Updates in Minimally Invasive Approaches to Apical Pelvic Organ Prolapse Repair
- 13 Downloads
Purpose of Review
The purpose of this article is to review and comment on the recent medical evidence regarding minimally invasive procedures for apical pelvic organ prolapse repair.
Sacrocolpopexy remains the “gold standard” repair for apical prolapse for those who desire to maintain sexual function, and minimally invasive approaches offer equal efficacy with lower risk than open sacrocolpopexy. Similar to the impact on hysterectomy rates, the introduction of robotic technology has converted a large number of open abdominal sacrocolpopexy procedures to a minimally invasive approach in the USA. Newer surgical approaches such as nerve-sparing techniques of dissection at the sacral promontory, use of the iliopectineal ligaments, and natural orifice vaginal sacrocolpopexy offer potential improvements for apical repair. Whether using traditional laparoscopy or robotic assistance, prolapse recurrence is consistently noted in at least 10% of patients. Recent evidence has confirmed that ancillary factors including pre-operative prolapse stage, retention of the cervix and/or uterus, type of mesh implant, and genital hiatus size all adversely affect surgical efficacy. Minimally invasive apical repair procedures seem well suited to early recovery after surgery protocols. While overall complication rates are low, small bowel injury is higher with any abdominal approach and aggressive evaluation of women not meeting routine post-operative goals is advised.
Minimally invasive sacrocolpopexy has achieved similar outcomes to the traditional abdominal route and should be considered the new “gold standard” in apical prolapse repair. Alterations in surgical techniques can reduce the risk of constipation.
KeywordsApical prolapse Minimally invasive Update Sacrocolpopexy Pelvic organ prolapse
Compliance with Ethical Standards
Conflict of Interest
Jeffrey S. Schachar and Catherine A. Matthews declare no conflict 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.
Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance
- 7.•• Nygaard I, Brubaker L, Zyczynski HM, Cundiff G, Richter H, Gantz M, et al. Long-term outcomes following abdominal sacrocolpopexy for pelvic organ prolapse. JAMA. 2013;309(19):2016–24 Randomized controlled trial with long-term data on outcomes of abdominal sacrocolpopexy as well as the benefits of concomitant urethropexy.CrossRefGoogle Scholar
- 8.•• Jelovsek JE, Barber MD, Brubaker L, Norton P, Gantz M, Richter HE, et al. Effect of uterosacral ligament suspension vs sacrospinous ligament fixation with or without perioperative behavioral therapy for pelvic organ vaginal prolapse on surgical outcomes and prolapse symptoms at 5 years in the optimal randomized clinical trial. JAMA. 2018;319(15):1554 Randomized controlled trial with long-term data on outcomes of apical vaginal repairs as well as the impact of pelvic floor physical therapy on outcomes. CrossRefGoogle Scholar
- 9.Bataller E, Ros C, Anglès S, Gallego M, Espuña-Pons M, Carmona F. Anatomical outcomes 1 year after pelvic organ prolapse surgery in patients with and without a uterus at a high risk of recurrence: a randomised controlled trial comparing laparoscopic sacrocolpopexy/cervicopexy and anterior vaginal mesh. Int Urogynecol J. 2018. https://doi.org/10.1007/s00192-018-3702-7.
- 11.Obinata D, Sugihara T, Yasunaga H, Mochida J, Yamaguchi K, Murata Y, et al. Tension-free vaginal mesh surgery versus laparoscopic sacrocolpopexy for pelvic organ prolapse: analysis of perioperative outcomes using a Japanese national inpatient database. Int J Urol. 2018;25(7):655–9.CrossRefGoogle Scholar
- 13.• Dandolu V, Akiyama M, Allenback G, Pathak P. Mesh complications and failure rates after transvaginal mesh repair compared with abdominal or laparoscopic sacrocolpopexy and to native tissue repair in treating apical prolapse. Int Urogynecol J. 2017;28(2):215–22 Large review of several surgical options for treating apical vaginal prolapse. CrossRefGoogle Scholar
- 17.van Zanten F, van Iersel JJ, Hartog FE, Aalders KIM, Lenters E, Broeders IAMJ, et al. Mesh exposure after robot-assisted laparoscopic pelvic floor surgery: a prospective cohort study. J Minim Invasive Gynecol. 2018. https://doi.org/10.1016/j.jmig.2018.06.015.
- 18.• Bradley MS, Askew AL, Vaughan MH, Kawasaki A, Visco AG. Robotic-assisted sacrocolpopexy: early postoperative outcomes after surgical reduction of enlarged genital hiatus. Am J Obstet Gynecol, 2018. 218(5):514.e1–8 Normalizing the genital hiatus improves outcomes of reconstructive surgery. Google Scholar
- 23.• Houlihan S, Kim-Fine S, Birch C, Tang S, Brennand EA. Uterosacral vault suspension (USLS) at the time of hysterectomy: laparoscopic versus vaginal approach. Int Urogynecol J. 2018 https://doi.org/10.1007/s00192-018-3801-5. Laparoscopic uterosacral ligament suspension has fewer complications and improved outcomes over the the vaginal approach.
- 24.•• Linder BJ, Occhino JA, Habermann EB, Glasgow AE, Bews KA, Gershman B. A national contemporary analysis of perioperative outcomes of open versus minimally invasive sacrocolpopexy. J Urol. 2018;200(4):862–7 Large review that highlights the benefits of minimally invasive techniques on complication rates during and after surgery. CrossRefGoogle Scholar
- 27.• De Gouveia De Sa M, Claydon LS, Whitlow B, Dolcet Artahona MA. Laparoscopic versus open sacrocolpopexy for treatment of prolapse of the apical segment of the vagina: a systematic review and meta-analysis. Int Urogynecol J. 2016;27(1):3–17 Large systematic review and meta-analysis comparing abdominal and minimally invasive sacrocolpopexy techniques.Google Scholar
- 31.• Mueller MG, Jacobs KM, Mueller ER, Abernethy MG, Kenton KS. Outcomes in 450 women after minimally invasive abdominal sacrocolpopexy for pelvic organ prolapse. Female Pelvic Med Reconstr Surg. 2016;22(4):267–71 Rate of bowel complications was about 3% when the sacrocolpopexy mesh was not retroperitonealized.Google Scholar
- 32.• Pan K, Zhang Y, Wang Y, Wang Y, Xu H. A systematic review and meta-analysis of conventional laparoscopic sacrocolpopexy versus robot-assisted laparoscopic sacrocolpopexy. Int J Gynecol Obstet. 2016;132(3):284–91 Cost of robotic sacrocolpopexies were higher than laparoscopic techniques in this systematic review.Google Scholar
- 34.• Banerjee C, Noé KG. Laparoscopic pectopexy: a new technique of prolapse surgery for obese patients. Arch Gynecol Obstet. 2011;284(3):631–5 Description of a new technique for apical prolapse repair.Google Scholar
- 35.Noé K-G, Schiermeier S, Alkatout I, Anapolski M. Laparoscopic pectopexy: a prospective, randomized, comparative clinical trial of standard laparoscopic sacral colpocervicopexy with the new laparoscopic pectopexy-postoperative results and intermediate-term follow-up in a pilot study. J Endourol. 2015;29(2):210–5.CrossRefGoogle Scholar
- 37.• Nair R, Nikolopoulos KI, Claydon LS. Clinical outcomes in women undergoing laparoscopic hysteropexy: a systematic review. Eur J Obstet Gynecol Reprod Biol. 2017;208:71–80 Review of laparoscopic hysteropexy concludes that they have high rates of success with few complications.Google Scholar
- 38.• Gutman RE, Rardin CR, Sokol ER, Matthews C, Park AJ, Iglesia CB, et al. Vaginal and laparoscopic mesh hysteropexy for uterovaginal prolapse: a parallel cohort study. Am J Obstet Gynecol. 2017;216(1):38.e1–38.e11 Multicenter prospective trial comparing laparoscopic and vaginal mesh hysteropexies concluded similar high rates of success however the laparoscopic approach had fewer mesh complications.Google Scholar
- 41.• Askew AL, Visco AG, Weidner AC, Truong T, Siddiqui NY, Bradley MS. Does mesh weight affect time to failure after robotic-assisted laparoscopic sacrocolpopexy? Female Pelvic Med Reconstr Surg. 2018 12;1. https://doi.org/10.1097/SPV.0000000000000632 Highlights the increased failure rate associated with ultra-lightweight mesh.
- 51.Kisby CK, Polin MR, Visco AG, Siddiqui NY. Same-day discharge after robotic-assisted sacrocolpopexy. Female Pelvic Med Reconstr Surg. 2018;27:1.Google Scholar