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    The future of treating pelvic organ prolapse

     

    Surgical management

    Patient-centered care and patient involvement in medical decision-making is critically important when a woman is considering elective surgery. Clinicians must recognize that patients’ values are rooted in personal and cultural beliefs that are not always captured in traditional medical guidelines.20

    Surgical reconstructive procedures

    The surgical route for pelvic organ prolapse can be vaginal, laparoscopic/robot-assisted, or abdominal. Addressing the vaginal apex is a key component of successful prolapse repair.21 Experts recommend that whenever a surgeon performs a hysterectomy, especially for prolapse, the apex must be supported or the repair is doomed to fail. Despite adequate support of the apex, all prolapse procedures carry with them a risk of failure.

    Native tissue repair

    Native tissue repair refers to correction of prolapse using the patient’s own tissue and suture material without mesh augmentation. These procedures typically include apical repairs, such as uterosacral ligament suspension (USLS) or sacrospinous ligament suspension (SSLS). Such procedures can be performed immediately after a vaginal hysterectomy or with vaginal vault prolapse. A large randomized controlled trial (RCT) comparing USLS to SSLS reported no difference in surgical success rate (composite of subjective and objective measures) or adverse events between the 2 surgical techniques at 2 years. USLS success rate was 64.5% vs 63.1% for SSLS, P=0.84.22

    Mesh-augmented repairs

    Sacrocolpopexy utilizes a non-absorbable polypropylene mesh that is affixed to the anterior and posterior vagina and secured to the anterior longitudinal ligament of the sacrum. Although it is traditionally performed abdominally, over the past 10 years, more surgeons have adopted a minimally invasive technique.23

    The clinical benefit for a robot-assisted laparoscopic sacrocolpopexy (RALSC) over a laparoscopic sacrocolpopexy (LSC) has yet to be established. A recent meta-analysis and systematic review comparing LSC and RALSC found that the mean operative time for the RALSC was significantly longer than for the LSC (245.9 minutes vs 205.9 minutes, P < 0.001), estimated blood loss and complications were similar, but costs were significantly higher with the RASLS.24

    SCP has long been considered the “gold standard” surgery for POP as it had higher and longer-lasting rates of success compared to vaginal procedures.25 However, 7-year follow up from a RCT of women undergoing abdominal SCP with or without a urethropexy demonstrated higher failure rates for colpopexy than previously believed. Composite treatment failure was reported in approximately one-third of all subjects and the rate of mesh erosion was 10.5%.26

    Importantly, 95% of the patients had no retreatment for POP, similar to low rates of retreatment for native tissue and vaginal mesh repairs.22,26,27 The findings from this trial have called into question the true durability of all surgical treatments for POP.

    Colpocleisis

    Colpocleisis is an obliterative vaginal procedure with a shorter operative time and decreased perioperative morbidity compared to other reconstructive procedures.28 It carries a very low risk of prolapse recurrence with success rates reported as high as 90% to 100%.21,29,30 Colpocleisis results in a shortened vagina and narrower genital hiatus, preventing vaginal intercourse. For that reason, it is more commonly offered to patients who are older, medically frail, or who have more complicated conditions and who are no longer interested in sexual activity.21,29,31,32

    Because patients undergoing the procedure are typically sicker, it may still carry significant morbidity. Patient and physician must discuss both the morbidity of the procedure depending on the health of the individual as well as the high success rates. It is key that a patient’s sexual preferences/activities be considered.

    The majority of patients (86% to 94%) report high levels of satisfaction with colpocleisis. Fewer than 10% of women reported dissatisfaction and no patients cited loss of sexual function as a reason for regret in a study of 152 women undergoing colpocleisis.33 Nonetheless, if a patient desires future vaginal intercourse, colpocleisis is not a viable option regardless of age and medical comorbidities.

    Special considerations

    Vaginal mesh procedures

    Transvaginal mesh (TVM) has been used in an effort to improve upon the success of native tissue repairs. The introduction of TVM kits resulted in a dramatic increase in their use for POP repair until 2008, followed by a decrease in their use beginning in 2011.34 In 2008 the US Food and Drug Administration released a public health notification related to complications associated with vaginal mesh for the treatment of POP. In 2011 that was expanded to a Safety Communication. The key message was that serious complications from TVM for the repair of POP were “not rare.”35 Given this controversy and concern for complications, many TVM kits were removed from the market and have been replaced with more lightweight mesh and trocar-free placement.

    TVM has since been reclassified as a class III device and requires post-market studies, several of which are currently under way. A systematic review found evidence that TVM is successful in improving apical support in the short term but with increased risk of reoperation for mesh complications (4.6%–10.7%). TVM decreased reoperation for recurrent POP but had higher rates of repeat surgery for combined outcomes of POP, stress urinary incontinence, and mesh exposure.27,36 Societies such as the American Urogynecologic Society have subsequently released “Guidelines for Providing Privileges and Credentials to Physicians for Transvaginal Placement of Surgical Mesh for Pelvic Organ Prolapse,” an informed consent toolkit, and created the Pelvic Floor Disorders Registry (PFDR). The PFDR is a national patient registry created for both patients and providers to track outcomes from prolapse surgery.37 The future role of TVM in POP treatment is uncertain; comparative long-term studies are needed to help guide clinicians and patients.

     

    Cara Ninivaggio, MD, FACOG
    Dr Ninivaggio is a fellow in the Division of Female Pelvic Medicine & Reconstructive Surgery, Department of Obstetrics and Gynecology, ...
    Gena Dunivan, MD, FACOG
    Dr Dunivan is an Associate Professor and Fellowship Program Director in the Division of Female Pelvic Medicine & Reconstructive Surgery, ...

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