Abstract
Recurrent pelvic organ prolapse is a challenging clinical scenario for the urogynecologist. Recurrence can be objective based on physical examination, or subjective based on patient-reported return of symptoms. Management of recurrent prolapse is dependent on the risks and benefits of proposed management options and should be driven by patient’s desires and expectations. Surgical correction of recurrent prolapse can be addressed via vaginal, abdominal, or laparoscopic routes. The need for apical suspension should always be evaluated and addressed as indicated. Native tissue repairs have good outcomes with low complication rates. Mesh can be considered for recurrent apical and anterior compartment prolapse.
Commentary by Howard B. Goldman, Cleveland Clinic, Glickman Urologic and Kidney Institute, Cleveland, OH, USA
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Michigan four-wall sacrospinous ligament suspension for vaginal vault prolapse. (Courtesy of Kindra Larson, MD, Daniel Morgan, MD, John O.L. DeLancey, MD) (MP4 76773 kb)
Commentary
Commentary
Recurrence after pelvic organ prolapse repair is not an uncommon occurrence. Drs. Schmidt and Fenner do an excellent job reviewing risk factors, evaluation, and management options of such recurrences. A few important points they noted to prevent recurrence are highlighted.
It is unusual to have significant prolapse, particularly involving the anterior compartment, without associated apical prolapse. Accordingly, it is critical that apical prolapse be identified and addressed, as failure to do so almost certainly dooms the isolated anterior repair to failure. This points to the challenge of an effective anterior compartment repair. This compartment appears to be the most likely to recur, particularly when stage 3 or greater.
Opposing compartment defects should also be identified. As the authors note, mild prolapse in one compartment may enlarge to fill the space occupied by an opposing larger prolapse after the larger one is repaired. Thus, prolapse of any significance should be repaired if one is embarking on the repair of any symptomatic prolapse.
The importance of a colpocleisis or some other obliterative procedure – perhaps a levator myorrhaphy in those without any significant posterior prolapse – in the woman who has no plans for future sexual activity should not be understated. These procedures have high success rates, low complication rates, and are not difficult to perform. For the appropriate patient, an obliterative procedure is ideal as either the primary or secondary operation.
There is an inherent recurrence rate after prolapse repair. Future advances in regenerative medicine may hold the promise of reducing or preventing prolapse and its recurrence. Only time will tell.
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Schmidt, P., Fenner, D.E. (2021). Addressing Recurrent Pelvic Organ Prolapse: Unique Challenges of Recurrent Prolapse. In: Kobashi, K.C., Wexner, S.D. (eds) Female Pelvic Medicine. Springer, Cham. https://doi.org/10.1007/978-3-030-54839-1_16
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