4th Annual Jefferson Urology Symposium: Focus on Urinary Incontinence

© The Canadian Journal of Urology TM : International Supplement, August 2021 Surgical management of vaginal prolapse: current surgical concepts Alana M. Murphy, MD, 1 Cassra B. Clark, MD, 1 Andrew A. Denisenko, 1 Maria J. D’Amico, MD, 1 Sandip P. Vasavada, MD 2 1 Department of Urology, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania, USA 2 Department of Urology, Cleveland Clinic Foundation, Cleveland, Ohio, USA MURPHY AM, CLARK CB, DENISENKO AA, D’AMICOMJ, VASAVADASP. Surgical management of vaginal prolapse: current surgical concepts. Can J Urol 2021;28(Suppl 2):22-26. Introduction: Pelvic organ prolapse (POP) is a condition defined by a loss of structural integrity within the vagina and often results in symptoms which greatly interfere with quality of life in women. POP is expected to increase in prevalence over the coming years, and the number of patients undergoing surgery for POP is expected to increase by up to 13%. Two categories of surgery for POP include obliterative and reconstructive surgery. Patient health status, goals, and desired outcomes must be carefully considered when selecting a surgical approach, as obliterative surgeries result in an inability to have sexual intercourse postoperatively. Materials and methods: This review article covers the role of traditional native tissue repairs, surgical options and techniques for vaginal and abdominal reconstruction for POP and the associated complications, and considerations for prevention and management of post-cystectomy vaginal prolapse. Results: Studies comparing native and augmented anterior repairs demonstrate better anatomic outcomes in patients with mesh at the cost of more surgical complications, while different procedures for posterior repair result in similar improvements in symptoms and quality of life. In the management of apical prolapse, vaginal obliterative repair, namely colpocleisis, results in very low risk of recurrence at the cost of the impossibility of having sexual intercourse postoperatively. Reconstructive procedures preserve vaginal length along with the ability to have intercourse, but show higher failure rates over time. They can be divided into vaginal approaches which include sacrospinous ligament fixation (SSLF) and uterosacral vaginal vault suspension (USVS), and the abdominal approach which primarily includes abdominal sacrocolpopexy (ASC). There is evidence that ASC confers a distinct advantage over vaginal approaches with respect to symptom recurrence, sexual function, and quality of life. Patients who have had radical cystectomy for bladder cancer are at an increased risk of POP, and may benefit from preventative measures and prophylactic repair during surgery. Importantly, the success rates of POP surgery vary depending on whether anatomic or clinical definitions of success are used, with success rates improving when metrics such as the presence of symptoms are incorporated. Conclusions: The surgical management of POP should greatly take into account the postoperative goals of every patient, as different approaches result in different sexual and quality of life outcomes. It is important to consider clinical metrics in the evaluation of success for POP surgery as opposed to using exclusively anatomic criteria. Preoperative counseling is critical in managing expectations and increasing patient satisfaction postoperatively. KeyWords: pelvic organ proplapse, apical prolapse, colpocleisis, vaginal reconstruction, abdominal sacrocolpopexy Address correspondence to Dr. Alana M. Murphy, Department of Urology, Thomas Jefferson University, 1025 Walnut Street, Suite 1100, Philadelphia, PA 19107 USA Introduction Pelvic organ prolapse (POP) is defined as the descent of any or all of the following: anterior vaginal wall, posterior vaginal wall, and vaginal apex. Symptoms of POP can include a vaginal bulge, pelvic pressure, 22 urinary and fecal symptoms, and sexual dysfunction. 1 Risk factors associated with POP include parity (particularly an instrumented vaginal delivery), aging, obesity, connective tissue disorder, and history of pelvic surgery. 2 In the Oxford Family Planning Association study, the cumulative risk of POP rises from 1% 3 years following hysterectomy to 5% at 15 years after hysterectomy. 3 Furthermore, the study showed that the risk of prolapse is 5.5 times higher in women whose reason for hysterectomy was due to prolapse. It is estimated that up to 13% of women in