Surgery for Apical Vaginal Prolapse

Note: This is an abridged version of the article.

There has been a trend toward site-specific defect repairs in surgery for vaginal apex prolapse and enterocele. These surgical procedures may be performed by abdominal, vaginal, or laparoscopic routes. Technologic advances have also contributed to the evolution of pelvic reconstructive procedures. The uterosacral vaginal vault suspension and laparoscopic sacral colpopexy are summarized.

Introduction

Surgery for vaginal apex prolapse is evolving due to adoption of defect-specific approaches, implementation of new technology, and increased awareness of pelvic floor neurophysiology. The gold standard for surgical treatment of vaginal apex prolapse by abdominal route is the sacral colpopexy. Although this procedure has been performed by laparoscopic route, the technically feasible laparoscopic uterosacral ligament-vaginal vault suspension is gaining popularity. By vaginal route, many surgeons prefer defect-specific repair utilizing the uterosacral ligaments, and consider it more anatomic than the sacrospinous ligament suspension. There has been a shift toward minimally invasive procedures in all facets of gynecologic surgery due to the advantages of less blood loss, cosmetic incisions, decreased pain, shorter hospitalization, rapid recovery, and rapid return to work ¹. The uterosacral ligament-vaginal apex suspension and laparoscopic sacral colpopexy are reviewed in this article.

Uterosacral Ligament-Vaginal Vault Suspension

Many surgeons believe that the role of laparoscopic surgery is to convert abdominal procedures to minimally invasive procedures-performing the identical operation through smaller ports with longer instrumentation. I would argue that this is not the case with treatment of severe vaginal apex prolapse because a vaginal and/or laparoscopic procedure, namely the uterosacral ligament-vaginal vault suspension, is the procedure of choice. During this operation, the uterosacral ligament remnants are sutured to the pubocervical and rectovaginal fasciae at the vaginal apex, thus restoring Level I anatomic support as described by DeLancey ².

Why are so many surgeons embracing this technique? There are several reasons: 1) The laparoscopic approach simplifies this surgery because of excellent visualization and magnification of the anatomy, especially the ureters, which can be easily injured when stitches are placed in the uterosacral ligaments; 2) Relaxing peritoneal incisions can be made lateral to the uterosacral ligament to further safeguard the ureters from injury or kinking; 3) When a surgeon is fascile at laparoscopic suturing, even an expert vaginal surgeon can accomplish this surgery more safely and rapidly than by vaginal route; 4) exposure is much better than by vaginal route because the bowel, even when overdistended, is easily retracted out of the way; and 5) The laparoscopic sacral colpopexy is time-intensive, and requires more skill because of dissection in the presacral space and a greater amount of sutures placed to secure the mesh over a broad surface. ...