Surgical Management The primary aims of surgery are to relieve symptoms, which may be caused by prolapse, and, in most cases, to restore vaginal anatomy so that sexual function may be maintained or improved without significant adverse effects or complications. Occasionally, when sexual function is not desired, obliterative or constrictive surgery is more appropriate and also may relieve symptoms. There is no steadfast rule as to when surgery is indicated. Many patients with more advanced prolapse have few or no symptoms, whereas some with lesser degrees of prolapse have what they describe as severe symptoms. This is confounded by the observation that many of the “symptoms” may not be specifically related to the anatomic defect or may be worsened by anxiety. In general, surgery should be offered to patients who have tried conservative therapy and were not satisfied with the results or who do not desire conservative therapy. The prolapse should be symptomatic or should be greater than or equal to stage II with apparent progression. All patients should be given the alternative of trying conservative treatments when applicable (51).
Approaches to surgery include vaginal, abdominal, and laparoscopic routes, or a combination of approaches. Depending on the extent and location of prolapse, surgery may involve a combination of repairs directed to the anterior vagina, vaginal apex, posterior vagina, and perineum. Concomitant surgery may be planned for urinary or fecal incontinence. The surgical route is chosen based on the type and severity of prolapse, the surgeon’s training and experience, the patient’s preference, and the expected or desired surgical outcome.
Procedures for prolapse can be broadly categorized into three groups: (i) restorative, which use the patient’s endogenous support structures; (ii) compensatory, which attempt to replace deficient support with permanent graft material; and (iii) obliterative, which close or partially close the vagina (51).
These groupings are somewhat arbitrary and not entirely exclusive. For example, grafts may be used to reinforce repairs, such as colporrhaphy, or to replace support that is deficient or lacking. Graft use in sacrocolpopexy substitutes for the connective tissues attachments (cardinal and uterosacral ligaments) that would normally support the vaginal apex. In addition to the primary goal of relieving symptoms related to prolapse, urinary, defecatory, and sexual function must be considered in choosing the appropriate procedures.
Whether to repair all defects is controversial. Restorative repairs may be less successful than compensatory repairs in patients with generally “poor tissue,” and at times one defect repair may exert more tension on the repair of another defect. Management should be based on the patient’s presentation, expectations, the specific anatomical defects noted (preoperatively and, at times, intraoperatively), and on the presence or absence of lower urinary and bowel dysfunction (51).
The Apical Compartment Examination for apical defects is at times difficult. Such defects may be missed when large anterior or posterior defects are present. In cases when apical defects are suspected but not confirmed, surgeons should evaluate the apical support intraoperatively and plan for management of these defects when they are found. Traction on the cervix with a tenaculum or on the vaginal cuff both centrally and laterally with Allis clamps may reveal otherwise unrecognized defects.
Transvaginal repairs include extraperitoneal procedures such as sacrospinous suspensions, iliococcygeal suspensions, and high paravaginal suspensions of the apical vaginal fornices to the arcus tendineus at the level of the ischial spine or to the endopelvic fascia, and intraperitoneal suspensions such as uterosacral suspensions and McCall culdoplasties (51). Accepted practice is that the vaginal apex should be resuspended in a posterior cephalad direction to a site or sites posterior and caudad to the sacral promontory. Anterior apical suspensions change the direction of the vaginal axis and may be fraught with a greater incidence of posterior compartment defects, including rectoceles, enteroceles, and sigmoidoceles.