].

• Pessaries should be managed with regular follow-up care to minimize complications [14•].

• Minimally invasive sacrocolpopexy appears as effective as the gold standard abdominal sacrocolpopexy (ASC) [42•].

• Robotic assisted sacrocolpopexy (RASC) and laparoscopic assisted sacrocolpopexy (LASC) are equally effective and should be utilized by pelvic floor surgeons based on their skill level and expertise in laparoscopy [44, 45•].

• Uterosacral ligament suspension (USLS) and sacrospinous ligament suspension (SSLS) are considered equally effective procedures and can be combined with a vaginal hysterectomy.

• Obliterative procedures are effective but are considered definitive surgery [24••].

• The use of transvaginal mesh has been shown in some studies to be superior to native tissue repairs with regard to anatomic outcomes, but complication rates are higher. Transvaginal mesh should be reserved for surgeons with adequate training so that complications are minimized.

Keywords

Pelvic organ prolapse Apical support Apical suspension Sacrocolpopexy 

Notes

Compliance with Ethics Guidelines

Conflict of Interest

Dr. Alexandriah N. Alas and Dr. Jennifer T. Anger each declare no potential conflicts of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

References

Papers of particular interest, published recently, have been highlighted as • Of importance •• Of major importance

  1. 1.
    Abrams P, Cardozo L, Fall M, et al. The standardisation of terminology of lower urinary tract function: report from the Standardisation Sub-committee of the International Continence Society. Neurourol Urodyn. 2002;21(2):167–78.CrossRefPubMedGoogle Scholar
  2. 2.•
    Wu JM, Matthews CA, Conover MM, Pate V, Jonsson FM. Lifetime risk of stress urinary incontinence or pelvic organ prolapse surgery. Obstet Gynecol. 2014;123:1201–6. The prevalence of pelvic organ prolpse is expected to rise to 9.2 million by the year 2050. CrossRefPubMedGoogle Scholar
  3. 3.
    Wu JM, Hundley AF, Fulton RG, Myers ER. Forecasting the prevalence of pelvic floor disorders in U.S. women: 2010 to 2050. Obstet Gynecol. 2009;114(6):1278–83.CrossRefPubMedGoogle Scholar
  4. 4.
    Rooney K, Kenton K, Mueller ER, FitzGerald MP, Brubaker L. Advanced anterior vaginal wall prolapse is highly correlated with apical prolapse. Am J Obstet Gynecol. 2006;195(6):1837–40.CrossRefPubMedGoogle Scholar
  5. 5.
    Hsu Y, Chen L, Summers A, Ashton-Miller JA, DeLancey JO. Anterior vaginal wall length and degree of anterior compartment prolapse seen on dynamic MRI. Int Urogynecol J Pelvic Floor Dysfunct. 2008;19(1):137–42.CrossRefPubMedCentralPubMedGoogle Scholar
  6. 6.
    Chen L, Ashton-Miller JA, Hsu Y, DeLancey JO. Interaction among apical support, levator ani impairment, and anterior vaginal wall prolapse. Obstet Gynecol. 2006;108:324–32.CrossRefPubMedCentralPubMedGoogle Scholar
  7. 7.
    Toozs-Hobson P, Boos K, Cardozo L. Management of vaginal vault prolapse. Br J Obstet Gynaecol. 1998;105(1):13–7.CrossRefPubMedGoogle Scholar
  8. 8.
    Shull BL. Pelvic organ prolapse: anterior, superior, and posterior vaginal segment defects. Am J Obstet Gynecol. 1999;181(1):6–11.CrossRefPubMedGoogle Scholar
  9. 9.•
    Eilber KS, Alperin M, Khan A, et al. Outcomes of vaginal prolapse surgery among female medicare beneficiaries: the role of apical support. Obstet Gynecol. 2013;122(5):981–7. A RCT demonmstrated that formal pelvic floor therapy is more benificial than self-taught Kegel exercises. CrossRefPubMedGoogle Scholar
  10. 10.
    Hagen S, Stark D, Glazener C, et al. Individualised pelvic floor muscle training in women with pelvic organ prolapse (POPPY): a multicentre randomised controlled trial. Lancet. 2014;383(9919):796–806.CrossRefPubMedGoogle Scholar
  11. 11.
    Walters MD, Karram MM. Urogynecology and reconstructive pelvic surgery. 3rd ed. Philadelphia: Mosby Elsevier; 2007.Google Scholar
  12. 12.
    Pott-Grinstein E, Newcomer JR. Gynecologists’ patterns of prescribing pessaries. J Reprod Med. 2001;46(3):205–8.PubMedGoogle Scholar
  13. 13.
    Alperin M, Khan A, Dubina E, et al. Patterns of pessary care and outcomes for medicare beneficiaries with pelvic organ prolapse. Female Pelvic Med Reconstr Surg. 2013;19:142–7.CrossRefPubMedCentralPubMedGoogle Scholar
  14. 14.•
    Anger JT, Scott VC, Kiyosaki K, et al. Quality-of-care indicators for pelvic organ prolapse: development of an infrastructure for quality assessment. Int Urogynecol J. 2013;24(12):2039–47. With limited evidence to support propper pessary management, an expert panel recommended pessary visits every six months to minimize complications. CrossRefPubMedCentralPubMedGoogle Scholar
  15. 15.•
    Wiegersma M, Panman CM, Kollen BJ, et al. Pelvic floor muscle training versus watchful waiting or pessary treatment for pelvic organ prolapse (POPPS): design and participant baseline characteristics of two parallel pragmatic randomized controlled trials in primary care. Maturitas. 2014;77:168–73. An ongoing RCT is comparing pessary treatment to formal pelvic floor physical therapy and to observation alone. CrossRefPubMedGoogle Scholar
  16. 16.
    Mc CM. Posterior culdeplasty; surgical correction of enterocele during vaginal hysterectomy; a preliminary report. Obstet Gynecol. 1957;10:595–602.CrossRefGoogle Scholar
  17. 17.
    Webb MJ, Aronson MP, Ferguson LK, Lee RA. Posthysterectomy vaginal vault prolapse: primary repair in 693 patients. Obstet Gynecol. 1998;92(2):281–5.CrossRefPubMedGoogle Scholar
  18. 18.
    Colombo M, Milani R. Sacrospinous ligament fixation and modified McCall culdoplasty during vaginal hysterectomy for advanced uterovaginal prolapse. Am J Obstet Gynecol. 1998;179(1):13–20.CrossRefPubMedGoogle Scholar
  19. 19.
    Walters MD, Ridgeway BM. Surgical treatment of vaginal apex prolapse. Obstet Gynecol. 2013;121(2):354–74.PubMedGoogle Scholar
  20. 20.
    Cam C, Karateke A, Asoglu MR, et al. Possible cause of failure after McCall culdoplasty. Arch Gynecol Obstet. 2011;283(4):791–4.CrossRefPubMedGoogle Scholar
  21. 21.
    Miller NF. A new method of correcting complete inversion of the vagina. Surg Gynecol Obstet. 1927;44:550–4.Google Scholar
  22. 22.
    Karram M, Goldwasser S, Kleeman S, Steele A, Vassallo B, Walsh P. High uterosacral vaginal vault suspension with fascial reconstruction for vaginal repair of enterocele and vaginal vault prolapse. Am J Obstet Gynecol. 2001;185:1339–42; discussion 1342–3.CrossRefPubMedGoogle Scholar
  23. 23.
    Margulies RU, Lewicky-Gaupp C, Fenner DE, McGuire EJ, Clemens JQ, Delancey JOL. Complications requiring reoperation following vaginal mesh kit procedures for prolapse. Am J Obstet Gynecol: Elsevier; 2008:678.e1-.e4.Google Scholar
  24. 24.••
    Barber MD, Brubaker L, Burgio KL, Richter HE. Comparison of 2 transvaginal surgical approaches and perioperative behavioral therapy for apical vaginal prolapse: the OPTIMAL randomized trial. JAMA. 2014;31(10):1023–34. This RCT, was a 2 × 2 factorial design which randomized patients to perioperative pelvic floor physical therapy versus no intervention in the first randomization, and then to sacrospinous versus uterosacral vault suspension. There was found to be no benefit to pelvic floor therapy, and both surgical intervention had equivalent success at two years. CrossRefGoogle Scholar
  25. 25.
    Sederl J. Surgery in prolapse of a blind-end vagina. Geburtshilfe Frauenheilkd. 1958;18(6):824–8.PubMedGoogle Scholar
  26. 26.
    Maher CF, Qatawneh AM, Dwyer PL, Carey MP, Cornish A, Schluter PJ. Abdominal sacral colpopexy or vaginal sacrospinous colpopexy for vaginal vault prolapse: a prospective randomized study. Am J Obstet Gynecol. 2004;190(1):20–6.CrossRefPubMedGoogle Scholar
  27. 27.
    Morgan DM, Rogers MAM, Huebner M, Wei JT, Delancey JO. Heterogeneity in anatomic outcome of sacrospinous ligament fixation for prolapse: a systematic review. Obstet Gynecol. 2007;109(6):1424–33.CrossRefPubMedGoogle Scholar
  28. 28.
    Sze EH, Karram MM. Transvaginal repair of vault prolapse: a review. Obstet Gynecol. 1997;89(3):466–75.CrossRefPubMedGoogle Scholar
  29. 29.
    Administration UFaD. FDA public health notification: serious complications associated with transvaginal placement of surgical mesh in repair of pelvic organ prolapse and stress urinary incontinence. US Food and Drug Administration 2008. Available from: http://www.fda.gov/MedicalDevices/Safety/AlertsandNotices/PublicHealthNotifications/ucm061976.htm. Accessed 3 Sept 2014.
  30. 30.
    Administration UFaD. FDA safety communication: update on serious complications associated with transvaginal placement of surgical mesh for pelvic organ prolapse. US Food and Drug Administration 2011. Available from: http://www.fda.gov/Safety/MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalProducts/ucm079028.htm. Accessed 3 Sept 2014.
  31. 31.•
    AUGS Position Statement on the Restriction of Surgical Options for Pelvic Floor Disorders 2013. Available from: http://www.augs.org/guidelines-statements. Accessed 3 Sept 2014. After the FDA vaginal mesh warning, the American Urogynecological Society released their position statement. They stated that the FDA warning only applied to vaginal prolpase mesh, and not to abdominal or incontinence slings. They also stated that choosing to use such devices should be a descision made between the patient and the surgeon.
  32. 32.
    Altman D, Väyrynen T, Engh ME, Axelsen S, Falconer C. Anterior colporrhaphy versus transvaginal mesh for pelvic-organ prolapse. N Engl J Med. 2011;364(19):1826–36.CrossRefPubMedGoogle Scholar
  33. 33.•
    Su T-H, Lau H-H, Huang W-C, Hsieh C-H, Chang R-C, Su C-H. Single-incision mesh repair versus traditional native tissue repair for pelvic organ prolapse: results of a cohort study. Int Urogynecol J. 2014;25(7):901–8. At one year, use of a single incision vaginal prolapse mesh kit improved anterior compartment outcomes, but not outcomes in the posterior or apical components. CrossRefPubMedGoogle Scholar
  34. 34.•
    Rapp DE, King AB, Rowe B, Wolters JP. Comprehensive evaluation of anterior elevate system for the treatment of anterior and apical pelvic floor descent: 2-year followup. J Urol. 2014;191(2):389–94. This small cohort demonstrated significant improvent in both objective and subjective outcomes at two years using a single incision anterior vaginal mesh kit. CrossRefPubMedGoogle Scholar
  35. 35.•
    Charles Nager MD. Study of Uterine Prolapse Procedures - Randomized Trial (SUPeR). Available at: http://clinicaltrials.gov/show/NCT01802281. Accessed 3 Sept 2014. This ongoing RCT will compare vaginal hysterectomy with uterosacral vault suspension to hysteropexy using a sacrospinous mesh kit evaluating three year outcome data.
  36. 36.
    Lane FE. Repair of posthysterectomy vaginal-vault prolapse. Obstet Gynecol. 1962;20(1):72–7.CrossRefPubMedGoogle Scholar
  37. 37.
    Nygaard IE, McCreery R, Brubaker L, et al. Abdominal sacrocolpopexy: a comprehensive review. Obstet Gynecol. 2004;104(4):805–23.CrossRefPubMedGoogle Scholar
  38. 38.•
    Nygaard I, Brubaker L, Zyczynski HM, et al. Long-term outcomes following abdominal sacrocolpopexy for pelvic organ prolapse. JAMA. 2013;309(19):2016–24. A multicenter RCT demonstrated that treatment failures for abdominal sacrocolpopexy after seven years are more than previously reported. CrossRefPubMedCentralPubMedGoogle Scholar
  39. 39.•
    Maher C, Feiner B, Baessler K, Schmid C. Surgical management of pelvic organ prolapse in women. Cochrane Database Syst Rev. 2013;4:CD004014. A Cochrane review found that although sacrospinous ligament suspension had less pain and shorter operating time, it also was associated with more apical prolapse reocurrances than abdominal sacrocolpopexy. PubMedGoogle Scholar
  40. 40.•
    Akyol A, Akca A, Ulker V, et al. Additional surgical risk factors and patient characteristics for mesh erosion after abdominal sacrocolpopexy. J Obstet Gynaecol Res. 2014;40(5):1368–74. A retrospective study demonstrated that the greatest risk factors for mesh erosion after abdominal sacrocolpopexy were in those patients with ≥ stage 3 prolapse, previous or concurrent hysterectomy, or more than three procedures performed concomitantly. CrossRefPubMedGoogle Scholar
  41. 41.•
    Nosti PA, Umoh Andy U, Kane S, et al. Outcomes of abdominal and minimally invasive sacrocolpopexy: a retrospective cohort study. Female Pelvic Med Reconstr Surg. 2014;20(1):33–7. A retrospective study demonstrated no significant difference in outcomes between minimally invasive sacrocolpopexy and abdominal sacrocolpopexy. CrossRefPubMedGoogle Scholar
  42. 42.•
    Freeman RM, Pantazis K, Thomson A. A randomised controlled trial of abdominal versus laparoscopic sacrocolpopexy for the treatment of post-hysterectomy vaginal vault prolapse: LAS study. Int Urogynecol J. 2013;24(3):377–84. In a multicenter, two-sided equivalence trial, there was found to be no difference in patient satisfaction or recurrent prolapse at one year between abdominal and laparoscopic sacrocolpopexy. CrossRefPubMedGoogle Scholar
  43. 43.•
    Gracia M, Perello M, Bataller E, et al. Comparison between laparoscopic sacral hysteropexy and subtotal hysterectomy plus cervicopexy in pelvic organ prolapse: a pilot study. Neurourol Urodyn. 2014. doi: 10.1002/nau.22641. A small prospective trial demonstrated that total laparoscopic hysterectomy with cervicopexy had higher success than hysteropexy with anterior and posterior mesh strips. PubMedGoogle Scholar
  44. 44.
    Paraiso MFR, Jelovsek JE, Frick A, Chen CCG, Barber MD. Laparoscopic compared with robotic sacrocolpopexy for vaginal prolapse: a randomized controlled trial. Obstet Gynecol. 2011;118(5):1005–13.CrossRefPubMedGoogle Scholar
  45. 45.•
    Anger JT, Mueller ER, Tarnay C, et al. Robotic compared with laparoscopic sacrocolpopexy: a randomized controlled trial. Obstet Gynecol. 2014;123(1):5–12. A multicenter RCT demonstrated that laparoscopic and robotic sacrocolpopexy have equal subjective and objective sucess at six months. CrossRefPubMedCentralPubMedGoogle Scholar
  46. 46.
    Abbasy S, Kenton K. Obliterative procedures for pelvic organ prolapse. Clin Obstet Gynecol. 2010;53(1):86–98.CrossRefPubMedGoogle Scholar
  47. 47.
    Barber MD, Amundsen CL, Paraiso MFR, Weidner AC, Romero A, Walters MD. Quality of life after surgery for genital prolapse in elderly women: obliterative and reconstructive surgery. Int Urogynecol J. 2006;18(7):799–806.CrossRefGoogle Scholar
  48. 48.•
    Zebede S, Smith AL, Plowright LN, Hegde A, Aguilar VC, Davila GW. Obliterative LeFort colpocleisis in a large group of elderly women. Obstet Gynecol. 2013;121(2 Pt 1):279–84. This is the largest retrospective study to date, which reported high anatomical success and patient satisfaction with LeFort colpocleisis with minimal complication rates. PubMedGoogle Scholar
  49. 49.
    Moore RD, Miklos JR. Colpocleisis and tension-free vaginal tape sling for severe uterine and vaginal prolapse and stress urinary incontinence under local anesthesia. J Am Assoc Gynecol Laparosc. 2003;10(2):276–80.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2015

Authors and Affiliations

  1. 1.Department of Gynecology, Division of Female Pelvic Medicine and Reconstructive SurgeryCleveland Clinic FloridaWestonUSA
  2. 2.Department of Surgery, Division of UrologyCedars-Sinai Medical CenterLos AngelesUSA
  3. 3.UCLABeverly HillsUSA

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