The aim of surgical repair must address the need to preserve or improve function and should restore normal anatomy. The route of surgical management is rife with controversy. There are different procedures that can be performed by the vaginal, abdominal and the laparoscopic or robotic laparoscopic approach.
Proponents of the vaginal approach claim that the presence of good pelvic floor tone and the presence of good endopelvic fascia are prerequisites for a vaginal procedure. However, the argument against this would be that it would seldom be the case in patients with existing vault prolapse.
A longitudinal incision is made over the posterior vaginal wall and extended to the apex of the vaginal wall. The vaginal mucosa is dissected away from the rectovaginalis fascia until the puborectalis muscle is identified. The sacrospinous ligament that runs from the ischial spine to the sacrum is then identified by sharp and blunt dissection. Two sutures are inserted through the sacrospinous ligament and secured to the apex of the vagina. This has been made technically easier by the introduction of newer devices to capture the suture during insertion into the sacrospinous ligament.
A long-term follow-up of 55 patients reported a high rate of sexual dysfunction. Good vault suspension was reported. However, more than a third of the patients had prolapse of the other compartments.
A review of articles on sacrospinous fixation between 1996 and 2010 concluded that sacrospinous fixation achieves good long-term objective and subjective outcomes and improves quality of life in women with pelvic organ prolapse. The complication rates were stated to be comparable to those of abdominal sacrocolpopexy and lesser than those of transvaginal mesh procedures. Surgeons who approve of this procedure argue that it is cost effective and time tested.
Maher et al. reviewed three trials and reported no significant difference in prolapse outcomes with abdominal or vaginal sacrospinous colpopexy. However, subjective failure of the procedure was twice as much in the vaginal arm compared with abdominal sacrocolpopexy.
An incision is made in the posterior vaginal wall along with an incision in each gluteal region. A tunnelling device is used to insert the mesh through one buttock and with a finger in the vaginal incision, it is passed around the rectum. The mesh is then guided through the vagina and retrieved through the contralateral gluteal incision. This is then sutured to the top of the vagina as a tension free mesh.
A prospective study of 21 patients reported that, in the short term, there was both subjective and objective improvement in prolapse symptoms. The studies analysed by the NICE guidance for iliococcygeal fixation concluded that failure occurred in 10% and 2–30% had further surgery. Mesh erosion occurred in 7–21%, infection in 5% and rectal perforation in 1%. The main criticism of this procedure by surgeons preferring the abdominal route is a high incidence of mesh erosion with the attendant complications of bleeding, pain and dyspareunia.
Hence, NICE recommended that, due to inadequate data on efficacy and safety of this procedure, it ‘should only be used with special arrangements for clinical governance, consent and audit or research’.
This was first described by Le Fort in the late 18th century. There has been renewed interest in the procedure in recent years. A short series of cases has reported good patient satisfaction, objective improvement in prolapse outcomes and improved quality of life measures. Various modifications have been suggested including perineocleisis, partial and near total vaginectomy and colpocleisis in combination with incontinence procedures. This is often the procedure of choice in older patients over 80 years of age, with comorbid conditions. It restores quality of life, especially in patients with limited mobility, complications with the use of pessary such as ulceration and bleeding or to aid care of such patients by carers in homes. Success rates as high as 97% have been reported in a short-term follow-up study.
Vaginal mesh kits
There has been a recent increase in the availability of trocar-based vaginal devices for surgical treatment of vaginal prolapse. The FDA has reviewed the evidence and concluded that ‘surgical mesh in the transvaginal repair of pelvic organ prolapse does not improve symptoms or quality of life more than non-mesh repair’. The commonly reported complications were mesh erosion into the vagina needing further surgery, mesh contraction with vaginal shortening, tightening and pain. Better quality meshes and more robust evidence is required before widespread use of this procedure. There is a need for these new procedures to be research-driven rather than be industry-driven.
A recent review by the Canadian Urogynaecology Committee concluded that the vaginal mesh kits must be considered novel until further evidence is available. It also stressed the need for specialist training before undertaking these complex surgical procedures.
The use of vaginal mesh is a rapidly advancing and evolving science. Well constructed trials should establish patient selection criteria and the required surgical techniques to minimise complication rates.
The proponents of this route for the treatment of vaginal vault prolapse argue that it preserves vaginal length, prevents scarring and thereby improves sexual function by avoiding shortening and dyspareunia. Inherent to this approach, however, is longer recovery and hospital stay compared with the vaginal route.
A long-term follow-up of 21 patients with a median of 55 months concluded that abdominal sacrocolpopexy provided long-term symptom relief as well as anatomical stability.
A review by Maher concluded on the basis of three randomised trials that abdominal sacrocolpopexy had lesser recurrence of vault prolapse and dyspareunia when compared with sacrospinous fixation. However, an abdominal procedure involves longer surgical and recovery time and is less cost-effective. A more recent update of the topic has confirmed that there are no ongoing randomised controlled trials currently. NICE guidance recommends that the current evidence on the safety and efficacy of sacrocolpopexy using mesh for vaginal vault prolapse repair appears adequate to support the use of this procedure.
This is becoming increasingly popular with the added benefits of minimal access surgery such as shorter hospital stay, lesser analgesia and quicker recovery which are often criticisms when the open sacrocolpopexy is compared with and the vaginal procedures such as sacrospinous ligament fixation. It does take a longer surgical time in comparison to other procedures. A recent randomised trial between the total vaginal mesh and the laparoscopic sacrocolpopexy concluded that the laparoscopic sacrocolpopexy group had a longer operating time, reduced inpatient days, and quicker return to activities of daily living compared with the total vaginal mesh group. The follow-up review after 2 years concluded that both total objective prolapse rates for all compartments as well as reoperation rates were considerably higher in the vaginal mesh group.
The 1 year follow-up from the laparoscopic sacro-colpopexy trial in the UK concludes that the laparoscopic sacrocolpopexy with mesh is equivalent to open sacrocolpopexy with regard to vaginal vault correction with inherent advantages of the laparoscopic approach for these patients.
Robotic laparoscopic sacrocolpopexy
A recent development is the robot-assisted laparoscopic approach. It offers better visualisation and precise movements during surgery. The procedure itself is similar in principle to the abdominal sacrocolpopexy. The ports include the central umbilical camera port, three surgical robot ports and a port for the assistant. This has the added benefit of shorter hospital stay, less bleeding and better patient satisfaction. The capital cost of setting up the service is very high.