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Joint report on terminology for surgical procedures to treat pelvic organ prolapse

A Correction to this article was published on 08 May 2020

This article has been updated

Abstract

Surgeries for pelvic organ prolapse (POP) are common, but standardization of surgical terms is needed to improve the quality of investigation and clinical care around these procedures. The American Urogynecologic Society and the International Urogynecologic Association convened a joint writing group consisting of 5 designees from each society to standardize terminology around common surgical terms in POP repair including the following: sacrocolpopexy (including sacral colpoperineopexy), sacrocervicopexy, uterosacral ligament suspension, sacrospinous ligament fixation, iliococcygeus fixation, uterine preservation prolapse procedures or hysteropexy (including sacrohysteropexy, uterosacral hysteropexy, sacrospinous hysteropexy, anterior abdominal wall hysteropexy, Manchester procedure), anterior prolapse procedures (including anterior vaginal repair, anterior vaginal repair with graft, and paravaginal repair), posterior prolapse procedures (including posterior vaginal repair, posterior vaginal repair with graft, levator plication, and perineal repair), and obliterative prolapse repairs (including colpocleisis with hysterectomy, colpocleisis without hysterectomy, and colpocleisis of the vaginal vault). Each of these terms is clearly defined in this document including the required steps of the procedure, surgical variations, and recommendations for procedural terminology.

Although surgeries for pelvic organ prolapse (POP) are common [1], lack of standardized terminology leads to confusion among health providers and patients. This inconsistent terminology limits both patient and health care provider understanding and inhibits our ability to perform clinical research [2, 3].

Despite the introduction of several standardization documents on terminology for POP and pelvic floor dysfunction [3,4,5,6], no such document exists for the surgical procedures to repair POP. Different eras in the history of female pelvic reconstructive surgery practice have seen procedures for POP change dramatically or become largely obsolete. For research to produce meaningful data about specific procedures, standardized and widely accepted terminology must be adopted. Each term for a given procedure must indicate to researchers, clinicians, and learners a specific and reliable minimal set of steps. The aim of this document is to propose a standardized terminology to describe common surgeries for POP.

Methods

The American Urogynecologic Society (AUGS) and the International Urogynecologic Association (IUGA) convened a joint writing group consisting of 5 designees from each society with expertise on surgical procedures for POP. The authors performed a literature review of commonly performed POP repair procedures and extracted surgical descriptions. After this, the writing group then engaged in an iterative process of discussion of terms and ultimately selected and agreed upon the relevant surgical terminology proposed in this document.

The aim of the writing group was to produce a clinically useful document that comprehensively defines the terminology for surgical repair of POP. The authors sought to develop specific joint terminology to do the following:

  1. 1.

    Produce preferred terminology for each surgical description and provide examples of both acceptable alternative terms and nonrecommended terminology.

  2. 2.

    Describe the historical context of the surgery.

  3. 3.

    Describe the surgery in a clear and stepwise manner, including detailed illustrations where appropriate.

  4. 4.

    Include specific materials and equipment used in the surgery.

  5. 5.

    Address specific limitations and pitfalls surrounding terminology for each surgery.

  6. 6.

    Combine input from AUGS and IUGA with the assistance of designated referees.

  7. 7.

    Provide clinically meaningful terminology for POP surgeries for common use by educators, learners, researchers, clinicians, physiotherapists, and midlevel healthcare providers.

This document clarifies and recommends standardized terminology and discusses the specific nature of a set of surgical terms (Fig. 1) for POP repair procedures that are commonly in use and/or sufficiently present in the medical literature to warrant definition. This document is not intended to discuss clinical outcomes of POP surgeries, review the evidence base for particular POP surgeries, or recommend a particular POP surgery in an individual situation. Inclusion of a surgical term in this document is not an endorsement of the procedure's value, safety, or availability; the aim of this document is to clarify the definition of the procedure as opposed to clinical judgment regarding its application. However, we have indicated in this document instances where surgical steps for a certain procedure have been specifically adapted for the purpose of improving specific outcomes or avoiding specific complications.

Fig. 1
figure 1

Flow chart of surgeries for POP by surgery characteristics

Sacrocolpopexy and Sacrocervicopexy

Sacrocolpopexy (SCP) is defined as suspension of the vaginal apex to the anterior longitudinal ligament of the sacrum using a graft, with possible incorporation of the graft into the fibromuscular layer of the anterior and/or posterior vaginal walls (Fig. 2). The term sacrocervicopexy (SCerP) is defined as suspension of the uterine cervix to the anterior longitudinal ligament of the sacrum using a bridging graft, with possible incorporation of the graft into the fibromuscular layer of the anterior and/or posterior vaginal walls (Table 1).

Fig. 2
figure 2

Sacrocolpopexy

Table 1 Surgical Terms and Definitions for POP Surgeries Defined in This Document Along With Acceptable Synonyms, Nonrecommended Alternative Terms, and Surgical Features That Would Disqualify a Surgery From Being Appropriate for Use of That Term

As early as 1962, the use of a graft to bridge the vaginal vault to the sacrum was described for the treatment of posthysterectomy prolapse [7]. Before that, in 1957, uterine hysteropexy, where the uterine fundus was attached to the anterior longitudinal ligament with suture, was suggested [8]. Suturing the graft to the anterior longitudinal ligament at the level of S1 to S2 has been recommended to minimize bleeding and to avoid the intervertebral disc and the risk of discitis [9, 10]. A wide variety of different grafts have been used for SCP in history. At present, Amid type 1, macroporous, monofilament, light-weight polypropylene mesh is the most used in published, high-quality studies [11,12,13,14]. Early descriptions of graft placement described suturing a single strip of graft from the sacral promontory along the rectovaginal septum to the perineum to distribute the graft attachments over a large surface area [15]. Another study proposed attaching the graft on both the anterior and posterior vagina to improve vaginal support across all compartments, which is now commonly performed [16].

Procedure description

Equipment

The most common routes for SCP and SCerP are abdominal, laparoscopic, and robotic, although vaginal approaches have been described, and equipment used would be consistent with approach (Table 2) [17, 18]. A vaginal retractor or dilator of some type is useful to manipulate and delineate the vagina during the case.

Table 2 Recommended Equipment for POP Surgery by Approach

List of steps

  1. Step 1:

    The procedure begins by gaining access to the intra-abdominal cavity (through an open, laparoscopic, or robotic approach), identifying relevant anatomic landmarks (such as the ureters and rectosigmoid), and retracting the rectosigmoid to the left of the sacrum to expose the peritoneum over the sacral promontory.

  2. Step 2:

    The retroperitoneal space over the bony sacral promontory is entered and a window overlying the anterior longitudinal ligament at the level of S1-S2 is developed.

  3. Step 3:

    The peritoneum is either divided from this dissection along the right pelvic side wall down to the vagina or a retroperitoneal tunnel under the peritoneum is created along the same course, taking care to identify and avoid the nearby ureter and the rectosigmoid. This step is undertaken to retroperitonealize the graft at the end of the procedure, although some surgeons do not perform this step.

  4. Step 4:

    The bladder is dissected anteriorly and the rectum posteriorly from the vaginal walls.

  5. Step 5:

    The graft of choice is introduced into the abdomen.

  6. Step 6:

    The anterior arm is sutured to the anterior vaginal wall and the posterior arm to the posterior vaginal wall using sutures.

  7. Step 7:

    The graft material is sutured or tacked to the anterior longitudinal ligament to obtain a suspension bridge between the vagina and the sacrum.

  8. Step 8:

    Peritoneal closure over the exposed graft is optional as there are no robust clinical trials evaluating this step, but it is frequently reapproximated for the theoretical prevention of bowel obstruction [19].

Technique variations

Sacrocolpopexies and SCerPs have many possible modifications. A variety of grafting materials have been used including nonabsorbable synthetic graft (eg, polypropylene, polyester, silicone rubber, polytetrafluoroethylene), absorbable synthetic graft (eg, polyglactin), and biologic (eg, autologous rectus fascia or fascia lata, cadaveric dura mater and fascia lata, xenoform porcine dermis) [20,21,22,23]. Grafts may be preformed or individually crafted, in 1 or 2 pieces (“Y” vs “L”-shaped grafts), fixed to the anterior sacrum with nonabsorbable and/or absorbable sutures or tacking/fixation devices, tunneled from the posterior broad ligament to the presacral space, or tensioned initially in a complete opening of the peritoneum on the right pelvic side wall from the presacral space to the posterior leaf of the broad ligament. The graft may also be a single piece that is sutured to the posterior vagina, rolled over and sutured to the vaginal apex or anterior vagina, and then secured to the sacrum. The graft may be attached to the anterior and/or the posterior fibromuscular layers of the vagina, attached to the vaginal apex (SCP) or anterior/posterior cervix (SCerP) only without more caudad extension, or both. Choices of suture for vaginal graft attachment include nonabsorbable, delayed absorbable, or barbed delayed absorbable. The number of sutures to the anterior sacrum (2–4), the vaginal apex or cervix (1 or 2), or the anterior or posterior vaginal wall (1 barbed suture with multiple attachment points or many interrupted sutures) can vary, as can the location of graft or graft attachment on the anterior (anywhere from the apex to the bladder neck) or posterior vaginal wall (anywhere from the apex to the perineal body). Finally, the graft can be attached to the anterior and posterior vaginal walls transvaginally and attached to the sacrum through an abdominal or laparoscopic approach [24].

Another important variation on SCP is the extension of the posterior vaginal graft attachment point down to the perineal body for the purpose of perineal support [25]. The term “sacral colpoperineopexy” has been used in the literature to describe this variation [26, 27], and we recommend that the variation that attaches the posterior vaginal graft to the perineal body be a specific subterm underneath the broader term of “sacrocolpopexy,” as this variation still meets the requirements for the definition of SCP. We recommend against the less specific term “perineopexy” for this technique of sacral colpoperineopexy, as it is easily confused with other perineal support procedures with different methods. Future directions for SCP and other procedures discussed in this document can be found in Appendix 1.

Special terminology considerations

In a patient with a uterus in situ, any route of hysterectomy can be followed by SCP as described previously. If a supracervical hysterectomy is chosen, the graft is usually attached to the cervix as well as the anterior and posterior vagina, and this is termed a SCerP. Some sources term this combination of supracervical hysterectomy and SCerP appropriately [28,29,30], whereas some sources use the term SCP interchangeably to describe this sequence of event [31]. We recommend the former.

Summary

SCP and SCerPs are apical prolapse procedures where the vagina or cervix, respectively, is bridged to the anterior longitudinal ligament of the sacrum at the level of S1-S2 using a graft. Surgeons should be clear with patients that the use of this terminology indicates a procedure performed in the intra-abdominal cavity and using some type of graft, to distinguish this surgery from procedures accomplished entirely through the vagina that use graft.

Uterosacral ligament suspension

Uterosacral ligament suspension (USLS) is defined as suspension of the vaginal apex to the unilateral or bilateral uterosacral ligament(s) (USL[s]) using suture. USLS was first described as a transvaginal procedure and is most commonly performed through a vaginal approach [32, 33], but laparoscopic modifications are reported [34, 35] and any abdominal entry approach (laparoscopic, robotic, or open) is possible for USLS. Uterosacral ligament suspension often is performed at the time of a hysterectomy because the USLs can be easily identified, but this technique can be used in posthysterectomy vaginal prolapse repair as well.

The concept of using the USLs to support the vaginal apex was first described in 1927 [32]. In 1957, a technique attaching the distal USLs to the vaginal apex with purse-string sutures to close an “enterocele” was described [36], and modifications were made to this technique to minimize suture number and risk of ureteral injury [33]. Most modern publications on USLS reference reports in the 1970s theorizing that prolapse is related to “isolated breaks” in the USLs rather than overall attenuation [37]. In 2000, 2 studies separately reported on a USLS in which 1 to 3 sutures were placed through each USL and then attached to the ipsilateral fibromuscular layer of the anterior and posterior vaginal apex [38, 39]. Most USLS trials use a modification of this ipsilateral technique [40].

Procedure description

Equipment

As mentioned above, USLS can be performed vaginally, laparoscopically, or in an open abdominal approach. Laparoscopic techniques use various methods of suspending the vaginal apex to the USLs without using transvaginal suturing [41, 42] but must include the steps below for the term to be termed a USLS. Cystoscopy for assessment of ureteral patency is considered clinically mandatory during USLS because of a high prevalence of ureteral injury [43], but use of the term USLS does not automatically imply that this vital step has been performed, so surgeons should clarify the performance of cystoscopy in communications regarding the surgery.

The transvaginal approach requires standard vaginal surgery equipment, such as long instruments and additional light sources, which can reach deep into the pelvis. Many surgeons describe using a combination of delayed-absorbable suture and nonabsorbable suture, whereas others use only delayed and/or rapidly absorbable sutures. In the laparoscopic approach, an instrument to manipulate the vaginal cuff, laparoscopic needle drivers, and possibly a knot pusher are needed.

List of steps

  1. Step 1:

    The peritoneal cavity is entered either transvaginally or abdominally. This suspension is often performed at the time of vaginal hysterectomy, in which case the peritoneal entry at the vaginal apex is used. For USLS remote from hysterectomy using a vaginal approach, the peritoneum is carefully entered through the vaginal vault to avoid bladder or bowel injury.

  2. Step 2:

    The USLs are identified. In the ipsilateral USLS technique (Fig. 3), sutures are placed in the USLs proximal to the ischial spine.

  3. Step 3:

    Sutures are placed through the posteromedial aspect of bilateral USLs and subsequently through the anterior and posterior vaginal cuff, ideally incorporating the fibromuscular layer. For absorbable sutures, the vaginal epithelium is incorporated into the suture as well; the vaginal epithelium is avoided with nonabsorbable sutures. Some authors describe performing a separate closure of the posterior cul-de-sac during USLS [38, 44, 45], but this step is not itself considered a procedure for prolapse correction or necessary for use of the term USLS.

Fig. 3
figure 3

Uterosacral ligament suspension using the ipsilateral technique variation

Technique variations

In another common variation, the USLs are plicated across the midline using sutures (Fig. 4). Sutures are passed first through the epithelium and fibromuscular layers of the anterior or posterior vaginal cuff, through the ipsilateral USL, reefed across the posterior peritoneum to the contralateral USL, through the contralateral USL, and again through the vaginal fibromuscular layer and out through the vaginal epithelium. Although this technique was originally described to close the posterior cul-de-sac [36, 46], this midline plication technique is frequently used to address apical vaginal prolapse and is appropriately termed USLS if the USLs are incorporated proximal to the level of the ischial spines.

Fig. 4
figure 4

Uterosacral ligament suspension using the midline plication technique variation

The ipsilateral USLS technique is typically performed with 1 to 3 sutures per side for a total of 2 to 6 sutures, whereas the midline plication technique uses 2 to 3 sutures across the midline with additional sutures if the peritoneum is being closed above the USL plication.

Laparoscopic or open approaches vary, but common features include identification of the USLs and mobilization of the ureters laterally and away from the site of planned USL suture placement. Sutures are then passed through the USLs and through the vaginal cuff incorporating the fibromuscular layers similar to the vaginal approach [34, 35]. Another modification of the USLS is an extraperitoneal technique, although this is less common [47, 48]. Unilateral USLS is also possible when sutures on one side of a planned bilateral suspension must be removed and replacement is avoided [49].

Special terminology considerations

Attachment of a graft from the vaginal apex to the presacral space, even in the proximity of where the USLs insert, would more appropriately be termed a SCP. Attaching the vaginal apex to the peritoneum only, without identification and confirmation of suture placement into the USLs, would not qualify as a USLS. In addition, reattachment of the vaginal apex or cuff to the cut ends of the USLs distal to the level of the ischial spines, as at the end of a hysterectomy, is not considered a USLS.

Summary

Uterosacral ligament suspension suspends the apex of the vagina to the USLs with the use of suture material. A wide variety of approaches to access the USLs and place the sutures exist, but the core principle is utilization of the USLs for apical support.

Sacrospinous ligament fixation with or without graft

Sacrospinous ligament fixation (SSLF) is defined as suspension of the vaginal apex to the unilateral or bilateral sacrospinous ligament(s) (SSL[s]) using suture (Fig. 5). Similarly, SSLF with graft is the suspension of the vaginal apex to the unilateral or bilateral SSL(s) with incorporation of graft (Fig. 6). Typically, the vaginal apex is attached to one or both SSL(s) at a location at least 2 to 3 cm medial to the ischial spine [50]. The SSLs are interconnected with the coccygeus muscles, so the anatomic term “sacrospinous ligament-coccygeus muscle complex” is used in many publications describing SSLF. Though initially described in 1958 [51], the procedure gained popularity in 1968 when further detailed in the literature [52].

Fig. 5
figure 5

Sacrospinous ligament fixation

Fig. 6
figure 6

Sacrospinous ligament fixation with graft using the technique variation with graft affixed to the anterior vaginal wall and the arms of the graft fixed to bilateral sacrospinous ligaments

Procedure description

Equipment

Sacrospinous ligament fixation is most commonly performed transvaginally and can be performed without entering the peritoneal cavity (Table 2). Although SSLF is usually performed transvaginally, a laparoscopic approach has been described [53]. If a uterus is present, the SSLF can be performed concurrently with a hysterectomy or leaving the uterus in place (see “sacrospinous hysteropexy” hereinafter).

With direct visualization, ligament perforation and retrieval can be aided with specific devices, such as a Deschamps ligature carrier or Miya hook [54, 55]. In an attempt to decrease morbidity associated with the dissection required for direct visualization of the SSL, instruments have been used for that facilitate SSL suture placement by “palpation” alone, such as the i-stitch®, Endo Stitch®, and Capio® devices [56].

List of steps

  1. Step 1:

    The SSLs are located in the pararectal space, contiguous with the retropubic space, and may be approached through an anterior, posterior, or apical vaginal incision. The posterior approach develops the rectovaginal space and the rectal pillars are perforated at the level of the ischial spine, thus gaining access to the pararectal space. The anterior approach develops the vesicovaginal space with entry of the retropubic space via perforating the arcus tendineus fasciae pelvis (ATFP), preferably near the pubic bone insertion. This is followed by development of the paravaginal space until the ischial spine is reached, leading to the identification of the SSL [57].

  2. Step 2:

    The SSL is identified by visualization and/or palpation and dissected [54]. If the peritoneal cavity is entered, the SSL can be approached through the posterior visceral peritoneum. This peritoneum is “peeled off” at 7 o'clock (for access to right SSL) and a cephalad finger motion allows reaching the SSL [55].

  3. Step 3:

    Sutures are passed through the SSL using either direct visualization or palpation [58, 59].

  4. Step 4:

    These sutures are then passed through the fibromuscular layer of the vaginal apex with or without incorporating the vaginal epithelium. The vaginal apex could be at the location of the former apical vaginal scar (posthysterectomy) or a new location on the cephalad vagina determined by the surgeon to be more ideal for restoring anatomy with this repair.

  5. Step 5:

    Sutures are tied to suspend the vaginal apex with or without additional plication of the fibromuscular layers of the anterior and/or posterior vaginal walls.

Technique variations

If graft is being used in a SSLF, the sutures passing into the SSL(s) may be part of a prefabricated graft product wherein the sutures have bullets to aid in their passage through the SSL(s) [60,61,62]. Sutures placed in the SSL may also be passed through a graft without any preattached sutures [63]. One example of SSLF with graft in the past used an anterior vaginal approach and involved an arced strap of type 1 polypropylene mesh that was attached to the bilateral SSLs by nonabsorbable sutures with bullets and fixed in the midline to the cervical stroma or vaginal apex [64]. Grafts of this type were withdrawn from use in the US market in 2019 (see Appendix 2). Grafts used in SSLF may also be attached at other points in the pelvis or additional graft pieces may be used, but the term SSLF with graft is appropriate if the graft material is affixed to one or both SSL(s).

Although the fixation near the ischial spine has been used in SSLF [65], most studies recommend a point of attachment 2 to 3 cm medial to the ischial spine to avoid neurovascular structures [55, 60]. Segments of the vagina incorporated into the suspension can be the posterior and/or anterior vaginal walls. The vaginal epithelium may or may not be included in the SSL sutures. Part of the vaginal apex may be excised if there is redundant vaginal length [66].

Suture material used for the suspension can be nonabsorbable (when vaginal epithelium is not incorporated) and/or delayed absorbable (when the sutures are tied within the vaginal lumen). The number of sutures placed in the SSL ranges from 1 to 4. Multiple sutures can incorporate anterior and posterior walls even in unilateral SSL [55]. Expert opinion suggests tying the knots in direct contact with the SSL.

Initial reports described bilateral suspension of the vaginal apex to both SSLs [52]. Some surgeons advocate unilateral suspension, usually right sided, as it theoretically decreases the incidence of rectal injury [54, 55, 67]. Left-sided SSLF has also been described in primary or repeat procedures [60].

Special terminology considerations

As noted previously, the distance of the placement of suture or graft from the ischial spine varies, but the ligament itself must be incorporated and confirmation of SSL placement must be a part of the procedure.

Summary

Sacrospinous ligament fixation is a procedure that attaches the vaginal apex to one or both SSL(s) either with suture material or with the incorporation of graft. This procedure can be performed without entry into the peritoneal cavity, typically through a transvaginal approach.

Iliococcygeus fixation

Iliococcygeus fixation (IF) is defined as a suspension of the vaginal apex to the unilateral or bilateral medial parietal fascia of the iliococcygeus muscle(s) medial to the ischial spine using suture material (Fig. 7). Fixation to the iliococcygeus fascia is typically caudad to the ischial spine to minimize the risk of neurovascular injury [68].

Fig. 7
figure 7

Iliococcygeus fixation

In 1963, suspension of the vaginal cuff to the iliococcygeus fascia was first suggested in situations when the USLs were attenuated and not adequate for support [69]. Another author then revised the procedure and reported experience using bilateral iliococcygeus fascia suspension for the vaginal vault [70]. This technique has been used primarily when the uterus is absent but may also be used concurrent with hysterectomy or theoretically with the uterus in place [71].

Procedure description

Equipment

Iliococcygeus fixation is always approached transvaginally but does not require as extensive of a dissection of the pararectal spaces as does SSLF [54, 71,72,73,74] and does not use the intraperitoneal space as is most often the case in USLS. Therefore, vaginal equipment is needed (Table 2), but the depth of lighting and retraction needed may be less extensive in IF than in SSLF or USLS.

List of steps

  1. Step 1:

    The pararectal space is approached through a vaginal incision. When the patient has had a prior hysterectomy, a midline vertical incision is made in the posterior vaginal wall. If a hysterectomy is being performed or the uterus is in place, a posterior vertical incision in the vaginal epithelium near the apex can be performed while still avoiding the vaginal cuff repair or cervix, respectively.

  2. Step 2:

    The posterior vaginal epithelium is dissected from the underlying rectovaginal fibromuscular layer [71]. The pararectal spaces are entered and the ischial spines palpated bilaterally. The levator ani muscles and their parietal fascia are identified lateral to the rectum and anterior to the ischial spine.

  3. Step 3:

    Several interrupted sutures are placed on the parietal fascia of the iliococcygeus on each side caudad to the ischial spines along an imaginary line connecting the ischial spine and the perineum.

  4. Step 4:

    The vaginal walls are then attached bilaterally to the IF sutures. The highest IF suture is placed at the vaginal apex, and the others are passed to coincide with the lateral vaginal fornices, each one approximately 2 cm more caudad than the previous suture.

  5. Step 5:

    The sutures are tied down to suspend the vaginal apex.

Technique variations

Iliococcygeus fixation can be unilateral or bilateral, and fixation sutures may be nonabsorbable or delayed absorbable. The iliococcygeus fascia 1 cm inferior to the ischial spine is the site of choice, but any location in the iliococcygeus fascia or both fascia and muscle can also be used.

Special terminology considerations

As the iliococcygeus muscle thickness is thin (2.54 mm) in anatomic studies [75], it is impossible for surgeons to distinguish if only the parietal fascia or both the fascia and muscle are in the suture, so both situations are appropriately termed an IF.

Summary

Iliococcygeus fixation suspends the vaginal apex to the parietal fascia of the iliococcygeus muscle through a transvaginal approach. Procedures that suspend from other ligaments, even ligaments in close approximation to the iliococcygeus muscle, such as the SSL or the ATFP, would not qualify for the use of the term IF.

Hysteropexies

Anatomical studies have established that the uterus is not a cause of prolapse [76], and it is known that hysterectomy is not itself a prolapse correction surgery [77]. Hysteropexies are prolapse procedures that suspend the uterine cervix or isthmus without removal of the uterus [78].

Several types of hysteropexies are performed worldwide. Sacrohysteropexy (SHP) refers to suspension of the uterine cervix or isthmus to the anterior longitudinal ligament of the sacrum using a graft, with possible incorporation of the graft into the anterior and/or posterior vaginal walls, with preservation of the uterine body [79, 80]. Anterior abdominal wall hysteropexy (AAWHP) is defined as suspension of the uterine cervix or isthmus and possibly the fibromuscular layer of the anterior vaginal wall to the anterior abdominal wall, with or without utilization of a graft, with preservation of the uterine body [81,82,83,84]. Transvaginal hysteropexies include uterosacral hysteropexy (USHP), sacrospinous hysteropexy (SSHP), and the Manchester procedure. Uterosacral hysteropexy is defined as suspension of the uterine cervix or isthmus to the unilateral or bilateral USL(s) using suture with preservation of the uterine body [85,86,87,88,89]. Sacrospinous hysteropexy is defined as suspension of the uterine cervix or isthmus to the unilateral or bilateral SSL(s) using suture with preservation of the uterine body [90, 91], whereas SSHP with graft is the same with incorporation of graft [62, 92,93,94]. The Manchester procedure is defined as the shortening or the amputation of the uterine cervix with preservation of the uterine body and plication of the USLs extraperitoneally caudad to this amputation [95,96,97,98].

The earliest uterine preservation procedure described for prolapse was the obliterative LeFort colpocleisis in the early 1800s [99]. The first reconstructive procedure preserving the uterus was the Manchester procedure, first described in 1888 by authors in Manchester, England and subsequently documented in a case series from 1936 to 1955 in Iowa State Hospitals [96]. Historically, hysteropexies have involved the same principles as other prolapse procedures that suspend the vagina (colpopexies), including use of the same anatomical attachment structures, such as the SSLs or USLs. Thus, most colpopexy procedures could be modified to preserve the uterus [100]. For example, some of the earliest descriptions of SCP during the late 1950s in France do not recommend a hysterectomy for the vaginal suspension [101, 102]. Like other POP surgeries, hysteropexy has shifted toward less invasive approaches in recent years [103, 104], with vaginal hysteropexies using graft having the most publications in the literature [78].

Procedure description by type of hysteropexy

Sacrohysteropexy

Equipment

Sacrohysteropexy may also be performed through open abdominal [86, 105], laparoscopic, or robotic approaches [93, 106, 107], so equipment will match the approach (Table 2).

List of steps

  1. Step 1:

    The abdominal cavity is entered.

  2. Step 2:

    The anterior and posterior cervix and vaginal walls are dissected.

  3. Step 3:

    The presacral space is dissected to reveal the anterior longitudinal ligament.

  4. Step 4:

    The graft is attached to the uterine cervix and/or isthmus and possibly also to the fibromuscular layer(s) of the anterior and/or posterior vaginal walls (Fig. 8). The anterior graft is passed unilaterally or bilaterally through the mesometrium of the broad ligament. Placement of the graft only posteriorly has also been described.

  5. Step 5:

    The base of the graft(s) opposite the end(s) attached to the vagina is/are attached to the anterior longitudinal ligament of the sacrum at the S1 level.

  6. Step 6:

    Closure of the peritoneum over the graft is optional as in SCP and SCerP.

Fig. 8
figure 8

Sacrohysteropexy

Technique variations

Variations mostly are similar to those in SCP and SCerP, with additional variations on technique of graft passage through the broad ligament as discussed previously.

Anterior abdominal wall hysteropexy

Equipment

These procedures are described with or without graft, and approaches are open abdominal (with or without entry into the intraperitoneal space depending on whether the structure for suspension is retroperitoneal), laparoscopic, or robotic. Equipment is particular to the approach, fixation points, and material used for fixation.

List of steps

  1. Step 1:

    Access to the abdominal cavity abdominally or laparoscopically.

  2. Step 2:

    The uterine cervix or isthmus, with or without involvement of the fibromuscular layers of the anterior and/or posterior vaginal wall, is attached to various structures involving the anterolateral abdominal wall (Fig. 9). These anterolateral abdominal wall structures could include the round ligament, pectineal ligament, or a point near to the anterior superior iliac spine (ASIS).

  3. Step 3:

    The retroperitoneal or retropubic space is closed (if relevant) and abdominal incisions are closed to exit the abdominal space.

Fig. 9
figure 9

Anterior abdominal wall hysteropexy using the technique variation fixing a graft to the anterior uterine isthmus with the lateral ends of the graft fixed to the anterior abdominal wall near the ASIS

Technique variations

Variations on AAWHP include bilateral or unilateral suspension, suture and/or graft use, fixation of graft (if used) to the uterine cervix or isthmus with sutures or adhesive, fixation of graft or sutures to the fibromuscular layers of the anterior and/or posterior vaginal wall, and the type of graft (autologous, biologic, or synthetic) or suture (nonabsorbable, absorbable, or both) used.

If a graft is being used for fixation to the anterior abdominal wall near the ASIS, this involves a synthetic graft fixed to the anterior cervix and the fibromuscular layer of the anterior vaginal wall after dissection of the vesicovaginal space. An instrument is inserted through an incision 4 cm posterior to the iliac spine and 2 cm above the iliac crest to retract the graft arms bilaterally in the retroperitoneal space caudad to the round ligaments. The graft is then symmetrically suspended to the anterior abdominal wall posterior to the ASIS [81, 108]. Closure of the peritoneum over the graft is optional. Laparoscopic approaches to this surgery have been described in the literature [81, 108] as well as an open approach [109].

For round ligament hysteropexy, critical steps involve entry into the peritoneal cavity and passage of sutures or graft through the round ligament at its uterine insertion point. The suture or graft is then extraperitonealized and passed out through the anterior abdominal wall fascia and fixed on the anterior abdominal wall fascia [82]. This procedure can also be performed using an autologous rectus fascial grafts on each side whose lateral ends are left fixed to the rectus fascia and whose medial ends are passed into the abdominal cavity through the deep inguinal ring for attachment to the posterior uterus just cephalad to the insertion of the USLs [84]. Synthetic grafts have been used for round ligament suspension as well [110]. Round ligament hysteropexy can be unilateral or bilateral suspension or plication of the round ligaments.

In a third form of AAWHP, pectineal ligament suspension, entry is made into the retropubic space to isolate the pectineal ligament, a nonabsorbable tape is fixed to the anterior uterine cervix, the ends of the tape are passed through the pectineal ligament on either side, and the ends of the tape are elevated to elevate the uterus per the discretion of the surgeon [83]. This surgery is described as being performed through open abdominal or laparoscopic approaches [83].

Uterosacral hysteropexy

Equipment

Approaches to the USHP include open abdominal [86], laparoscopic [87,88,89], and transvaginal routes [104] with appropriate equipment for the approach (Table 2).

List of steps

  1. Step 1:

    The intraperitoneal cavity is entered and visualization of posterior cul-de-sac is obtained.

  2. Step 2:

    The USLs are identified and marked.

  3. Step 3:

    The uterine cervix or isthmus (and possibly the apical vaginal apex) is attached to the USLs similar to USLS.

  4. Step 4:

    The vaginal epithelium at the apex is closed.

Technique variations

Possible variations to USHP are also those variations common in USLS and additionally include possible cervical amputation or trachelectomy.

Sacrospinous hysteropexy

Equipment

This procedure is always performed transvaginally, with appropriate equipment this narrow space (Table 2).

List of steps

  1. Step 1:

    The vaginal wall is entered anteriorly, posteriorly, or through the vaginal apex.

  2. Step 2:

    Extraperitoneal dissection is performed to enter into the retropubic/pararectal space.

  3. Step 3:

    One or both SSL(s) is/are palpated and/or visualized and dissected for access.

  4. Step 4:

    The SSL(s) are attached to the uterine cervix or isthmus with sutures (Fig. 10) [111, 112].

  5. Step 5:

    The vaginal epithelium is closed over the incisions.

Fig. 10
figure 10

Sacrospinous hysteropexy

Technique variations

Variations on SSHP are similar to SSLF, including location of sutures on the SSL with the ideal location at least 2 cm medial to the ischial spine [113]. There is also variation on the use of cervical amputation or trachelectomy. Sacrospinous hysteropexy can also be performed with graft materials, and the steps are similar to SSLF with graft. However, the graft is affixed to the cervix (and possibly to the vaginal apex) as well as to the SSL(s).

Manchester procedure

Equipment

This procedure is always performed with a vaginal approach, and equipment for visualization and access of the vaginal apex are needed (Table 2).

List of steps

  1. Step 1:

    Transvaginal trachelectomy is performed, with or without prior dissection of the vaginal epithelium and neighboring organs cephalad away from the cervix.

  2. Step 2:

    The extraperitoneal insertion of the USLs into the cervix and apical vagina is visualized and/or palpated for identification of these ligaments.

  3. Step 3:

    The USLs are plicated across the midline caudad to the level of the internal cervical os.

  4. Step 4:

    The vaginal epithelium is closed over the apical incision.

Technique variations

Variations of the Manchester procedure involve the number of sutures used to plicate the USLs across the midline, the use of nonabsorbable and/or absorbable sutures, and the extent of tissue removal with trachelectomy (total vs partial trachelectomy or number of centimeters of cervical tissue removed distally). Surgeons also vary in their method of trachelectomy, and use of cautery devices, such as electrode loops, has been described.

Special terminology considerations

Uterine preservation should not change the terminology stem of the procedure name, but the name would change to “hysteropexy” as opposed to “colpopexy” to indicate uterine preservation. Nearly all hysteropexies could have a corresponding colpopexy with similar steps, with modifications only to accommodate presence of a uterus. For example, procedures that typically use graft material for colpopexy, such as SCP, also use graft with uterine preservation.

Summary

Hysteropexies are prolapse repair procedures in which the uterine body is preserved, and the goal is to suspend the uterine cervix or isthmus. Hysteropexy surgical terms depend on the structures to which the uterus is being suspended.

Anterior vaginal wall prolapse repairs

The following 3 distinct surgeries are considered procedures specifically for anterior vaginal wall prolapse: anterior vaginal repair, anterior vaginal repair with graft (autologous graft, xenograft, or synthetic graft), and paravaginal repair. Although other previously discussed apical repair procedures could also be considered to address anterior vaginal wall prolapse, these surgeries specifically address the anterior vaginal wall.

Anterior vaginal wall repair with or without graft

Anterior vaginal repair is defined as repair of the fibromuscular layer of the anterior vaginal wall (Fig. 11), most commonly through either the subtechnique termed anterior colporrhaphy, defined as midline plication of the fibromuscular layer of the anterior vaginal wall, or the subtechnique of site-specific anterior vaginal repair, defined as the site-specific repair of specific defects in the fibromuscular layer of the anterior vaginal wall. Despite extensive variety in the literature and in practice [114], the core of what constitutes an anterior vaginal repair is the midline suture repair of the fibromuscular layer by one of these 2 techniques. In other aspects of the surgery, there is significant practice variation [115, 116].

Fig. 11
figure 11

Anterior vaginal repair

In 1886, the first anterior vaginal repair with full thickness excision of vaginal epithelium and resuturing was described. Soon after in 1901, 2 additional authors described the support of the pelvic floor with prominence given to repair of the anterior vaginal wall [114]. Site-specific anterior vaginal repair was a variation advocated in the 1990s, which was limited to reapproximation of breaks in the fibromuscular layer [117].

Anterior vaginal repair with graft is defined as the reinforcement of the fibromuscular layer of the anterior vaginal wall with implanted graft material. One of the first graft-augmented anterior vaginal repairs was performed with tantalum mesh in 1955, followed by use of collagen mesh in 1970. In 1992, autologous tissue was used for correction of recurrent prolapse. In the late 1990s and early 2000s, there were reports released on the use of synthetic mesh in anterior vaginal wall prolapse repair preceding the US Food and Drug Administration (FDA) the FDA reports of 2008 and 2011 and subsequent concerns about the safety of these procedures [118, 119].

Procedure description

Equipment

Anterior vaginal repair is always approached vaginally with appropriate equipment for vaginal visualization and retraction (Table 2).

List of steps

  1. Step 1:

    A longitudinal midline incision is made from the approximate location of the urethrovesical junction (typically 1–3 cm from the urethral meatus and often identified with use of an inflated bulb on a transurethral catheter) to the most proximal extent of the anterior vaginal wall prolapse. Often, the anterior vaginal wall is infiltrated with local anesthetic and/or a vasoconstricting agent for hydrodissection before the incision [120].

  2. Step 2:

    The vaginal epithelium is mobilized from the underlying fibromuscular layer of the anterior vaginal wall, ideally continuing laterally to the ATFP or the inferior pubic rami [114]. The site-specific defect(s) in the fibromuscular layer of the anterior vaginal wall, if relevant, is identified.

  3. Step 3:

    A series of sutures are placed to plicate the fibromuscular layer in the midline and/or suture is used to repair site-specific defects in this layer, reducing the anterior vaginal wall prolapse [121]. One or more plicating layers can be placed.

  4. Step 4:

    The vaginal epithelium is closed with or without trimming the edges.

Technique variations

If a graft is being used in an anterior vaginal repair, deeper injection of a hydrodissecting agent may help aid in the full-thickness fibromuscular layer dissection often recommended with graft placement in this space. The fibromuscular layer of the anterior vaginal wall may or may not be plicated at the time of anterior vaginal repair with or without graft placement, but plication of the fibromuscular layer is necessary to use the subterm “anterior colporrhaphy.” Graft fixation may be determined by the graft type or may be individually crafted to the patient's anatomy. Tensor fascia lata or rectus fascia may be used as autografts. Allografts can be harvested from human cadavers (fascia lata and acellular dermal matrix), and xenografts of bovine or porcine acellular extracts are harvested from pericardium, dermis, and intestine submucosa and contain collagen and extracellular matrix. Attachment points can be to the anterior vaginal fibromuscular layer only (“graft patch”) or to the ATFP, the obturator membrane and/or obturator muscles, the iliococcygeus muscle(s), the SSL(s), or some combination of the above. Attachment can be accomplished with absorbable or nonabsorbable sutures or with bullets on a prefabricated anterior synthetic mesh product.

The incisional type and extent can vary considerably in anterior vaginal repair without changing the terminology. Some surgeons opt for an elliptical incision, excising some vaginal epithelium at the start of the procedure. When anterior vaginal repair follows vaginal hysterectomy, some surgeons perform a triangular incision extending from the urethrovesical junction to the vaginal apical incision with the base of the triangle at the proximal portion of the anterior vaginal wall. Dissection of the vaginal epithelium from the underlying tissue can be conducted with sharp, blunt or mixed technique, and the plane of dissection may be superficial, dissecting the vaginal epithelium off all underlying tissue; deep, dissecting all tissue off the bladder; or both, wherein a free layer of fibromuscular tissue is dissected off both vagina and bladder. Plication of the fibromuscular layer (anterior colporrhaphy), if being performed, can be conducted with absorbable or delayed absorbable sutures, and can be interrupted, continuous, or in a purse string, followed by closure of the vaginal epithelium [122].

Special terminology considerations

In the case of anterior vaginal repair with graft, communications with the patient and in the medical record should distinguish what type of graft was used and what attachment points were used, thus distinguishing clearly from an anterior vaginal repair without graft and communicating the relevant anatomy.

Summary

Anterior vaginal repair is a specific repair of the anterior vaginal wall fibromuscular layer, most commonly with a midline plication technique, which defines the subterm anterior colporrhaphy. Anterior vaginal repair with graft refers to graft implanted in the vesicovaginal space to improve mechanical strength of an anterior repair while preserving the basic surgical approach.

Paravaginal repair

Paravaginal repair is defined as the approximation of the lateral fibromuscular layer of the anterior vaginal wall to the tendinous arch of the pelvic fascia (ATFP) (Fig. 12). In 1909, a transvaginal procedure consistent with a paravaginal repair was reported that involved anterior vaginal wall plication sutures reaching to the ATFP as opposed to merely plicating the fibromuscular layer as is performed in anterior colporrhaphy [123]. The same procedure was also suggested in 1976 when it was noted that detachment of the pubocervical fascia from the ATFP is associated with descent of the lateral part of the anterior wall. In 1981, the same author reported the outcome of paravaginal defect repair, and over a decade later, a case series reported the results of surgical repair of bilateral paravaginal defects [37, 117, 124].

Fig. 12
figure 12

Paravaginal repair

Procedure description

Equipment

This procedure can be accomplished through an open abdominal, laparoscopic, or a vaginal approach. Regardless of approach, surgery always takes place in the retropubic space and equipment should be appropriate to visualize, enter, and retract within this space (Table 2).

List of steps

  1. Step 1:

    In the abdominal or laparoscopic approach, the patient should be positioned in low dorsal lithotomy position to allow for a combined abdominal and vaginal approach. In the vaginal approach, standard lithotomy is most appropriate.

  2. Step 2:

    A transurethral catheter is inserted into the bladder.

  3. Step 3:

    The retropubic space is accessed via the peritoneal cavity through laparoscopic incisions, via the anterior abdominal wall by entering the rectus fascia through an open abdominal incision, or via perforation of the ATFP through a vaginal incision.

  4. Step 4:

    After opening the retropubic space, the bladder and vagina are retracted medially for better visualization of the lateral retropubic space. Gentle blunt dissection is used to visualize the ischial spine and ATFP.

  5. Step 5:

    Either delayed absorbable or nonabsorbable sutures are placed from the fibromuscular layer of the anterior vaginal wall to the ATFP. These sutures are placed bilaterally and extend from the ischial spine to the pubic bone insertion of the ATFP. Although the number of sutures varies (3–5 per side), they are typically placed at 1-cm intervals. If placing nonabsorbable sutures from the abdominal side (abdominal or laparoscopic approach), care is taken to avoid placing suture into the vaginal lumen. In the abdominal or laparoscopic approach, suture placement is facilitated by insertion of 2 fingers of the surgeon's nondominant hand into the vagina and retraction of the bladder with an atraumatic instrument.

  6. Step 6:

    The sutures are sequentially tied [121, 125].

  7. Step 7:

    The retropubic space is closed either by reperitonealizing the bladder (laparoscopic approach), closing the rectus fascia (open abdominal approach), or closing the vaginal epithelium (vaginal approach).

  8. Step 8:

    In the abdominal or laparoscopic approaches, subcutaneous and/or skin closure is performed.

Technique variations

In the vaginal approach, the surgeon may or may not incorporate the vaginal epithelium in the sutures attaching the fibromuscular layer of the anterior vaginal wall to the ATFP. If the epithelium is being incorporated, suture placement uses a 3-point closure that places the sutures in the ATFP, followed by suture passage through the fibromuscular layer and finally through the vaginal epithelium. A midline vaginal fibromuscular layer plication (anterior vaginal repair with the anterior colporrhaphy technique) may or may not be performed concurrently. The direction of suture placement may vary by approach; in the vaginal approach, the surgeon usually starts placing sutures as close to the urethral meatus as possible and works posteriorly toward the ischial spine. In the abdominal or laparoscopic approach, either direction may be used.

Special terminology considerations

Because of the retropubic location of this procedure and its specific support of the anterior vaginal wall, this procedure is often misconstrued as a surgery for stress urinary incontinence. To avoid terminology confusion, care should be taken to link paravaginal repair to the diagnosis of anterior vaginal wall prolapse and avoid terms such as “bladder lift” or “sling” in discussion of this procedure.

Summary

Paravaginal repair is the reattachment of the fibromuscular layer of the lateral anterior vaginal wall to the ATFP and may be achieved with vaginal, laparoscopic, or abdominal approach.

Posterior vaginal wall prolapse repairs

Anatomical structures involved in support of the posterior vaginal wall are the peritoneum of the cul-de-sac, the rectum, and the perineum [126]. Thus, the loss of fibromuscular support overlying the rectum, laxity and separation of the levator ani plate with widening of the levator hiatus, and tearing or separation of the perineal musculature are deficiencies associated with posterior vaginal wall prolapse. Surgeries to correct these deficits involve the following 4 distinct terms: (a) posterior vaginal repair [127], (b) posterior vaginal repair with graft [128], (c) perineal repair, and (d) levator plication.

Posterior vaginal repair with or without graft

Posterior vaginal repair is defined as repair of the fibromuscular layer of the posterior vaginal wall (Table 1, Fig. 13), either through a technique of midline plication of the vaginal fibromuscular layer, which defines the subterm posterior colporrhaphy or through a technique of deification and site-specific repairs of defect(s) in the fibromuscular layer defining the subterm site-specific posterior vaginal repair. The term posterior colporrhaphy was originated in Heidelberg, Germany, in 1867, when a surgeon applied it to 30 cases of uterine prolapse [129]. However, this term is now used to describe surgeries to correct posterior vaginal wall prolapse that plicate the fibromuscular layer in the midline. Site-specific posterior vaginal repair was a variation advocated in the 1990s, which was limited to reapproximation of breaks in the fibromuscular layer [130]. Plication of the levator ani muscle in the midline was formerly considered part of the posterior vaginal repair; it is now considered a separate procedure [127].

Fig. 13
figure 13

Posterior vaginal repair

Posterior vaginal repair with graft is defined as reinforcement of the fibromuscular layer of the posterior vaginal wall with implanted graft material (Table 1). The graft material is meant to act as a scaffold and potentially replace or augment the fibromuscular layer of the posterior vaginal wall [128].

Procedure description

Equipment

Posterior vaginal repair is typically performed transvaginally, but transabdominal (open or laparoscopic) [131], transanal, and transperineal [132, 133] approaches are also described. Equipment must be appropriate for the spaces entered (Table 2). All published studies on posterior vaginal repair with graft have used a transvaginal approach.

List of steps

  1. Step 1:

    A longitudinal incision is made in the posterior vaginal epithelium. The posterior vaginal wall is often infiltrated with local anesthetic and/or a vasoconstricting agent for hydrodissection before the incision.

  2. Step 2:

    The vaginal epithelium is dissected to expose the underlying fibromuscular layer, and this dissection is carried out laterally to the medial aspect of the levator ani muscles and inferiorly to the perineal body. If a graft is going to be used, an additional dissection may be performed opening the space between the fibromuscular layer and the rectum.

  3. Step 3:

    Defects(s) in the fibromuscular layer of the posterior vaginal wall (if relevant) are identified.

  4. Step 4:

    The fibromuscular layer of the posterior vaginal wall is plicated across the midline and/or site-specific defects in this layer is repaired with suture. This step must be performed cephalad to the hymenal ring. If a graft is being used, midline plication and/or site-specific repair with sutures is optional. The graft is trimmed if indicated and attached as desired to the fibromuscular layer of the posterior vaginal wall or surrounding structures. The graft may be placed in a plane anterior to, posterior to, or within the fibromuscular layer of the posterior vaginal wall.

  5. Step 5:

    The vaginal epithelium is closed over the repair.

Technique variations

Possible variations described in the literature include the extent of the vaginal incision, the layer(s) of dissection (above the fibromuscular layer, splitting the thickness of the fibromuscular layer, or removal the fibromuscular layer off the rectum), the use of nonabsorbable or delayed absorbable suture, different suture gauges (0 or 2-0), the number of sutures used, plication of the fibromuscular layer across the midline alone and/or repair of specific defect(s) (“site-specific posterior repair”) [134], and use of running or interrupted sutures for plication [135].

Variations of posterior vaginal repair with graft include different vaginal incisions, the layer(s) of dissection, use of nonabsorbable or absorbable sutures to fix the graft, whether or not underlying sutures in the fibromuscular layer are placed for plication and/or site-specific correction of defects, the number of graft arms or fixation points necessary to stabilize the augmented material, and the number of fixation points for the posterior graft. Graft attachment is ideally as close to the vaginal apex as possible in the cephalad direction, fixed laterally to the levator ani fascia, and fixed inferiorly to the perineal body, but different fixation points and sizes exist for different graft types. The most commonly described forms of graft materials are as follows: biologic graft (dermal, porcine submucosal), absorbable mesh (polyglactin, polydioxanone), nonabsorbable synthetic mesh (polypropylene), or composite (eg, polyglactin-polypropylene).

In posterior vaginal repair with graft, full-thickness dissection in the space between the vaginal epithelium and the fibromuscular layer of the posterior vaginal wall (as opposed to split thickness as often used in posterior vaginal repair without graft) often is described to theoretically reduce the risk of graft exposure. However, the depth of dissection or the layer in which the graft is placed would not change the terminology. Suturing of the graft into place is typically described as tension free, but the surgeon may modify the tension as clinically indicated without changing the terminology.

Special terminology considerations

As all techniques of posterior vaginal repair are performed in extremely close approximation to the rectum, the procedure may be mistaken for procedures to support the rectum (eg, rectopexy) or for reconstruction of the anal sphincter (eg, anal sphincteroplasty). As these are not vaginal prolapse indications, confusing terms, such as “rectal repair,” “anal repair,” or “rectocele repair,” are discouraged.

Summary

Posterior vaginal repairs use midline fibromuscular plication, which defines the subterm posterior colporrhaphy, and/or site-specific fibromuscular repair, which defines the subterm site-specific posterior vaginal repair. Posterior vaginal repair with graft carries the same definition as posterior vaginal without graft with the additional criteria that some type of graft material must be integrated into the posterior vaginal repair.

Perineal repair

A perineal repair is defined as approximation of the muscular tendon components of the perineal body back into the perineal body (Table 1, Fig. 14). The components approximated can include the deep and superficial transverse perineal muscles, the distal end of the fibromuscular layer of the posterior vaginal wall, the bulbospongiosus muscles, the anterior fibers of the external anal sphincter or its capsule, the puborectalis muscle, which contributes fibers to the superior external anal sphincter, and/or the perineal membrane. A perineal repair incorporates structures that are caudad to the hymenal remnant, in contrast to a posterior vaginal repair, which involves structures that are more proximal or cephalad to the hymenal remnant. The perineal body extends 2- to 3-cm proximal/cephalad to the hymenal ring and is attached laterally to the puborectalis muscle. The aim of perineal repair is to narrow the genital hiatus and lengthen the perineal body to provide distal support to the vagina [136].

Fig. 14
figure 14

Perineal repair

Perineal repair is historically performed at the end of various other prolapse repairs, especially posterior vaginal repair or colpocleisis; in most textbooks, this procedure is not described separately from the others. However, identification of this surgical term as an individual procedure is important in operative terminology.

Procedure description

Equipment

A perineal repair can be approached transvaginally or transperineally, and basic equipment is the same as for other vaginal prolapse surgeries (Table 2).

List of steps

  1. Step 1:

    A perineal repair is started by identifying the area of attenuation and the area of vaginal epithelium that needs to be excised. This is performed with Allis clamps at varying distances right and left of midline at the level of the hymen.

  2. Step 2:

    A diamond- or sickle-shaped incision is made to remove a portion of distal vaginal epithelium and perineal skin. The underlying fibromuscular tissue may be undermined from the vaginal epithelium as well.

  3. Step 3:

    Sutures are placed to approximate the selected perineal body components.

  4. Step 4:

    Optional closure of the vaginal epithelium overlying these deep sutures.

Technique variations

The starting point of the surgery may be the hymenal ring or the introitus, defined as where the line of the labia minora meets the perineum [137]. The extent of skin incision and dissection varies according to the extent of the defect [138]. There are variations in suture type and gauge [136]. The order of perineal muscle approximation can vary and may be performed individually or en bloc [136]. The approximated perineal body muscles can be attached superiorly to the levator ani muscles and/or the fibromuscular layer of the posterior vaginal wall [136].

Special terminology considerations

If the surgeon is performing a posterior vaginal repair at the same time, which is common, the terms “colpoperineorrhaphy” or “colpoperineoplasty” to designate the performance of both procedures should be avoided as it does not clearly delineate the posterior vaginal repair and the perineal repair. The term “perineoplasty” is not acceptable for perineal repair, as the term “perineoplasty” has been used interchangeably with widening genital hiatus for vaginal stenosis [139]. However, the synonym “perineorrhaphy” is acceptable as this term more specifically describes the nature of perineal repair.

In communications regarding this procedure, the specific components of the perineal body that the surgeon integrated should be specified, as the term perineal repair, while most appropriate, is not specific to which muscular or structural components are integrated by the surgeon. These details may be important in ongoing care of the patient or in the management of complications.

Summary

Perineal repair is performed to address a defect or attenuation of the perineal body, and it must approximate muscles of the perineal body. It generally results in a decrease in the size of the genital hiatus and an increase in the length of the perineal body.

Levator ani plication

Levator ani plication involves plication of the levator ani muscle toward the midline, incorporating a portion of the lateral fibromuscular layer of the posterior vaginal wall (Table 1) [140]. It is considered a constricting surgical procedure in which the goal is to narrow the distal vagina to close a defect in the genital hiatus. It is relatively contraindicated in women who have or desire future receptive vaginal intercourse because of high rates of dyspareunia.

Procedure description

Equipment

A levator plication can be performed transperineally or transvaginally, and basic equipment matches these approaches (Table 2).

List of steps

  1. Step 1:

    The distal portion of the levator ani muscles is identified either before or after the repair of the fibromuscular tissue in a posterior vaginal repair.

  2. Step 2:

    Sutures are placed laterally in the levator ani muscles incorporating a portion of the lateral fibromuscular layer of the posterior vaginal wall.

  3. Step 3:

    The sutures are tied in the midline to draw the muscles together to create a muscular shelf.

Technique variations

Variations include the direction of suture placement to approximate the levator muscles and how many sutures or what suture types are placed. Variation exists in closure of vaginal or perineal epithelium over the muscle approximation sutures; some surgeons do not close this at all, some do only if needed for hemostasis, and some routinely close the epithelium.

Special terminology considerations

Even if the appropriate term is being used in communications about this procedure, the number of sutures and type of suture should be described in the operative report, as this may inform subsequent care. “Levatorpexy” is not an acceptable term, but the terms levatorrhaphy or levator myorrhaphy are acceptable if not ideal, as they describe the anatomy and procedure accurately.

Summary

Levator ani plication is performed to narrow the vaginal caliber by approximating the anterior levator ani muscles with sutures to create a distal muscular shelf.

Obliterative procedures

Obliterative procedures for POP, often termed colpocleisis, are defined as obliteration of the vaginal canal by removal of vaginal epithelium on the anterior and posterior vaginal walls and suturing together the fibromuscular layers of the anterior and posterior vaginal walls (Fig. 15). These procedures have high anatomic success, low rates of complications, and high patient satisfaction [141,142,143,144,145]. Obliterative procedures can be performed with or without hysterectomy where the uterus is in place or performed in the setting of a prior hysterectomy (Table 1). Procedures leaving the uterus in place, such as the eponymous LeFort colpocleisis, often involve the creation of bilateral epithelialized tunnels from the cervix to the introitus.

Fig. 15
figure 15

Colpocleisis

A surgeon in Metz, France, first suggested the idea of colpocleisis in 1823. Nearly 40 years later, in 1867, L. Neugebauer of Warsaw, Poland, performed the first procedure successfully. Over a century later, L. Le Fort of Paris popularized the procedure in 1977 with a recommendation of a broader surface denudation before suturing the anterior and posterior vaginal fibromuscular layers together. In the United States, colpocleisis with uterine preservation is still known as a “LeFort” procedure, and in other European Union countries, it is known as “Neugebauer-Le Fort.” Although Le Fort did not originally include a concomitant hysterectomy with colpocleisis, 20th century advances in anesthesia allowed surgeons to include hysterectomy. The addition of hysterectomy was popularized to reduce the potential risk of future endometrial or cervical cancer [141, 146].

Procedure description

Equipment

These procedures are always approached vaginally and require minimal instrumentation without the need for long instruments or lighting for deep spaces. Some surgeons use synthetic of biological graft between the anterior and posterior vaginal layers [147]. If tunnels are being created in a colpocleisis without hysterectomy, a vessel loop or small catheter may be used to ensure patency [148].

List of steps

  1. Step 1:

    The vaginal epithelium is dissected off the underlying fibromuscular layers anteriorly and posteriorly, with or without leaving epithelial strips for later creation of tunnels for drainage.

  2. Step 2:

    Multiple layers of sutures are placed plicating the posterior to the anterior fibromuscular layer of the vaginal walls, either with purse-string or horizontal rows of interrupted sutures as appropriate.

  3. Step 3:

    The vaginal epithelium on the distal edge of the repair is closed to make a new vaginal apex within a few centimeters of the hymen [144, 149,150,151,152].

Technique variations

The decision to perform a hysterectomy at the time of colpocleisis should be individualized, and terminology used should specify if the uterus was present at the outset of the procedure, left in place, or if the colpocleisis was performed on a vaginal vault after a prior hysterectomy.

For a colpocleisis without hysterectomy (sometimes referred to as a modification of the Le Fort procedure), the anterior vaginal epithelium is removed proximal/cephalad to the urethrovesical junction to the cervix and the posterior vaginal epithelium is removed from the hymen to the cervix leaving at least 3-cm strips of intact vaginal epithelium along the lateral sides of the vagina. These remaining epithelial strips are used to create bilateral, epithelialized vaginal tunnels for potential uterine or cervical fluid drainage. The remaining fibromuscular layers of the anterior and posterior vaginal walls are then brought together with sequential rows of absorbable suture. A colpocleisis in the setting of either a prior hysterectomy or with a concurrent hysterectomy involves a more extensive denudation of the anterior and posterior vaginal epithelium without the creation of tunnels. It also involves approximation of the anterior and posterior fibromuscular layers in sequential sutures (either purse-string or horizontal rows).

Special terminology considerations

Extensive perineal repair and/or levator plication are often performed concurrently with colpocleisis to decrease the size of the genital hiatus, as colpocleisis patients typically do not desire future coital activity. However, the use of the term “colpocleisis” does not automatically imply a levator plication and/or a perineal repair, so if these are performed, they must be specified as separate procedures. Some surgeons opt to perform endometrial sampling before performance of colpocleisis without hysterectomy, but this procedure is not assumed when the term colpocleisis is used, so surgeons must specify if dilation and curettage are performed at the same time.

Summary

Obliterative procedures result in a narrow, short vagina without an internal opening when the uterus is absent (colpocleisis with hysterectomy or colpocleisis of vaginal vault). In colpocleisis without hysterectomy where the uterus is left in place (Le Fort variation), tunnels for uterine or cervical drainage are ensured. Colpocleisis is always accomplished by some type of attachment of the fibromuscular layers of the anterior and posterior vaginal walls to one another.

Discussion and recommendations

The joint writing group of AUGS and IUGA concludes that surgical procedures to address POP require standardized definitions and have presented in this document relevant surgical terminology with detailed discussion of the associated surgery. This standardized terminology was developed, where possible, to include wording that highlights anatomical structures involved in the procedures and is specific enough not to be confused with other procedures for POP for which standardized terms have been developed. Conversely, the terminology in this document was developed to allow for some appropriate variations in the surgical steps, which we have outlined above.

It should be noted that, in general, discussion of a term in this document is neither an endorsement of that procedure nor intended to be a comprehensive discussion of either all the variations that have and could arise in the future. In addition, definition of a term in this document does not signify that the required procedural steps cover all procedures that should or could be performed concurrently for POP or other indications. For example, it is recommended to perform cystoscopy and a digital rectal examination after completion of most POP repair surgeries, but correct use of a surgical term from this document would not automatically indicate that cystoscopy and rectal examination were performed and had normal findings. Therefore, surgeons must be clear in communications that these recommended adjunct steps were completed and note the resultant findings.

We recommend that this terminology be used in communications regarding patient care, research, academic discussion, and medical oversight (including tracking of quality metrics and productivity for individual surgeons or medical groups). Furthermore, it would be ideal for the medical profession to integrate these recommendations into medical terminology around billing, coding, and financial tracking in the future, as this could avoid further miscommunication. Acknowledgment of these standardized terms in written academic publications related to female pelvic floor disorders should be indicated in the section Methods and Materials, or its equivalent, to read as follows: “Methods, definitions and units conform to the standards jointly recommended by the American Urogynecologic Society and the International Urogynecological Association, except where specifically noted.”

The writing group's aim is that this terminology will allow sufficient clarity to communication of POP repair surgeries while still allowing sufficient variation and flexibility in an evolving surgical field.

Change history

  • 08 May 2020

    Developed by the Joint Writing Group of the American Urogynecologic Society and the International Urogynecological Association.

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Acknowledgements

The following are being recognized for their contributions to this article: Kate V. Meriwether, MD (University of New Mexico, Albuquerque, NM); Karen P. Gold, MD MSCI (University of Oklahoma, School of Community Medicine, OK); Renaud de Tayrac, MD (Service de Gynécologie-Obstétrique, CHU Carémeau, Nîmes Cedex 9, France); Sara B. Cichowski, MD (Oregon Health Sciences University, Portland, OR); Vatche A. Minassian, MD, MPH (Brigham and Women’s Hospital, Boston, MA); Rufus Cartwright, MD (Res), PhD (Oxford University Hospitals NHS Trust, London, United Kingdom); Pawel Miotla, MD, PhD (Medical University of Lublin, 2nd Department of Gynaecology, Lublin, Poland); Cara L. Grimes, MD, MAS (New York Medical College, Valhalla, NY); Luiz G.O. Brito, MD, PhD (Department of Obstetrics and Gynecology, State University of Campinas, Campinas, Brazil); Tony M. Bazi, MD (American University of Beirut Medical Center, Beirut, Lebanon); Cassandra L. Carberry, MD (Alpert Medical School of Brown University/Women and Infants Hospital, Providence, RI); Lan Zhu, MD (Peking Union Medical College, Dong Dan, Dongcheng, Beijing, China); and Rebecca G. Rogers, MD (University of Texas at Austin, Dell Medical School, Austin, TX).

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K.V.M. is a voting board member for Society of Gynecologic Surgeons with travel stipend and received book editor royalties from Elsevier publishing. R.G.R. received royalties from Uptodate and stipend and travel from the American Board of Obstetrics and Gynecology (ABOG) and International Urogynecologic Association (IUGA). C.L.G. is an expert witness for Johnson & Johnson. R. D. is a consultant for Boston Scientific (personnel fees and research grant) and for Coloplast (research grant) and received travel fund from the European Urogynaecological Association (EUGA). The other contributors have declared that there are no conflicts of interest.

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This report is being published concurrently in Female Pelvic Medicine and Reconstructive Surgery and in International Urogynecology Journal. The report is identical except for minor stylistic and spelling differences in keeping with each journal’s style. Citations from any of the two journals can be used when citing this article.

Correspondence: Kate V. Meriwether, University of New Mexico Hospital, 2211 Lomas Blvd NE, 4th Flr, Department of Obstetrics & Gynecology, Albuquerque, NM 87106, USA.

E-mail: meriwet2@salud.unm.edu.

Appendix 1: Future Directions of selected procedures

Appendix 1: Future Directions of selected procedures

Sacrocolpopexy:

The use of tacking devices to complete an all-vaginal approach [153], as well as transvaginal single-port laparoscopic SCP with the graft attached to the sacrum with suture, have been described [154, 155]. Fixation of the graft to the anterior and posterior vagina with adhesive at the time of SCP has been described and found to decrease the time of procedure [156,157,158].

Uterosacral ligament suspension:

These techniques have remained largely unchanged since their original description, but future directions could include improved suture materials, devices for USL tenting and suture placement in the same orientation, or improved lighting devices for better anatomical visualization.

Sacrospinous ligament fixation:

Similar to USLS, this procedure remains mostly unchanged since its initial description with the exception of newer needle passage devices. Future directions could include improved suture materials, more ergonomic or endoscopic linked suture passage devices, or improved lighting devices for better anatomical visualization.

Hysteropexy procedures:

The future of hysteropexy will likely involve development of natural orifice transluminal endoscopic surgery (NOTES) or graft fixation technology [159] to allow for less morbidity and increased durability of nonabsorbable graft use in approach to SHP [86, 93].

Anterior and posterior vaginal wall repairs:

Tissue culture engineering may aid in the creation of a biologically based graft that has ideal characteristics for implantation in anterior or posterior vaginal wall repairs. For posterior repair, some experimental studies with endometrial mesenchymal stem cells as targeted therapy for POP were published; however, human studies are needed [160]. To date, there is no innovative technology that has demonstrated improved clinical outcomes over native tissue repairs in the posterior compartment [127, 161,162,163], so the use of augmentation materials in prolapse surgery has been under scrutiny, and at present, studies in this area are not encouraging. The use of mesenchymal cells with synthetic grafts has been tested to improve use of the material, but no clinical evidence of better results to this moment [164].

Appendix 2: Transvaginal mesh procedures for POP in 2019

Certain prefabricated transvaginal grafts, which were available in early 2019, were withdrawn from the marketplace following an April 2019 order from the US FDA for “manufacturers of all remaining surgical mesh products indicated for the transvaginal repair of pelvic organ prolapse to stop the sale and distribution their products in the US immediately.” [165] This news release followed a convening of an advisory committee meeting “on the issue to share available evidence and seek expert opinion on how to evaluate the risks and benefits of these devices.” Specifically, they determined in their advisory committee that the manufacturers still with products on the market had not adequately demonstrated “reasonable assurance” that these devices had safety and effectiveness, which is the standard for class 3 surgical devices. Surgical mesh products for transvaginal repair of POP have been class 3 products since their reclassification by the FDA in January of 2016.

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Developed by the Joint Writing Group of the American Urogynecologic Society and the International Urogynecological Association. Joint report on terminology for surgical procedures to treat pelvic organ prolapse. Int Urogynecol J 31, 429–463 (2020). https://doi.org/10.1007/s00192-020-04236-1

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Keywords

  • vaginal prolapse
  • pelvic organ prolapse
  • surgery
  • repair
  • terminology
  • standardization