REVIEW O&G Forum 2014;24:???-??? Surgical options for uterine prolapse: something old and something new

Stephen T. Jeffery Head, Urogynaecology and Pelvic Floor Reconstruction, Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa

Abstract A broad range of surgical options are now available for women presenting with uterine prolapse. A vaginal coupled with a robust vault support procedure remains an excellent choice in dealing with uterine prolapse. The importance of ensuring adequate fixation of the vault after hysterectomy cannot be overemphasized. The two best procedures for cuff support are sacrospinous fixation and high uterosacral ligament suspension. The latter can also be used for vault support following vaginal hysterectomy for uterine prolapse. Retaining the prolapsed and performing a hysteropexy operation has recently become a very popular surgical technique. This usually involves attaching uterine support sutures to either the sacrospinous or uterosacral ligaments without doing a hysterectomy. Vaginal mesh procedures are available for women with uterine prolapse. If a mesh is used, it is important to use a device that offers adequate apical support and the newer single incision sacrospinous support mesh kits may be superior. The Le Fort colpopcleisis remains an excellent surgical procedure in the old and frail patient who has no desire to retain her potential for sexual activity. This is a minimally invasive operation with a significantly reduced risk of morbidity compared with more extensive procedures. The Manchester repair may now be re-emerging as treatment for uterine prolapse. The abdominal approach to uterine prolapse has recently become popular. This usually involves either a total or supracervical hysterectomy followed by sacrocolpopexy.

Keywords: Uterine prolapse; Sacrospinous fixation; Sacrocolpopexy; Hysteropexy; Uterosacral ligament suspension

Introduction a specific technique that can be considered as the gold Due to the less than perfect outcomes associated with many standard. of the commonly performed procedures for uterine When faced with a patient requesting surgery to correct prolapse, the management of a woman with this problem her uterine prolapse, a number of questions need to be remains a surgical challenge. In selecting an operative asked before deciding on the technique. One of the first technique, we are faced with a broad range of options, from questions is what the best route of surgery would be. In other older interventions such as the Manchester Repair and words, should this be approached vaginally or abdominally? colpocleisis, to modern, state-of-the-art robotic and mesh The surgeon will also need to decide if a hysterectomy procedures. should be performed or whether a uterine preservation and The ideal technique for correcting uterine prolapse suspension technique should be utilised. If the operation is should obviously result in a durable repair with a low being done vaginally, some surgeons still make use of mesh incidence of adverse events and a quick post-operative in managing women with uterine prolapse and the clinical recovery. It should also be accessible to the average decision needs to be on the appropriateness of using one of surgeon and not require an extensive array of new surgical these devices. skills and training. Unfortunately, the “ideal” operation There are very little comparative data on the various remains elusive and current research has not yet identified techniques to deal with these clinical challenges and most surgeons select their operation based on their training, skill set and personal preferences. The factors that may influence Correspondence the surgical approach include the severity of the prolapse, Stephen T. Jeffery the age of the patient, the presence of co-morbidities and email: [email protected] whether the woman is sexually active.

Obstetrics & Gynaecology Forum • Issue 4 2014 ?? REVIEW O&G Forum 2014;24:???-???

In this article, the various surgical options for uterine The advantage of performing the SSF through an prolapse and the indications for the individual procedures anterior incision is that it may result in less de novo post- will be reviewed. The options are summarised in Table I. operative anterior prolapse. This has long been cited as a significant complication of a SSF when it is performed Vaginal approaches to uterine prolapse through a posterior approach.3 It may, however, be easier Despite the large number of procedures available to us for to access the ligament posteriorly. uterine prolapse, a vaginal hysterectomy and vault Attaching a suture to the SSL is one of vaginal suspension remains one of the best options for even the reconstructive surgery’s great challenges. The ligament most extensive prolapse. It is essential to remember that is usually visualized using two or three long retractors. simply performing a hysterectomy for uterine prolapse is The suture is then secured using a Miya Hook (Fig. 1), a usually not sufficient and that the vaginal vault always Deschamps Ligature Carrier, or a long needle holder needs to be supported. The most frequently employed with sutures. The placement of the SSF suture has been vaginal vault suspension techniques include either a made considerably easier by the introduction of a Sacrospinous fixation (SSF) or a High Uterosacral Ligament number of new devices that facilitate the suture Suspension (HUSLS). These may also be used when attachment by digital palpation. These instruments performing a uterine sparing operation. Other options include the Capio (Boston Scientific), Fixt (Bard), Digitex include a Manchester Repair or mesh procedure. In a (Nuangle) and I-stitch (Akacia Surgical). The amount of woman who is medically frail, a colpocleisis may be the dissection required to access the ligament using these best approach. minimally invasive devices is significantly less, making the operation quicker and reducing morbidity. A recent Sacrospinous fixation This operation, originally described by Amreich and Richter, was used to address post-hysterectomy vault Figure 1: A Miya Hook for sacrospinous fixation prolapse, but it has been shown to be a successful procedure for vaginal vault suspension following hysterectomy for uterine prolapse.1 It is also possible to use the sacrospinous ligament (SSL) for apical support when undertaking a vaginal hysterectomy for prolapse and when performing a uterus conserving operation. When performing a SSF for vault support at hysterectomy, it is possible to approach the ligament through an incision in the anterior or posterior compartment. The vaginal vault incision is extended anteriorly towards the urethra and bladder neck, in the midline, and then the paravaginal dissection is continued toward the obturator fascia and SSL. Exposure of the ligament is commenced using sharp dissection, and once the ischial spine is palpated, the remainder of the dissection is completed with digital stripping of the tissues overlying the ligament. It is acceptable to perform a unilateral fixation. This usually results in an asymmetrical vaginal axis, but this has not been shown to be associated with any functional disturbance.2 It may be possible to restore a normal anatomical vaginal axis by performing a bilateral fixation, but this in turn has the potential risk for increased vaginal tension.

Table I: Surgical options for Uterine prolapse

Vaginal Approach (with or without hysterectomy) Abdominal Approach

• High uterosacral ligament suspension (HUSLS) • Total or subtotal hysterectomy and sacrocolpopexy

• Sacrospinous ligament suspension •

• Manchester Repair

• Mesh Procedure

• Colpocleisis

Obstetrics & Gynaecology Forum • Issue 4 2014 ?? REVIEW O&G Forum 2014;24:???-??? randomized controlled trial (RCT) comparing the It is essential to confirm ureteric patency after attachment of the SSF suture using the Capio to a performing the HUSLS. This is best done by performing a traditional suture and needle-holder technique showed a cystoscopy and inspecting the ureteric orifii for efflux. By 30% reduction in operating times in the group where the injecting an intravenous dose of either Methylene-Blue or Capio was used.4 Indigo-Carmine, the ureteric efflux is easier to see. If a A broad range of suture options is available when blue or green jet is not observed from either ureters, it is performing a SSF at vaginal hysterectomy for uterine essential to remove the HUSLS sutures sequentially until prolapse. The delayed absorbable polydioxanone (PDS) ureteric patency is confirmed. suture is often preferable. The advantage of using the PDS There is some debate concerning the type of suture is that the suture can be brought out through the vaginal that should be used for the HUSLS. In a study comparing skin and tied outside the vault and this allows for a more Prolene to PDS, Kasturi et al. showed that there was no secure vault fixation. Other options include a difference in anatomical outcomes between the two monofilament non-absorbabale suture (Prolene), or a non- groups.6 There was, however, a high incidence of suture absorbable braided suture (Ethibond). It is, however, erosion (22%) in those women in the Prolene group. A advisable to avoid using Ethibond since it has been shown monofilament delayed absorbable suture such as PDS may to be associated with abscess formation.5 The non- be preferable. absorbable sutures are usually brought through the vault The HUSLS has been shown to be associated with incision and cut short after vaginal closure. excellent outcomes. In a review of the outcomes of HUSLS SSF is associated with excellent anatomic outcomes, as for uterine prolapse, Khunda et al. reported anatomical demonstrated in a review by Beer and Kuhn of 2239 success rates of between 87% and 100%, in a systematic women, reporting success rates of up to 98%.3 The review of transvaginal uterosacral ligament suspension, greatest risk of sacrospinous fixation is long term buttock Margulies et al. reported a re-operation rate of 9.4% and and perineal pain. This may be due to pudendal or ureteric re-implantation rate of 0.6%.7.8 inferior rectal nerve entrapment. If this occurs post- operatively, early recourse to suture removal is essential. High uterosacral ligament suspension versus Sacrospinous Fixation High uterosacral ligament suspension (HUSLS) Both the SSF and HUSLS have been shown to be The uterosacral ligaments connect the and proximal associated with excellent functional and anatomical portions of the to the sacrum at about level S2 to outcomes when done in women with uterine prolapse. S3. They provide the most important endopelvic support Both procedures, however, have their own technical to the uterus and vagina. It therefore makes physiological challenges and complications. These two procedures were sense to reattach the remaining portion of the vaginal vault reviewed in an RCT by Barber et al that was recently to these ligaments when performing a hysterectomy for published in the JAMA.9 In their comparison of the HUSLS uterine prolapse. and SSF, they demonstrated no difference in anatomical or For every surgeon embarking on a HUSLS, it is functional outcomes between the two groups. The success essential to appreciate the anatomical relationship rates were 59% and 60% for the HUSLS and SSF between the uterosacral ligament and the ureter. As it respectively, and they used very strict anatomical outcome descends in the pelvis, the ureter converges with the measures. The re-operation rate was, however, very low in uterosacral ligament. In its distal portion it is only 1cm both groups, with 3% of the HUSLS and 2.6% of the SSF from the ureter. More superiorly and closer to the sacrum group requiring repeat surgical intervention for prolapse. it is about 4cm from the ureter. When performing this Barber et al. have shown the two procedures to be of procedure it is therefore safer to place the suture higher equal efficacy, but the majority of the women in that trial and closer to the sacrum. Figure 2 depicts the typical had grade 2 uterine prolapse.9 The SSF may be a better positioning of the High Uterosacral Ligament sutures. option in women with more extensive uterine prolapse. It makes anatomic sense that a more secure and higher suspension can be achieved with the SSF. In their Figure 2: High Uterosacral Ligament Suspension systematic review, Margulies et al. report a successful anatomic outcome in 92% of women with pre-operative grade 2 prolapse compared to 67% in those with pre- operative grade 3, which further suggests that the HUSLS should be reserved for smaller degrees of uterine prolapse.8 It is also important to consider the complication profile of each of these procedures, which was elegantly demonstrated by the Barber trial.9 They reported a ureteric injury rate of 3.2% in the HUSLS group compared to 0% in the SSF group. Most of these injuries were recognized intra-operatively and in only 0.5% of the HUSLS cohort was there a need for post-operative intervention for a ureteric reimplantation. One of the potential concerns with the SSF is long term pain due to

Obstetrics & Gynaecology Forum • Issue 4 2014 ?? REVIEW O&G Forum 2014;24:???-??? nerve damage. Barber et al. reported that 4.3% of the SSF single incision anterior mesh kits. These include the Nuvia cohort had persistent pain, compared to only 0.5% of the (Bard), Uphold (Boston Scientific) or the Elevate Kit (AMS). HUSLS cohort. These systems all have two apical arms that attach onto the sacrospinous ligament through an anterior incision. Manchester repair The procedure is therefore, in principle, a modified SSF The Manchester repair was developed by Archibald operation with the addition of mesh. Uterine support is Donald in the early 20th century in a city that is now more provided by attaching the apical (proximal) edge of the famous for football than prolapse surgery. Interestingly, it mesh to the cervix with two or three sutures. was Donald’s senior registrar, William Fothergill who saw A case series reported by Vu et al. on the use of the the potential of this procedure for uterine prolapse and anterior single incision mesh kit in women with uterine was the first to publish a paper on the technique. This prolapse demonstrated excellent functional, anatomical archaic operation is associated with excellent outcomes and sexual function outcomes.13 It would appear, however, and interest in it continues to grow, as evidenced from a that most of their cohort had relatively mild degrees of number of recent published papers on this technique.10,11 uterine prolapse. They reported a median pre-operative The advantage of this operation is that the uterus is stage 1 for the uterus. spared and it therefore has the potential to reduce the With the excellent outcomes associated with native risks associated with hysterectomy. The procedure tissue surgery for uterine prolapse, mesh should be involves detachment of the uterosacral ligaments from reserved for special indications. This includes, for their insertion points in the cervix, followed by amputation example, a woman who has a recurrent with of the cervix. The cut uterosacral ends are then pulled grade 2 or less uterine prolapse. In particular, a mesh across the cervical stump and re-attached onto the procedure should be avoided in women with a large, contralateral side of the cervix. A novel way of performing bulky cervix or in someone with a grade 3 uterine this step is to pull one of the uterosacrals over the anterior prolapse. A more durable outcome is achievable with a part of the cervix stump and the other over the posterior hysterectomy and vault suspension in these women. When part. Most women with uterine prolapse also have a using a mesh kit in these women, the cervix often tends to significant cystocele and rectocele and the Manchester ‘ride’ over the top edge of the mesh and give rise to repair usually involves an anterior and posterior recurrence of the prolapse. Adding a mesh kit to a colporrhaphy. The large raw exposed area of the cervical hysterectomy for prolapse is associated with a higher risk stump is closed using the Sturmdorff suture at the end of for mesh erosion and this is therefore considered to be a the procedure. relative contraindication to mesh.14 In a small case series of the Manchester-Fothergill operation, Alkı et al. recently reported re-operation rates Colpocleisis of 4%.10 They had one bladder perforation and one case of The colpocleisis was first described in 1877 by Leon urinary retention in their series of about 50 patients. A Clement Le Fort.15 From the Greek translation kolpos case control study comparing Manchester repair to (vagina) and kleisis (close), this literally means to close the vaginal hysterectomy and HUSLS reported excellent vagina. It remains an underutilised procedure in women outcomes for both procedures.11 At 4 and 8 year follow up, with uterine prolapse who do not wish to retain their functional and anatomical outcomes were the same. The potential for sexual activity. It has the advantage of being a Manchester repair had the significant advantage of less relatively quick and simple procedure with low morbidity, blood loss and shorter operating time when compared to making it the ideal approach for elderly and frail women the vaginal hysterectomy and HUSLS. who have failed conservative treatment with pessaries. The procedure is performed by removing two large Vaginal Mesh Procedures rectangles of vaginal skin, one anteriorly and another Any surgeon considering using a vaginal mesh in a posteriorly, and then suturing these together to obliterate woman with uterine prolapse needs to appreciate that this the vagina. This should always be followed by a tight is undoubtedly the most controversial of all issues in perineorrhaphy. Many surgeons will also do a prophylactic urogynaecology. The last three years has seen a decline in mid-urethral sling, due to the high incidence of de novo the use of mesh for pelvic floor surgery mainly due to the stress incontinence following the operation. Many women US Food and Drug Administration (FDA) warnings in July have post-operative voiding dysfunction but this usually 2011.12 The FDA document highlighted the complications resolves with conservative management over the course of of mesh surgery and emphasized the lack of data for a a few weeks. number of the products in use. An increase in litigation in A large case series of 325 patients undergoing women suffering complications from mesh surgery may colpocleisis, with a mean age of 81 years, was reported by also have contributed to the decline in use of these Zebede et al.16 The anatomical success rate in this study products. In selected patients and in experienced hands, was 98%. however, a mesh kit remains an excellent option. There has been an evolution in the design and Uterine sparing procedures versus hysterectomy for application systems in the mesh kit industry and these uterine prolapse changes have made them safer and more effective. We Many prolapse surgeons are now opting for a uterine also have better data, indicating where these mesh kits sparing approach in women with uterine prolapse. This would be most suitable. We currently make use of the has obvious potential advantages relating to operation

Obstetrics & Gynaecology Forum • Issue 4 2014 ?? REVIEW O&G Forum 2014;24:???-??? time, blood loss and complication rates. It also retains the sacrocolpopexy-type procedure for uterine prolapse. The patient’s fertility and may be associated with fewer most popular approach is to perform either a total or subtotal ureteric injuries. In addition, some women are reluctant to hysterectomy followed by a mesh sacrocolpopexy. A uterine- have a hysterectomy for cultural or other personal reasons. sparing alternative is the mesh sacrohysteropexy.21 There are unfortunately limited good data comparing The major disadvantage of the abdominal approach is the the hysterectomy to the uterine sparing techniques for potentially increased morbidity and longer recovery time. uterine prolapse. Romanzi et al. looked at prolapse This has, however, changed substantially over recent recurrence rates in women undergoing surgery for uterine decades with the advent of the laparoscopic and robotic prolapse.17 There was no difference between the groups techniques. These minimally invasive options have made the having a hysterectomy and uterosacral ligament abdominal approach an attractive option for women with suspension or uterine preservation and uterosacral uterine prolapse.21 ligament suspension, with regard to recurrence rates for vault prolapse, cystocele and rectocele. In a further Total and subtotal hysterectomy and sacrocolpopexy retrospective study, Maher et al. compared the prolapse Whether this operation is done by open laparotomy, outcomes in women having uterine preservation or laparoscopy or robotically; the principles of the procedure hysterectomy at sacrospinous colpopexy for uterine remain the same. The mesh is attached in a similar manner prolapse.18 The subjective success rate was 86% in the as with a sacrocolpopexy for vault prolapse. hysterectomy group and 78% in the hysteropexy group It is advisable to commence the sacrocolpopexy (p=0.70). More importantly, the mean operation time was procedures, both open and laparoscopic, by identifying the 91 minutes for the hysterectomy group, compared to 59 sacral promontory. This is potentially the most difficult and minutes in the uterine preservation group, and mean dangerous part of the operation. The peritoneum over the blood loss was 402 ml and 198 ml in the two groups promontory is opened and the retroperitoneal dissection is respectively. taken down toward the Pouch of Douglas. The rectum will be Before embarking on a uterine preservation technique, medial to the peritoneal incision line; and the right ureter, it is important to rule out endometrial pathology. Kow et al. lateral to the dissection. If these organs are adequately have described a useful list of considerations in women visualized, it is safe to proceed with the dissection to the considering uterine conservation and these are listed in posterior aspect of the vagina. A probe is then inserted into Table II.19 the vagina and the vaginal mesh attachment areas are We urgently need of data comparing the uterine prepared, prior to removal of the uterus. sparing and hysterectomy approaches in women with After the vaginal dissection has been completed, a uterine prolapse. Performing a hysterectomy may be hysterectomy is performed. A subtotal hysterectomy avoids associated with a more robust repair in women with a opening the vaginal vault, which increases the risk of vaginal large and bulky cervix and in patients with a large grade 3 mesh erosion. There are very few data on this issue of or 4 uterine prolapse but at present the data are not whether to perform a total or subtotal hysterectomy. Tan-Kim available. et al., in a retrospective analysis, report a mesh erosion rate of 5% following subtotal hysterectomy and sacrocolpopexy, Abdominal approaches to uterine prolapse compared to 23% in those women having total vaginal There is excellent level 1 evidence to suggest that the hysterectomy and sacrocolpopexy.21 Warner et al. reported a abdominal sacrocolpopexy (SCP) for post-hysterectomy lower incidence of erosion in their large study of 390 vaginal vault prolapse is superior to the vaginal approach women.22 They had no erosions in the sub-total hysterectomy in terms of anatomical outcomes and sexual function.20 group and 4% in the women who had a total hysterectomy. Compared to the SSF, SCP has been shown to be Prior to the performance of a subtotal hysterectomy and associated with a more anatomical vaginal axis and sacrocolpopexy for uterine prolapse, it is essential to assess superior vaginal length. The SCP is also a tension free the length of the cervix. If the cervix is lengthened, a total procedure. The superiority of the SCP for vault prolapse abdominal hysterectomy, total vaginal hysterectomy or pre- has prompted increasing interest in performing a operative cervix amputation may be necessary.

Table II: Preoperative considerations in women considering uterine preservation (Kow et al.)19

Future pregnancy Obstetrical history including mode of delivery

Risk assessment for cervical disease Recent normal pap smears Negative test for oncogenic HPV or History of prior HPV vaccine

Risk assessment for uterine disease Normal menstrual cycles in premenopausal women No abnormal uterine bleeding No history of postmenopausal bleeding Ultrasound (recommended if history of abnormal uterine bleeding)

Counseling regarding need for continued screening for gynaecologic disease.

Obstetrics & Gynaecology Forum • Issue 4 2014 ?? REVIEW O&G Forum 2014;24:???-???

Sacrohysteropexy prolapse into an abdominal sacrohysteropexy or vaginal This is the uterine-sparing alternative to hysterectomy and hysterectomy and uterosacral ligament suspension.24 Those sacrocolpopexy. It has recently gained popularity among women who had vaginal surgery had better outcomes in surgeons wishing to retain the reproductive potential of their multiple domains on the quality of life questionnaires. The patients. In a woman with an isolated uterine prolapse and abdominal approach was also associated with a much very little anterior and posterior prolapse, the technique is higher re-operation rate (22% vs 2%). They concluded that extremely simple. A single strap of mesh is attached vaginal hysterectomy with anterior and/or posterior posteriorly at the cervico-uterine junction and this is colporraphy is preferable to abdominal sacrocolpopexy attached to the sacral promontory. with preservation of the uterus as surgical correction in If there is a significant cystocele, two pieces of mesh are patients with uterine prolapse grades 2-4. A further trial by used. The anterior mesh is cut to the shape of a ‘trouser-leg’. Robinson et al. looked at perioperative complications of the (Figure 3). The upper part of the ‘trousers’ is attached to the vaginal and abdominal robotic approach in women older anterior vagina and the two ‘legs’ are brought through two than 65 years of age.25 Robotic procedures included windows in the broad ligament and attached to the sacrocolpopexy and sacrocervicopexy. The vaginal promontory. A single strap of mesh is attached posteriorly to procedures were either uterosacral ligament suspension, the cervix and this is in turn attached to the promontory.21 sacrospinous ligament suspension, colpocleisis or Uphold (Figure 4) vaginal mesh placement. They concluded that, overall, all There are relatively little data on this technique. Price et procedures were associated with few complications, and al. performed a two-strap sacrohysteropexy in 84 women.23 At either route may be reasonable in the elderly population. follow-up they all had good vault support. They also reported De la Cruz et al. compared the change from pre- to subjective improvements in prolapse symptoms and sexual postoperative total vaginal length (TVL) in women who well-being with significant reductions in the respective underwent either a total vaginal hysterectomy (TVH) with questionnaire scores. uterosacral ligament suspension or a robotic hysterectomy with SCP.26 Recurrent prolapse (defined as any prolapse at or beyond the hymen) was not different between groups. Figure 3: Sacrohysteropexy: Anterior mesh attachment. Vaginal length was decreased in the vaginal hysterectomy Note the mesh is in the shape of a pair of trousers group compared with the robotic group but this did not make a difference to postoperative sexual function or pelvic floor function between the groups.26 Prolapse surgery is more of an art than a science. Before embarking on a specific technique, a large number of factors should be considered. The abdominal approach is most suited to young, fit women who are sexually active. An abdominal or laparoscopic hysterectomy and sacrocolpopexy will however be much more difficult in women with a high BMI and previous abdominal surgery. The potential morbidity of sacrocolpopexy is significant. Patients should be counseled regarding the risk of bladder and bowel injury, severe haemorrhage from the sacral venous plexus and spondilodiscitis. These are all potentially life-changing events and also place the surgeon at risk for Figure 4: Sacrohysteropexy: Posterior mesh attachment. litigation if they do occur. Note both parts of the mesh are attached onto the sacral Many surgeons are not proficient at the abdominal promontory approach to uterine prolapse. For these doctors, the current data would support the use of the vaginal approach, rather than embarking on potentially difficult surgery without adequate training and experience.

Conclusion Uterine prolapse is a common pelvic floor disorder and selecting an appropriate technique is important. Despite the advent of new techniques, a vaginal hysterectomy coupled with a robust vault support procedure remains an excellent option for uterine prolapse. The importance of ensuring adequate fixation of the vault after hysterectomy cannot be overemphasized. Surgeons should resist the temptation of simply re-attaching the uterosacral pedicles onto the vault Selecting your approach: abdominal or vaginal? since this often leads to vaginal shortening and failure of the There are relatively few data comparing the outcomes of the procedure. An abdominal approach is an excellent option in abdominal to the vaginal approach in women with uterine the young, sexually active patient and this usually includes a prolapse. Roovers et al. randomized 84 women with uterine sacral mesh attachment to provide apical support.

Obstetrics & Gynaecology Forum • Issue 4 2014 ?? REVIEW O&G Forum 2014;24:???-???

References Urogynecol J 2012; 23(12):1753-61. 1. Neeser E, Keller E, Hirsch HA. Prevention of vaginal prolapse in 14. Tijdink MM, Vierhout ME, Heesakkers JP, Withagen MI. Surgical hysterectomy by suspension of the vaginal stump. Geburtshilfe management of mesh-related complications after prior pelvic floor Frauenheilkd 1990; 50(10):789-93. reconstructive surgery with mesh. Int Urogynecol J 2011; 2. Kuhn A, Brunnmayr G, Stadlmayr W, Kuhn P, Mueller MD. Male and 22(11):1395-404. female sexual function after surgical repair of female organ 15. Le Fort LC. Nouveau procédé pour la guérison du prolapsus prolapse. J Sex Med 2009; 6(5):1324-34. utérin. Bull gén de thérapie 1877; 92; 337-44. 3. Beer M, Kuhn A. Surgical techniques for vault prolapse: a review of 16. Zebede S, Smith AL, Plowright LN, Hegde A, Aguilar VC, Davila the literature. Eur J Obstet Gynecol Reprod Biol 2005; 119(2):144-55. GW. Obliterative LeFort colpocleisis in a large group of elderly 4. Leone Roberti Maggiore U, Alessandri F, Remorgida V, Venturini PL, women. Obstet Gynecol 2013; 121(2.1):279-84. Ferrero S. Vaginal sacrospinous colpopexy using the Capio suture- 17. Romanzi LJ, Tyagi R. Hysteropexy compared to hysterectomy for capturing device versus traditional technique: feasibility and uterine prolapse surgery: does durability differ? Int Urogynecol J outcome. Arch Gynecol Obstet 2013;287(2):267-74. 2012; 23(5):625-31. 5. Patel M, Currie J, Tulikangas PK. Abdominal extraperitoneal 18. Maher CF, Cary MP, Slack MC, Murray CJ, Milligan M, Schluter P. excision of a foreign body in the pararectal space. Female Pelvic Uterine preservation or hysterectomy at sacrospinous colpopexy Med Reconstr Surg 2011; 7(3):144-6. for uterovaginal prolapse? Int Urogynecol J Pelvic Floor Dysfunct. 6. Kasturi S, Bentley-Taylor M, Woodman PJ, Terry CL, Hale DS. High 2001; 12(6):381-4. uterosacral ligament vaginal vault suspension: comparison of 19. Kow N, Goldman HB, Ridgeway B. Management options for women absorbable vs. permanent suture for apical fixation. Int Urogynecol with uterine prolapse interested in uterine preservation. Curr Urol J 2012; 23(7):941-5. Rep 2013;14(5):395-402. 7. Khunda A, Vashisht A, Cutner A. New procedures for uterine 20. Maher CM, Feiner B, Baessler K, Glazener CM. Surgical management prolapse. Best Pract Res Clin Obstet Gynaecol 2013; 27(3):363-79. of in women: the updated summary version 8. Margulies RU, Rogers MA, Morgan DM. Outcomes of transvaginal Cochrane review. Int Urogynecol J 2011; 22(11):1445-57. uterosacral ligament suspension: systematic review and 21. Tan-Kim J, Menefee SA, Luber KM, Nager CW, Lukacz ES. metaanalysis. Am J Obstet Gynecol 2010; 202(2):124-34. Prevalence and risk factors for mesh erosion after laparoscopic- 9. Barber MD, Brubaker L, Burgio KL, Richter HE, Nygaard I, Weidner assisted sacrocolpopexy. Int Urogynecol J 2011; 22(2):205-12. AC et al, Eunice Kennedy Shriver National Institute of Child Health 22. Warner WB, Vora S, Hurtado EA, Welgoss JA, Horbach NS, von and Human Development Pelvic Floor Disorders Network. Pechmann WS. Effect of operative technique on mesh exposure in Comparison of 2 transvaginal surgical approaches and laparoscopic sacrocolpopexy. Female Pelvic Med Reconstr Surg perioperative behavioral therapy for apical vaginal prolapse: the 2012; 18(2):113-7. OPTIMAL randomized trial. JAMA 2014; 311(10):1023-34. 23. Price N, Slack A, Jackson SR. Laparoscopic sacrocolpopexy: an 10. Alkı I, Karaman E, Han A, Gülaç B, Ark HC. The outcome of observational study of functional and anatomical outcomes. Int Manchester-Fothergill operation for uterine decensus repair: a Urogynecol J 2011;22(1):77-82. single center experience. Arch Gynecol Obstet. 2014 Mar 18. 24. Roovers JP, van der Vaart CH, van der Bom JG, van Leeuwen JH, [Epub ahead of print] PubMed PMID: 24633983. Scholten PC, Heintz AP. A randomised controlled trial comparing 11. Thys SD, Coolen A, Martens IR, Oosterbaan HP, Roovers J, Mol B et abdominal and vaginal prolapse surgery: effects on urogenital al. A comparison of long-term outcome between Manchester function. BJOG 2004;111(1):50-6. Fothergill and vaginal hysterectomy as treatment for uterine 25. Robinson BL, Parnell BA, Sandbulte JT, Geller EJ, Connolly A, descent. Int Urogynecol J 2011; 22(9):1171-8. Matthews CA. Robotic versus vaginal urogynecologic surgery: a 12. U.S. Food and Drug Administration (FDA) Safety Communication: retrospective cohort study of perioperative complications in elderly Update on serious complications associated with transvaginal women. Female Pelvic Med Reconstr Surg 2013;19(4):230-7. placement of surgical mesh for pelvic organ prolapse. 2011 July 13. 26. De La Cruz JF, Myers EM, Geller EJ. Vaginal Versus Robotic 13. Vu MK, Letko J, Jirschele K, Gafni-Kane A, Nguyen A, Du H, Hysterectomy and Concomitant Pelvic Support Surgery: A Comparison Goldberg RP. Minimal mesh repair for apical and anterior of Postoperative Vaginal Length and Sexual Function. J Minim Invasive prolapse: initial anatomical and subjective outcomes. Int Gynecol. 2014 Apr 26. jmig.2014.04.011. [Epub ahead of print]

VISIT OUR WEBSITE www.ihpublishing.co.za

Obstetrics & Gynaecology Forum • Issue 4 2014 ??