(Uterine and Vault Prolapse): a FIGO Working Group Report

Neurourology and Urodynamics

Management of Apical Compartment Prolapse (Uterine and Vault Prolapse): A FIGO Working Group Report

Cornelia Betschart,1* Mauro Cervigni,2 Oscar Contreras Ortiz,3 Stergios K. Doumouchtsis,4 Masayasu Koyama,5 Carlos Medina,6 Jorge Milhem Haddad,7 Filippo la Torre,8 and Giuliano Zanni9 1Department of Gynecology, University Hospital, Zurich, Switzerland 2Department of Obstetrics and Gynecology, Catholic University of the Sacred Heart, Rome, Italy 3Faculty of Medicine, University of Buenos Aires, Buenos Aires, Argentina 4Department of Gynecology, St. George’s University of London, London, United Kingdom 5Department of Obstetrics and Gynecology, Osaka City Graduate School of Medicine, Osaka, Japan 6Department of Obstetrics and Gynecology, University of Miami School of Medicine, Miami, Florida 7Gynecology Division, Universidade de Sao~ Paulo, Sao~ Paulo, SP, Brazil 8Surgical Department, Policlinico ‘‘Umberto I’’, Sapienza University, Rome, Italy 9Department of Obstetrics and Gynecology, Hospital of Vicenza, Vicenza, Italy

Aim: Apical prolapse includes descent of the uterus, vagina cuff, or rarely solely of the cervix. It is estimated that women have an 11–19% life-time risk of undergoing surgery for POP. This rate is projected to increase over the next 2–3 decades. In this FIGO working group report we address the conservative and surgical treatment options for apical prolapse. Methods: The FIGO working group ‘‘Pelvic Floor Medicine and Reconstructive Surgery’’ describes the different treatments for apical prolapse based on the literature evidence, the cost-effectiveness, the degree of difficulty and summed them up with an experts recommendation. Results: Among the conservative treatment options, pessaries are the most successful options since centuries with a low complication rate and low costs. Among the vaginal operative procedures the sacrospinous ligament fixation (SSLF) and the uterosacral ligament suspension (USLS) show comparable outcomes and efficacy with a different, however, rather low complication pattern and a favorable cost-benefit profile. Sacrocolpopexy, independent on the open abdominal, laparoscopic, or robotic-assisted laparoscopic technique has a good durability and quality of life performance. The minimal invasive techniques are as effective as the open abdominal techniques and there is no difference in mesh exposure. Conclusion: Vaginal procedures are well described procedures with favorable outcomes and cost-benefit profiles. Sacral colpopexy has a high-effectivity; data on the route of performance and long-term outcome are awaited. The cost with mesh implants are higher compared to the operations with autologous tissue or any conservative treatment and further studies are recommended to evaluate the cure rates in the span of decades and the possible long-term mesh complications. Neurourol. Urodynam. # 2015 Wiley Periodicals, Inc.

Key words: apical compartment; conservative treatment; International Federation of Gynecology and Obstetrics (FIGO); pelvic organ prolapse (POP); surgery

INTRODUCTION complex,10,11 and (2) birth-related levator ani muscle injury.12,13 In most cases, childbirth is thought to be the primary Apical prolapse includes descent of the uterus, vaginal cuff, or factor responsible for pelvic neuropathies and tissue injury that rarely solely of the cervix. Pelvic organ prolapse (POP) is predispose to the development of POP. Aging, breaks in the common and can be seen in up to 50% or more of parous women connective tissue, neuromuscular damage, congential connec- depending on definition of POP.1 Unfortunately, there still is tive tissue disorders, and operative procedures also contribute not an optimal definition that combines anatomical findings to pelvic support defects.14–16 Uterine prolapse is the result of a and symptoms. The annual aggregated rate of associated defect in apical support with damage to the cardinal and surgery is in the range of 10–30 per 10,000 women.2 It is estimated that women have an 11–19% life-time risk of undergoing surgery for POP.3,4 This rate is projected to increase over the next 2–3 decades.5–7 Authors contribution: The authors participated in both of the FIGO consensus meetings in Sao Paulo 2013 and Vicenza 2014. The manuscript was drafted by a ANATOMICAL ASPECTS OF APICAL DESCENT process of ongoing review following an action plan in the interim period. All authors were involved in the manuscript writing and revising, and in the review POP is usually caused by weakness of the pelvic diaphragm, process. ligaments, and/or muscles. Subsequent increase in intra- Dr. Fred Milani led the peer-review process as the Associate Editor responsible for the paper. abdominal pressure may exacerbate any tendency to prolapse. Potential conflicts of interest: Nothing to disclose. Anatomical cadaver studies showed that pelvic organs are ÃCorrespondence to: Cornelia Betschart, Department of Gynecology, University suspended by the uterosacral and cardinal ligaments and Hospital, Zurich 8091, Switzerland. E-mail: [email protected] supported by the levator ani muscle and endopelvic fascia.8,9 Received 2 July 2015; Accepted 7 October 2015 Published online in Wiley Online Library Biomechanical reasons for apical descent are (1) the loss (wileyonlinelibrary.com). of apical support for the cardinal/uterosacral ligament DOI 10.1002/nau.22916

# 2015 Wiley Periodicals, Inc. 2 Betschart et al. uterosacral ligaments. A normal-sized uterus itself plays little Classification of POP ought to be in accordance with anatomy or no role in uterine prolapse. and symptoms and ought to be easy to perform, teach, and For decades, knowledge of prolapse was gained from cadaver learn, as well as sensitive and specific to relevant changes in studies, nowadays imaging studies contribute to the better anatomy. Two such systems are discussed below: understanding of prolapse. Magnetic resonance imaging (MRI) One of the first clinical quantification systems was the and ultrasonography have begun to define the dynamics of the Baden Walker classification (1971).24 In 1997, the POP-Q pelvic floor and are able to identify specific tissue lesions system which is an objective and specific prolapse quantifi- involved in this process.17,18 One of the early MRI studies cation system for reporting POP was introduced.25 Today, the revealed that the levator ani muscle in living women was POP-Q is the internationally accepted standard in science. dome-shaped at rest.19 During voluntary pelvic contractions it More recently, a simplified version of the POP-Q has become straightens, becoming more horizontal, and during bearing available (S-POP-Q) because of the perceived complexity of down it becomes basin shaped. In correcting pelvic floor the full tool. Its use in clinical practice showed a substantial anatomy, it is crucial that the vaginal axis is situated over the association with the POP-Q.26 levator ani plate, so that the anterior and posterior vaginal wall Currently, the authors would recommend the routine use of can sustain the pressure differences exerted by movements and the POP-Q for standardized assessment of POP. loads. Colpography has shown that the upper vagina lies on an almost horizontal axis towards the sacrum.20 Using vaginog- MANAGEMENT OF APICAL DEFECTS raphy, an angulated shape of the normal upper vagina was confirmed and that the angle between the upper and lower Apical compartment uterine and vault prolapse vaginal axis is about 1308.21,22 (A) non-surgical management In this clinical opinion article, we report the conservative and (B) surgical management surgical treatment options for apical prolapse, with level 1 23 support according to DeLanceys description. The FIGO (a) uterine prolapse working group ‘‘Pelvic Floor Medicine and Reconstructive (b) vaginal vault prolapse Surgery’’ discussed the management of apical prolapse during meetings, the literature was reviewed, and consensus opinions in areas where either the data were poor, or not of good quality was provided. The FIGO working group addresses apical (A) Non-Surgical Management of Apical Prolapse descent, a day-to-day problem of Ob/Gyn practitioners Conservative therapy for symptomatic prolapse includes worldwide, with the objective of providing some consensus observation, life style recommendations, pelvic floor physical where the evidence was poor. The document is presented as a therapy (PFPT), and pessaries. Patients desiring future fertility consensus statement and not as a systematic review. should not undergo surgery unless they are symptomatic, or Where appropriate, the different treatments are described pelvic floor muscle training (PFMT) did not lead to improve- based on the literature evidence (EBM levels 1a–5) and ment and pessary use is not an option for the patient. cost-effectiveness. The degree of difficulty involved is also (1) Pessaries. Pessaries may be considered an ideal solution that discussed as expert opinion (level 5) and summed up with eventually prevents progression of the POP.27 As such, pessaries recommendations (Grades of Recommendation A–D, abbrevi- can be a first line treatment in conservative therapy and can ated as grade A–D). be used for any site and grade of prolapse at any life-stage. Examples of where pessaries confer a significant benefit include DIAGNOSIS OF APICAL DEFECT women with an active desire for children, for women where frailty or comorbidity would be a risk for surgery or for any Diagnosis is usually based on the following: women wishing to avoid surgery. Pessary insertions are recommended between 6 weeks and 6 months, depending on (1) History of presenting complaint. the woman’s mental and physical capacity to maintain adequate (2) Clinical examination. hygiene and to change the pessary herself.28 Adherence to (3) Investigations, e.g., urodynamic examination, MRI, CT, pessary use is often high and there is no increase of the generally ultrasound (according to national guidelines). rare and mild complications in long-term users.29 Conversely, some studies demonstrate high discontinuation rates and adverse events in long-term vaginal ring pessary users. One Australian study showed 56% of women experienced complica- (1) History tions including bleeding, extrusion, severe vaginal discharge, Patient history should include suspected etiological factors pain, and constipation.30 Adherence to long-term use of pessary like mode of delivery, symptoms relating to bladder, bowel and is, therefore, patient and situation dependent. Preoperatively, sexual dysfunction as well as relevant co-morbidities which may pessaries can be used to unmask occult incontinence.31 They also impact on the choice of surgery and previous urogynecological can be combined with other conservative treatments like PFMT operations, as they may also predispose to recurrence of POP. for improving prolapse symptoms and incontinence.32 Evaluation of symptoms can be facilitated by validated Cost-effectiveness for pessary use has been given. Also, in the questionnaires. case patients who transitioned to surgery later on.33 FIGO working group RECOMMENDATION for pessaries. Pessaries can be offered to women with symptomatic POP as first-line (2) Clinical Examination management if they desire conservative treatment (EBM The clinical examination refers to a common classification level 2a). Preoperatively, pessaries can be used to unmask system and agreement in which symptoms are recorded as occult incontinence (EBM level 2b) and they can be combined related to prolapse and expected to improve by prolapse with other conservative treatments for improving SUI, such as surgery. PFMT, although this has low evidence (EBM level 3).

Neurourology and Urodynamics DOI 10.1002/nau Management of Apical Compartment Prolapse 3

(2) Life-style change and PFMT. Although obese women with (2) Sacrospinous ligament fixation (SSLF) for vault and uterine POP may benefit from weight reduction, good consistent prolapse. The SSLF aims to fix the cuff of the vagina or uterus to evidence showing improvement of symptoms and POP-Q the sacrospinous ligament—most commonly to the right side parameters is lacking.34,35 Apart from body weight and gravity, to prevent lesions of the rectum (Fig. 1).42 there exists also an association between physical workload, The sacrospinous ligament is the anchor point of the proximal heavy occupational lifting, and prolapse.36 mesh straps of the majority of the transvaginal mesh kits. There is some evidence that PFMT is beneficial for POP.37,38 Anatomical recurrence most commonly occurs in the anterior One highly ranked study demonstrated that PFMT was superior compartment as the resultant vaginal axis is changed with a in patient reported prolapse symptoms improvement at potential increase on the stresses of the anterior compartment. 12 months compared to lifestyle modification (POPPY trial) in For recurrence in the apex either a repeat SSLF or SCP has proven women with symptomatic mild and moderate POP.39 Compar- effective.43,44 A bilateral SSF would offer more fixation points, isons of effectiveness of PFMT or pessary use and whether although it is believed to perhaps shorten the functional part preoperative PFMT is effective in subjective and objective of the vagina and further expose the anterior compartment outcome parameters are still under investigation. Data on (grade C) and has no demonstrable benefit. The transvaginal the cost-effectiveness of PFMT in POP treatment are not SSF requires adequate vaginal length to reach the sacrospinous available yet. ligament. FIGO working group RECOMMENDATION for PFMT. PFMT may During intra-abdominal rise of pressure, the vagina is pressed have a beneficial effect on reducing prolapse symptoms in toward the levator plate. The vagina keeps its diameter and motivated patients. There is limited evidence for an anatomical generally its length unless repair of associated defects yields to improvement in moderate-to-severe prolapse. Long-term ef- vaginal narrowing. fects of PFMT and its cost-effectiveness have to be investigated Literature evidence of SSLF. In a literature review identifying in future research. studies including 2,390 patients with SSF, subjective cure rates for prolapse-related symptoms ranged from 70% to 98% (only four studies reported subjective results) and objective cure rates (B) Management of Apical Prolapse of between 67% and 97%.45 At 2-year follow-up, re-operation (1) Where hysterectomy has not been previously performed: due to recurrent vaginal vault prolapse ranged from 3% to 29%. Vaginal hysterectomy. Prolapse of the apical compartment Similar and non-inferior recurrence rates were found for 46,47 treated by vaginal hysterectomy requires vault suspension sacrospinous hysteropexy. Postoperative dyspareunia rates techniques. Removing the uterus itself does not ensure apical ranged from 2% to 36% of sexually active patients. The majority support. There are different apical fixation points in the pelvis of recurrences occur in the anterior compartment and only 7.2% 48–51 on durable and strong ligaments, like the longitudinal occur in the apex. ligament, the sacrospinous ligament and sacrotuberous liga- Objective evidence following SSF of grade 2 prolapse, using ment, which are not affected by birth-related injuries or aging either the Baden–Walker or POP-Q classification system was (Fig. 1). found in 10–30% in the anterior compartment (cystoceles) and 52 McCallculdeplasty(gradeB),SSF(gradeA),orsuturing 6% in the posterior compartment (rectoceles). the cardinal and deep uterosacral ligaments to the vaginal The long-term stability of the SSF in a cohort of 60-year-old cuff (grade A) and high circumferential obliteration of the women was high, however, for those <60 years, functional 53 pouch of Douglas at the time of vaginal hysterectomy outcomes and satisfaction declined at 5 years follow-up. (grade B) are recommended for uterovaginal prolapse The procedure can be performed at places with low financial 54 management.40,41 resources. The SSLF is a cost-effective procedure. Degree of difficulty. Knowledge of the anatomy of the sacrospinous ligament is essential for doing this procedure. We recommend this procedure to be performed by experienced surgeons with advanced skills who have undergone appropriate training. Potential serious risks include neurovascular injury to the pudendal bundle, lesser risks include persistent buttock pain. FIGO working group recommendation. SSF is a procedure with a high success rate (EBM level 1a, grade A) and it is also a safe procedure for women who desire preservation of the uterus (EBM level 2a, grade B). (3) Uterosacral ligament suspension (USLS). The uterosacral ligament vaginal apical suspension is the most anatomically correct of the repairs. The original McCall suture was reported as culdeplasty for enterocele and has been improved afterwards as the modified McCall procedure involving lateral placement of one to three permanent sutures through the uterosacral ligament, useful to recover both the axis and depth of the vaginal canal.55 The vaginal cuff is suspended from the Fig. 1. View from superior into the female pelvis. Attachment points for remaining part of each uterosacral ligament incorporating apical suspension: in the sacrospinous ligament, the filled dots are the most the rectovaginal and the pubocervical fascia and the anterior commonly used fixation points for unilateral vaginal SSLF, the unfilled dots and posterior vaginal epithelium into the suture at the apex for bilateral sacrospinous ligament fixation. The three bilateral dots in the (Fig. 1). uterosacral ligament are used for USL suspension. Dots on the promontrium are used for the sacro(hystero) colpopexy. Uterus and tubes, dashed lines; The proximal part of the uterosacral ligament and cardinal vagina, solid line. ligament complex is the most appropriate part with enough

Neurourology and Urodynamics DOI 10.1002/nau 4 Betschart et al. strength to suspend the vagina at level 1, while the distal part of % prolapse reoperation rate, and a 2.7 % mesh exposure rate. this ligament complex is often damaged and attenuated in POP Conversion rates, operative times, and complications have patients. There is the potential for any suture to create ureteral decreased with increased laparoscopy experience over the past obstruction due to the close anatomical relationship of the 20 years.62 56 ureter to this ligament complex which occurs due to either One recent U.K. multicenter prospective trial continues to kinking or injury in up to 11%. In a review, the authors reported support minimally invasive laparoscopic sacral colpopexy (LSC) 57 a rate of 5.9% directly attributable to USLS. The issue may be as a clinically equivalent approach to that of the traditional resolved by cystoscopy after ligation of the McCall suture with open procedure.63 administration of indigo carmine or methylene blue or the LSC for vaginal vault prolapse has been compared to total 1 observation of ureteric jets without a dye. vaginal mesh (TVM ) at 2 years, LSC had higher satisfaction and Literature evidence of USLS. There are more than 30 clinical objective success rates with lower perioperative morbidity and studies that have been published between 1970 and 2014. reoperation rates and costs.64,65 Recurrence rates of POP ranged from 7% to 16%. Large meta- The cumulative overall mesh exposure rate reported for the analysis showed that the pooled rates for a successful outcome, abdominal approach was 3.4% (70/2,178) with polypropylene which was defined then as ‘‘no surgery for recurrent vaginal demonstrating the lowest synthetic mesh exposure rate of 0.5% relaxation’’ were 81%, 98%, and 87% in the anterior, apical, and (1/211).62 There is conflicting data on concurrent hysterectomy posterior compartments, respectively.58 Subjective complaints as a modifiable risk factor for mesh exposure. Cundiff et al. like feeling a bulge after USLS in a more than 5-year follow-up (2008)66 reported an increased associated risk contrary to was 11.5% and the re-operation rate was 5.2%.59 findings by Nosti et al. (2009)67 who reported no significant risk. In a retrospective study, 23 patients with symptomatic A recent study demonstrated laparoscopic hysteropexy as a uterine prolapse and the desire for uterine preservation feasible and effective procedure for uterine sparing prolapse underwent surgical repair with laparoscopic uterosacral surgery with promising long-term results of up to 4 years.68,69 uterine suspension. The POP-Q scores for point C and D were In a large retrospective cohort from 1999 to 2010 including significantly further away from the hymen after operation than 104 completely laparoscopic uterosacral hysteropexies and 160 compared with the preoperative values (À0.6 vs À7.8 and À5.0 laparovaginal hysterectomies, with laparoscopic uterosacral vs À8.6; P < 0.01 respectively).60 The USLS procedure is not colpopexy fixing the USL to the cervix with permanent braided demanding in terms of resources, and is comparable with the sutures, with a median follow-up of 2.5 years, the total SSLF as only stitches, threads, and standard vaginal instru- objective failure rate for hysteropexy was 52.9% and for ments have to be available. Its cost effectivity, however, has not hysterectomy with uterosacral colpopexy was 37.5%. Repeat been a research topic. overall operation rates were similar (hysteropexy 27.9% vs. Degree of difficulty. Understanding the anatomy of the hysterectomy/uterosacral colpopexy 20.6%) in a follow up of uterosacral ligament is essential for doing this procedure. It 34 and 21 months respectively.70 Success rates ranging is important to use the strong and deep part of the ligament for between 86% and 95% for laparoscopic USLS and sacral a durable outcome. colpopexy with a mesh have also been shown in a retrospective We recommend this procedure to be performed by experi- cohort study.71 The success in this study depended on the enced surgeons with advanced skills who have undergone prolapse stage rather than on the operative technique. This appropriate training. The procedure itself can be performed at study also demonstrated that the anterior compartment places with low financial resources. Inspection of the ureters prolapse had better results with the laparoscopic sacrocolpo- cystoscopically is mandatory and it is suggested to confirm pexy than the laparoscopic USLS without any statistically patency of the ureters before closing. significant differences in the apex or posterior compartment 71 FIGO working group recommendation. USLS can correct the position or in PFDI (Pelvic Floor Distress Inventory) scores. vaginal apical part to an anatomically normal position rather Biografts such as porcine dermis as an alternative to than SSLF. USLS is a safe procedure with a high success rate synthetic meshes showed similar 12 months objective out- (EBM level 1a, grade A). comes in a double-blinded, randomized, controlled trial against (4) Abdominal (laparoscopic/robotic) sacrocolpopexy/sacrohys- polypropylene mesh; however, there is lack of long-term 72 teropexy. The ‘‘gold standard’’ procedure for vault prolapse is success rates. the sacral colpopexy that suspends the vaginal vault by LSC has lower operating times, pain, and cost when compared 73 reinforcing the anterior and posterior vaginal fibromuscularis with the robotic-assisted procedure. The cost-effectiveness for with mesh secured to the anterior longitudinal sacral ligament robotic LSC is not given yet, as most level 1 data show increased on the height of the promontorium (filled dots, Fig. 1) or at the operating time and cost compared with conventional laparo- 74 sacral bone (S2) (unfilled dots). This procedure has evolved from scopic sacrocolpopexy. mesh attachment solely to the apex, to an extension down the Degree of difficulty. Exposure of the anterior longitudinal anterior and posterior vaginal walls. ligament at the level of the promontory requires identification A comprehensive review reported long-term durability with of vulnerable anatomical structures. The vesicovaginal space success rates ranging from 78% to 100%.61 in scarred tissue goes along with higher complications In sacrohysteropexy, the uterus is attached to the anterior (bladder lesion, vesicovaginal fistula). The anterior preparation longitudinal ligament over the sacrum. A mesh is used to hold should be developed up to the bladder neck, especially in the uterus in place. It is a variation of the sacral colpopexy to sacrohysterocolpopexy. correct apical prolapse without hysterectomy for women who Clinicians should be aware that laparoscopic procedures desire uterine preservation and have no risks or clinical signs of involve a high level of expertise and longer operation time than uterine pathology. open procedures. Literature evidence of sacrocolpopexy. A recent review com- Sacrohysteropexy: advanced laparoscopic skills coming from posed by 11 retrospective series of laparoscopic sacrocoplopexy appropriate training are required. Additional difficulty will be with 1,197 total patients with a mean follow-up of 24.6 months expected when combining anterior and posterior repair (EBM demonstrated an overall 94.4% subjective satisfaction rate, 6.2 level 5).

Neurourology and Urodynamics DOI 10.1002/nau Management of Apical Compartment Prolapse 5

FIGO working group recommendation. Sacrocolpopexy is the preservation of coital function, is a minimally invasive and safe preferred procedure when vaginal capacity is reduced and procedure. ongoing sexual function is important. Colpocleisis can be performed under general or regional Current evidence on the safety and efficacy of sacrocolpopexy anesthesia. using mesh for vaginal vault prolapse repair appears adequate Literature evidence of colpocleisis. Colpocleisis is an effective to support the use of this procedure provided that normal procedure for treatment of advanced POP with success arrangements are in place for clinical governance and audit. rates ranging from 90% to 100% in patients who no longer The procedure should only be carried out by surgeons desire preservation of coital function.78 Colpocleisis provides specialized in the management of POP and female urinary good relief of pelvic floor symptoms without significant incontinence. morbidity.79 Sacrocolpopexy is a highly recommended apical prolapse Obliterative procedures yield a low rate of perioperative procedure (grade A). There is consistent evidence (EBM level 1a) morbidity in a high-risk patient population, the operative that sacrocolpopexy is more effective when compared to duration is short, and the risk of prolapse recurrence is sacrospinous fixation. low.76,80–83 The laparoscopic approach to sacral colpopexy is a safe and A retrospective study of women who underwent colpocleisis durable procedure to correct apical and complex vault prolapse reported that 8 of 30 developed de novo SUI postoperatively and with reduced perioperative morbidity compared with the open recurrent hernia of the perineum.84 approach when executed by skilled surgeons. Women with bothersome SUI should be counseled regarding Regarding mesh-associated complications, we recommend a concomitant procedure for SUI, regardless of preoperative limiting the amount of mesh and the use of a Type 1 urinary retention. In a case series of 38 women with POP and macroporous monofilament synthetic polypropylene mesh. SUI undergoing colpocleisis and midurethral sling, 11 women Comparative studies of abdominal/laparoscopic inserted mesh had preoperative urinary retention.85 Ten of 11 women with showed the same outcome (grade B). preoperative retention had resolution of retention and no Mesh problems have been consistently reported, which may women experienced prolonged retention requiring sling release relate to the use of permanent sutures. In such cases, the after surgery. Therefore, it seems reasonable to offer women resolution of pain or extrusion can easily be solved by vaginal with POP and bothersome SUI a midurethral sling at the time of removal of the stitches. colpocleisis. Laparoscopic SCP appears to be as effective as open SCP Most bothersome bowel symptoms resolve after colpocleisis, (grade B). especially obstructive and incontinence symptoms, with low Patients interested in uterine preservation must be aware of rates of de novo symptoms.86,87 the probable deleterious effects that pregnancy may have on The new onset of symptoms like frequency and urgency must the durability of sacrohysteropexy. be included in patients’ counseling.88 Uterine preserving procedures are to be avoided in patients Degree of difficulty. This procedure should be performed by a with abnormal bleeding or precancerous cervical lesions. surgeon with appropriate training. It is a safe procedure and Access to uterine and cervical surveillance, the possible need can be performed in countries with low resources. for hysterectomy for future pathology may be more difficult and long-term experience is lacking. FIGO working group recommendation. Obliterative procedures Because of the various qualities of the trials, a more precise are an effective option for women who cannot tolerate estimate of the need (or the needlessness) of a concomitant extensive surgery and who are not planning future vaginal hysterectomy in women that do not desire longer fertility intercourse (EBM level 2b). cannot be determined yet. For women with a uterus or cervix who are undergoing (5) Manchester (Donald–Fothergill) operation. This procedure colpocleisis, partial colpocleisis is suggested (EBM level 2c). can be considered occasionally for cases with elongation of the (7) Posterior intravaginal sling (P-IVS). IVS was first described uterine cervix and in women who wish to retain the uterus. in 1997 as a new method in order to repair level 1 defects of The Manchester operation consists of a cervical amputation vaginal vault descent.89 with mobilization and attachment of the cardinal ligaments A synthetic mesh tape is placed through the ischiorectal anterior to the cervix, followed by an anterior colporrhaphy to space and iliococcygeus muscle on both sides to the level of the support the vagina. Post-Manchester cervical incompetence vaginal vault and attached in the midline of the vaginal cuff. may lead to preterm deliveries and cervical stenosis may lead to According to the integral theory, the procedure specifically mechanical dysmenorrhea and to secondary infertility.75 tightens zones of laxity of the uterosacral ligaments, and thus FIGO working group recommendation. The Manchester Opera- differs fundamentally from sacrocolpopexy, vaginal sacrospi- 90,91 tion is largely obsolete and nowadays not a preferred procedure nous ligament fixation, or McCall techniques. for vaginal prolapse operation due to better alternatives for Literature evidence of P-IVS. The symptomatic cure rates for women who desire preservation of their fertility. prolapse were 75–91% in a follow-up of 4.5 years.90,91 (6) Colpocleisis. Total colpocleisis is generally reserved for In a randomized trial comparing P-IVS to SSF, postoperative vaginal vault prolapse and refers to removal of the majority of cystocele occurred in 4.8% of women after IVS and 25% after SSF the vaginal epithelium. This procedure is also referred to as (P > 0.05).92 After initially promising results, reports of high complete colpocleisis, colpectomy, or vaginectomy.76 Partial failure rates93 and delayed problems, like chronic infection, colpocleisis (Le Fort colpocleisis) is done in patients in whom fistulas, abscesses, chronic pain, also during defecation and intercourse, necrotising fasciits, osteomyelitis, and osteonec- the uterus is left in situ and includes removal of strips of 1 anterior and posterior vaginal epithelium, leaving a small strip rosis were described. The Intravaginal Slingplasty (P-IVS) like a of lateral epithelium on each side. The purpose for leaving number of microporous or multifilament slings has been the lateral strips is to provide an outlet for cervical or uterine removed from the market, mainly for an unaccepted rate of bleeding in patients where the uterus is left in situ.77 sling-related infections, occurring even months or years after The colpectomy in elderly or frail patients, who do not desire insertion.

Neurourology and Urodynamics DOI 10.1002/nau 6 Betschart et al.

Manufacturers appear to be replacing multifilament tapes 3. Olsen AL, Smith VJ, Bergstrom JO, et al. Epidemiology of surgically managed with monofilament products.94 These may or may not yet prove pelvic organ prolapse and urinary incontinence. Obstet Gynecol 1997;89: to be successful. 501–6. 4. Smith FJ, Holman CD, Moorin RE, et al. Lifetime risk of undergoing surgery for Degree of difficulty. Understanding of anatomy of the para- pelvic organ prolapse. Obstet Gynecol 2010;116:1096–100. rectal fossa has to be addressed in both undergraduate and 5. Luber KM, Boero S, Choe JY. The demographics of pelvic floor disorders: postgraduate training programs to perform this procedure. Current observations and future projections. Am J Obstet Gynecol 2001;184: 1496–501. FIGO working group recommendation. The posterior IVS and the 6. Nygaard I, Bradley C, Brandt D. Pelvic organ prolapse in older women: infracoccygeal sacropexy showed initially comparable anatom- Prevalence and risk factors. Obstet Gynecol 2004;104:489–97. ical and functional results (EBM level 2b). Later reports on 7. Wu JM, Hundley AF, Fulton RG, et al. Forecasting the prevalence of pelvic floor disorders in U. S. Women: 2010 to 2050. Obstet Gynecol 2009;114:1278–83. complications did not show any advantage in comparison to 8. DeLancey JOL. Anatomic aspects of vaginal eversion after hysterectomy. Am J the SSF. The IVS procedure should not be performed with Obstet Gynecol 1992;166:1717–28. multifilamentous meshes (grade A). This procedure does not 9. DeLancey JOL. The anatomy of the pelvic floor. Curr Opin Obstet Gynecol restore and correct anatomically weak ligaments as assumed 1994;6:313–6. 10. Summers A, Winkel LA, Hussain HK, et al. The relationship between anterior by several authors, but may be more anatomically neutral than and apical compartment support. Am J Obstet Gynecol 2006;194:1438–43. SSF. Current evidence on the efficacy and safety of infracoccy- 11. Smith TM, Luo J, Hsu Y, et al. A novel technique to measure in vivo uterine geal sacropexy using mesh for uterine and vaginal vault suspensory ligament stiffness. Am J Obstet Gynecol 2013;209:484.e1–7. prolapse repair is inadequate. The FIGO working group only 12. DeLancey JO, Morgan DM, Fenner DE, et al. Comparison of levator ani muscle defects and function in women with and without pelvic organ prolapse. recommends this procedure as part of a study or under the Obstet Gynecol 2007;109:295–302. supervision of the authorities and the control of an indepen- 13. Dietz HP. Quantification of major morphological abnormalities of the levator dent monitoring board to audit benefit/success for the patients. ani. Ultrasound Obstet Gynecol 2007;29:329–34. The role of transvaginal mesh kits for apical support is 14. Moalli PA, Shand SH, Zyczynski HM, et al. Remodeling of vaginal connective tissue in patients with prolapse. Obstet Gynecol 2005;106:953–63. reviewed in the FIGO publication on anterior compartment 15. 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