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Apical Prolapse

Dr Samera F.AlBasri

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Overview Apical prolapse is one type of POP and refers to the downward displacement of the vaginal apex.

Support of the vaginal apex is primarily derived from the integrity of the Uterosacral and cardinal ligaments, the continuity of the fibro muscular layer surrounding the vagina, and a neuromuscularly intact levator ani.

The etiology of apical prolapse is likely related to connective tissue, neural, and/or muscular defects in these normal supports.

It is rare to find isolated support defects of the anterior or posterior vaginal walls or an isolated apical defect since the defects in the connective tissue, neural pathways, and muscle are not confined to one small site Therefore, if an anterior or posterior prolapse is diagnosed, one should examine the patient carefully (preferably standing) to

ensure that a concomitant apical defect is not present as well .

Many experts believe that adequate suspension of the apex is the cornerstone of any successful prolapse repair . If the vaginal muscularis is intact and well suspended at the apex, many anterior and posterior defects will also resolve

The most common risk factors for developing prolapse are vaginal delivery and previous hysterectomy

The incidence of surgical repair for apical prolapse is increased in any woman who has had a prior hysterectomy, and even further increased in women who have had a hysterectomy for prolapse Therefore, some type of apical

suspension should be done at the time of every hysterectomy .

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CLINICAL MANIFESTATIONS  

The most common symptom of clinically significant apical prolapse is a protrusion of tissue from the vaginal opening.

.Women with prolapse may also report a sensation of pelvic pressure, voiding difficulty, a need to splint to urinate or defecate, bowel symptoms, and pelvic or low back pain. The prolapsed vagina may protrude on standing, leading to chronic discharge and bleeding from chronic ulceration. Rare cases of vaginal evisceration have been reported in prolapse that has been chronically neglected.

Traditionally, experts believed that these symptoms became progressively worse as the prolapse gradually increased over time .

Several well-designed studies have shown that low back and pelvic pain are not associated with prolapse and that many pelvic floor symptoms, particularly bowel symptoms, do not increase with advanced stage prolapse

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DIAGNOSIS AND PREOPERATIVE EVALUATION  

History  — 

Women with symptomatic apical prolapse should undergo a careful history which focuses on related pelvic floor symptoms, given that pelvic floor disorders rarely occur in isolation .

They should be questioned about concomitant urinary incontinence, voiding difficulties, fecal incontinence, and defecatory problems.

Since prolapse is a quality of life disorder, it is also essential to determine which symptoms are most bothersome to the individual patient and to tailor a treatment plan accordingly

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DIAGNOSIS AND PREOPERATIVE EVALUATION

Physical examination—  

A thorough speculum and bimanual examination should be done .

The apical prolapse can be visualized during speculum examination with the woman straining as the speculum is slowly withdrawn from the upper third of the vagina. It is often helpful to use half of the speculum, placed posteriorly to examine the anterior wall and apex, then placed anteriorly to examine the posterior wall .

The anterior vaginal wall is frequently the most prolapsed vaginal segment, even in women with apical prolapse. It is important to identify the position of the apex.

Women should also be examined in the standing strain position to maximize the prolapse and aid in identification of other defects in pelvic support that will require concomitant repair. Theoretically, an operation that corrects all existing defects may decrease the likelihood that a subsequent operation will be necessary

The findings of the examination should be recorded using a quantitative and reproducible method for recording pelvic organ prolapse.

The system currently recommended by the International Continence Society and the American Urogynecologic Society is the Pelvic Organ Prolapse Quantification (POP-Q) system

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DIAGNOSIS AND PREOPERATIVE EVALUATION

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DIAGNOSIS AND PREOPERATIVE EVALUATION

Evaluation for urinary dysfunction—  Apical prolapse frequently coexists with lower urinary tract dysfunction: urinary incontinence and urinary retention are common,

so a thorough apical prolapse evaluation should assess for both .

Urinary retention can be evaluated by checking a post void residual urine volume (PVR) within 10 minutes of the patient voiding. In general, a PVR of less than 50 mL is considered adequate emptying, and a PVR greater than 200 mL is considered inadequate. Ninety percent of elevated post-void residual urine volumes normalize after surgical correction of prolapse.

Many women with advanced apical prolapse remain continent despite loss of anterior vaginal and bladder/urethral support. However, 8 to 40 percent of continent women develop symptoms of stress urinary incontinence after

surgical correction of the prolapse.Urethral pressure measurements and electromyography performed during urodynamics in women with advanced prolapse suggest that the prolapse "kinks" or obstructs the urethra, thus maintaining continence.

Therefore, to identify "occult" or "potential" stress incontinence, all women with apical prolapse should have a preoperative evaluation of stress continence with the prolapse reduced. In addition, all women having surgical correction of prolapse should be counseled regarding the potential for postoperative incontinence.

In a large randomized trial, the Colpopexy and Urinary Reduction Efforts (CARE) trial, stress continent women with stage II to IV apical prolapse underwent preoperative urodynamics testing . When testing was performed without reduction of the prolapse, only 3.7 % of participants exhibited SUI. Women who had SUI with prolapse reduction prior to surgery and then underwent sacral colpopexy alone (without concomitant incontinence surgery), had a significantly increased risk of postoperative SUI. The results of different methods of prolapse reduction (manual, pessary, speculum, swab, forceps) were variable; a swab was the method most likely to predict postoperative stress incontinence, and a pessary was the least likely

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OPTIONS FOR SURGICAL THERAPY  Colpocleisis— 

 Women who do not desire future vaginal intercourse and/or are in poor general health may consider an obliterative

procedure, such as Colpocleisis .Colpocleisis is highly effective with low morbidity for correcting apical prolapse in such women

Procedure

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Colpocleisis— 

—The procedure is performed under general or spinal anesthesia and can be done with the uterus in situ or after hysterectomy

.Concomitant hysterectomy at the time of Colpocleisis increases morbidity without improving surgical success

Using sharp and blunt dissection, the vaginal epithelium is dissected from the underlying muscularis. A total Colpocleisis removes all of the vaginal epithelium, while a partial Colpocleisis leaves a small portion of vaginal epithelium on each side to provide drainage tracts in women with a uterusThe leading edge of the prolapse is identified and successive interrupted sutures are used to reduce the prolapse until it lies above the levator plate, effectively obliterating the vaginal canal. Care should be taken not to pull the posterior urethra down when suturing the anterior and posterior vagina.

Finally, a wide perineorrhaphy is created by removing a large diamond shaped area of perineal skin and distal vaginal epithelium. The levator muscles are then approximated with non-absorbable sutures. The area from above the rectum to the urethrovesical junction should be closed

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Colpocleisis— 

Complications

Significant postoperative complication rates occur in approximately 2 percent of patients and are frequently attributed to the older age and frail condition of patients selected for this procedure .

Transfusion is the most commonly reported major complication related to the surgery itself. Some women develop stress urinary incontinence after Colpocleisis, which, as described, is likely secondary to "un-kinking" the urethra.

[Optimal management of potential stress incontinence is unclear. Most women choose Colpocleisis for its simplicity and quick recovery and wish to avoid the morbidity of an additional major continence

procedure .

Performance of a minimally invasive mid-urethral sling may be appropriate in these cases; however, the role of this procedure at the time of Colpocleisis has not been studied.

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OPTIONS FOR SURGICAL THERAPY

Vaginal versus abdominal procedures — 

In women who desire a reconstructive procedure, route of access should be determined based on risks, benefits, and complications of abdominal and vaginal surgery, as well as the use of synthetic meshes.This may be the most controversial area in the treatment of apical prolapse, subject to debate amongst experts with ample evidence from observational studies supporting both sides .

In the past, gynecologic surgeons favored the vaginal approach for its low complication rates and quick recovery; however, abdominal routes have gained popularity more recentlyEvidence from randomized trials has demonstrated that abdominal repairs are more durable, while vaginal repairs have fewer complications, including foreign body complications.

Choosing a vaginal or abdominal route to correct apical prolapse must be individualized based on patient expectations, goals, and wishes. While the abdominal route seems to have increased durability, it comes at the expense of a longer recovery period and possibly more complications .

A younger, active woman may choose the higher success of abdominal sacrocolpopexy, accepting the longer recovery and potential for foreign body erosion. In contrast, a frail, elderly woman may opt for a higher chance of recurrence in exchange for a quicker return to her daily activities

Given these data, recommendations regarding surgical approach among pelvic surgeons differ dramatically based on their own experiences and biases

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VAGINAL APICAL SUSPENSION PROCEDURES  

Sacrospinous ligament suspension

 Sacrospinous ligament suspension is the best-studied vaginal procedure for treating apical prolapse. Anatomic cure rates after Sacrospinous ligament suspension range from 63 to 97 percent.

The failure rate is relatively low when the procedure is performed for apical prolapse 2 to 11 percent, depending on criteria for failure, but is high when performed for anterior vaginal wall prolapse 4 to 40 percent.

.Therefore, women with large anterior wall defects in addition to apical defects may benefit from another type of prolapse repair, which more directly addresses the anterior vagina.

Randomized trials* have shown that Sacrospinous ligament suspension is slightly inferior to abdominal sacrocolpopexy in anatomic restoration, but results in similar patient satisfaction Procedure

—Sacrospinous ligament suspension is generally performed unilaterally. Some surgeons have proposed bilateral Sacrospinous ligament suspension, although the value of this modification has not been proven

. The bilateral technique depends upon adequate vaginal length and depthAm J Obstet Gynecol 1996 and 2004*

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Cont.: Sacrospinous ligament suspension

Before starting the procedure, the surgeon must ensure that the vagina is long enough to reach the Sacrospinous ligament without a suture bridge since a vagina shortened from previous vaginal surgery may preclude Sacrospinous ligament suspension.

Marking sutures are placed on the vaginal epithelium at the site where it is going to attach to the ligament .The posterior vagina is opened in the midline from the perineal body to the apex .The vaginal epithelium is then separated from the underlying muscularis and the dissection continued to the level of the ischial spine .

The rectovaginal space is opened by gently pushing the rectum medially, and the rectal pillar is perforated.Once the perirectal space is entered, the ischial spine can be palpated and the ligament can be found medially.

A long right angle retractor, e.g., Briesky-Navratil, is placed on the ischial spine to protect the pudendal neurovascular bundle and another is used to retract the bladder superiorly and the rectum medially.

Once the ligament is clearly visible, two to three permanent sutures are placed through the ligament approximately one and one-half finger-breadths medial to the ischial spine.

Several techniques and devices are available to assist placing the suture through the ligament (Miya hook, Deschamps ligature carrier).After securing the sutures to the ligament complex, each of the sutures is placed through the muscularis on the undersurface of the posterior vaginal epithelium and tied by a pulley stitch, while the free end of the suture is held .

Traction on the free end of the suture draws the vaginal apex directly onto the Sacrospinous ligament.

A common modification of this technique is the "Michigan Modification” .In the Michigan Modification, all four vaginal walls are directly approximated to the Sacrospinous ligament (instead of just the posterior vaginal

wall), theoretically decreasing the risk of anterior vaginal wall recurrence. The point on each vaginal wall that reaches the ligament is identified and the intervening vagina excised. The sutures are placed through the Sacrospinous ligament, as described above, then sewn to the anterior and posterior vagina and tied to the ligament.

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Cont.: Sacrospinous ligament suspension

Complications

—Complications after Sacrospinous ligament suspension are uncommon. Intraoperative hemorrhage from laceration of the pudendal vessels is the most frequent complication. Pudendal hemorrhage is best treated by tightly packing the ischiorectal fossa and waiting for homeostasis to occur. Cystotomy and enterotomy are rarely reported.

Injury to the branches of the sciatic nerve that cross the coccygeus muscle-Sacrospinous ligament complex (C-SSL) is another possible source of postoperative pain or nerve dysfunction. One approach to decrease nerve entrapment is to perforate the Sacrospinous ligament with the needle in a vertical rather than a horizontal orientationHowever, if the sciatic nerve is entrapped in the suture despite careful surgical technique, the classic triad of sciatic entrapment occurs. The patient typically awakens with severe buttock pain radiating down the posterior leg. Delay in diagnosis and treatment can result in permanent neuropathy; therefore, regional anesthesia of prolonged duration should not be used for this type of surgery and the patient should be taken back to the operating room immediately upon diagnosis to have the sutures removed.

Postoperative bowel complications are rare as the procedure is meant to be extra peritoneal.

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Iliococcygeus suspension  

Iliococcygeus suspension is performed similar to the Sacrospinous colpopexy, but uses the Iliococcygeus fascia over the levator plate instead of the Sacrospinous ligament. The literature on this operation is sparse; however, subjective success rates appear to be similar for Sacrospinous and Iliococcygeus suspensions, while objective success after Sacrospinous ligament suspension is 14% higher than after Iliococcygeus suspension

reported advantages of the Iliococcygeus suspension include less frequent anterior vaginal wall recurrence and injury to the pudendal neurovascular bundle, although these benefits are not supported by any data .

Complications are similar to those described above for Sacrospinous ligament suspension.

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Uterosacral ligament suspension  

Procedure —The key to successful Uterosacral ligament suspension is simultaneous correction of

all defects in the apical endopelvic fascia. In the most commonly performed modification of the Uterosacral ligament suspension , the anterior and posterior vaginal walls are opened in the midline and the enterocele sac identified. The peritoneal cavity is entered and the Uterosacral ligaments identified. An Allis clamp

can be used to tent the Uterosacral ligament making it easier to identify .The rectum is retracted mediallyThree permanent sutures are placed 1.5 centimeters medial and 1.5 centimeters posterior to the ischial spine through the Uterosacral ligament on each sideThe sutures are numbered sequentially, 1 through 6, to facilitate vaginal placement. One arm of each permanent suture is placed through the anterior endopelvic fascia and the other through the posterior endopelvic fascia. The sutures are placed serially across the width of the vaginal apex. All sutures are then tied, re-approximating the anterior and posterior endopelvic fascia, closing any potential enterocele defect, and elevating the vaginal apex toward the sacrumCystoscopy should be performed after tying the sutures due to a significant rate of

ureteral kinking during this procedure

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Uterosacral ligament suspension

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Uterosacral ligament suspension Cont:

Complications

—Intra and postoperative complications after Uterosacral suspension are uncommon. Routine Cystoscopy should be done at the completion of each case before the patient leaves the operating room to prevent delayed recognition of ureteral injuries. Ureteral kinking from the Uterosacral suture is found during routine Intraoperative Cystoscopy in up to 11 percent of cases. If both ureters do not efflux briskly, the most lateral suture (closest to the ureter) on that side should be removed. Typically, removing this suture is sufficient to restore brisk ureteral efflux without further sequelae, although ureteral injury requiring uretero-neocystectomy has been reportedThe sacral nerves can be ligated if Uterosacral ligament suspension sutures are placed lateral to the ligament fibers or too deep into the pelvic sidewall.

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Abdominal sacral colpopexy

Laparoscopy and Laparotomy  Abdominal sacral colpopexy is the most durable apical prolapse procedure

The most common procedure is sacral colpopexy (attachment between the sacral promontory and the upper vagina); sacral hysteropexy (attachment between the sacral promontory and the lower uterus) and sacral cervicopexy (attachment between the sacral promontory and the cervix) are uncommonAnatomic success rates after sacral colpopexy range from

76 to 100% Am J Obst Gynecol 2002

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sacral colpopexy

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Abdominal sacral colpopexy

Laparoscopy and Laparotomy  Procedure

—Abdominal sacral colpopexy involves attaching a permanent mesh to the anterior and posterior vagina, and then attaching the free end of the mesh to the anterior longitudinal ligament of the sacrum, which reestablishes a somewhat horizontal vaginal axis . A commonly performed technique is to carefully open the presacral space and expose the anterior longitudinal ligament

of the sacrum .Two or three permanent sutures are placed through the anterior longitudinal ligament just below the promontory; when sutures are placed lower on the sacrum, at the S3 to S4 level, presacral

hemorrhage is more common .Next, a permanent mesh is attached to the posterior vagina to the level of the rectal reflection and to the anterior vagina for a distance of several centimeters. Two rows of permanent sutures should

be used to widely attach the mesh to the vagina to distribute the tension .The free end of the mesh is attached to the anterior longitudinal ligament using the previously placed sutures. Failure to attach the mesh anteriorly results in anterior vaginal wall recurrence rates of

almost 30.%

prophylactic Burch colposuspension should be performed at the time of abdominal sacrocolpopexy in women without preoperative symptoms of stress incontinence

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Abdominal sacral colpopexy

Laparoscopy and Laparotomy  Complications

Cystotomy (3.1 percent), enterotomy (1.6 percent), incisional problems (4.6 percent), ileus (3.6 percent), thromboembolic event (3.3 percent), and transfusion (4.4 %)

.Presacral hemorrhage is the most concerning intra-operative complication and can have life-threatening consequences. The presacral plexus of veins and the middle sacral artery can be lacerated during the presacral dissection, particularly if done at the S3-S4 level. Reconstructive surgeons should be prepared to manage presacral hemorrhage and have bone wax, concave

thumbtacks, and thrombin immediately available.

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POSTOPERATIVE CARE Postoperative care is similar regardless of surgical approach. However, recovery after sacral colpopexy may be slower due to the abdominal incision. Few data are available to guide postoperative care and most recommendations are based on the surgeon's experience and preferences

Ambulation — The woman can begin walking with assistance as soon as the day of surgery Diet — Women undergoing vaginal approaches can frequently tolerate oral intake the evening of surgery, and those having abdominal surgery the morning after surgery Bladder drainage — The urinary catheter placed preoperatively is left in place postoperatively as women frequently cannot empty their bladders immediately after pelvic and/or vaginal surgery, particularly if a concomitant continence procedure was done. The catheter can be removed on the first postoperative day in the absence of an intra-operative bladder injury, but a post-void residual urine volume should be checked to ensure complete bladder emptying. Continuous bladder drainage is not required

Lifting — Most surgeons place some lifting restrictions on patients after surgery, although these range dramatically from surgeon-to-surgeon. It is probably reasonable to suggest a moderate short-term lifting restriction, such as 10 pounds for two weeks, then resume-lifting activities as tolerated. This area has not been examined extensively, with a notable exception. One study found that there was no greater increase in intra-abdominal pressure with lifting 20 to 35 pounds or doing jumping jacks than simply rising from a chair . Satisfaction after surgery correlates with patient goal achievement, many of which are related to life-style, thus long-term lifting restrictions are probably not necessary or advisable

Nothing should be placed in the vagina (tampons, coitus) until complete healing occurs, typically in three to four weeks

Return to normal activities — Patients may resume normal activity (including sports) and return to work when they are no longer experiencing pain or fatigue related to surgery. A postoperative examination should be performed to ensure

complete healing and assess outcome of the repair

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Thank you