All women who are undergoing surgery for repair of pelvic organ prolapse should be evaluated for urinary incontinence. Women who report stress urinary incontinence and who demonstrate it on preoperative examination and have no contraindications to a continence procedure should have concomitant procedures for the treatment of these symptoms. Women who do not report stress urinary incontinence may also benefit from a prophylactic procedure if they demonstrate incontinence with reduction of their prolapse. There is also evidence that the addition of a continence procedure in the absence of any evidence of urinary incontinence may improve outcomes without significantly increasing the number of complications (135). The addition of continence procedures to prolapse procedures in patients who have both significant stress incontinence and voiding dysfunction remains controversial.
Comparison of Abdominal versus Vaginal Approaches
In recent years there has been controversy as to whether transvaginal or transabdominal procedures are best for prolapse. One cannot discern which is optimal from reports of retrospective and prospective case series because of the considerable differences in numerous factors, including follow-up, characteristics of the subjects, definitions of success and failure, and the expertise or experience of the surgeons performing the procedures. Three prospective randomized trials have compared sacrocolpopexy and sacrospinous suspension procedures (136–138). All three trials showed some increased durability in the sacrocolpopexy group; however, in one of these studies the differences were not statistically significant (138). In the study in which sexual function was examined, there was a greater incidence of dyspareunia in the transvaginal group (137). Most case series reveal that the incidence of serious complications, such as small bowel obstructions, significant hemorrhage, presacral graft infections, pulmonary embolus, and short-term problems (i.e., ileus, hernias, wound seromas or infections, and longer hospitalizations), are more likely to occur in the group undergoing sacrocolpopexy. Vaginal scarring, strictures, and vaginal wall erosions or granulation tissue appear more likely in the group undergoing transvaginal surgery. To date, there is no randomized comparison of vaginal procedures using high uterosacral suspensions and innovative repairs of the fibromuscular tissues, which are less likely to produce strictures than was the case 10 or more years ago.
Most pelvic surgeons would agree that (i) older, less healthy individuals who are more likely to have surgical and medical complications and cannot or will not tolerate a pessary would derive greater benefit from transvaginal approaches and occasionally obliterative approaches, and (ii) relatively healthy, sexually active women with relatively short vaginas and apical prolapse or with isolated apical defects would derive greater benefit from sacrocolpopexy. For the remainder of the patients with apical prolapse, with or without more distal defects, it would be ideal if surgeons were equally skilled, knowledgeable, and experienced in both abdominal and vaginal approaches to provide care that is truly individualized, rather than emphasizing one approach to the exclusion of another.
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