4th Annual Jefferson Urology Symposium: Focus on Urinary Incontinence

© The Canadian Journal of Urology TM : International Supplement, August 2021 23 Surgical management of vaginal prolapse: current surgical concepts the United States will undergo surgery for POP and that the number of women who will suffer from POP will increase twofold by the year 2050. 4 The two categories of surgical approach to POP are obliterative and reconstructive. The approach must be tailored to the patient as obliterative procedures, despite their high success rate and low perioperative morbidity, will eliminate the possibility of vaginal intercourse. In this paper, we will discuss the role of traditional native tissue repairs, surgical options for vaginal and abdominal reconstruction for apical prolapse, the latest considerations in abdominal sacrocolpopexy (ASC) and its complications, and considerations for prevention and management of post-cystectomy vaginal prolapse. Anterior and posterior vaginal prolapse Anterior colporrhaphy for anterior vaginal wall prolapse (also known as a cystocele) is performed by plicating the pubocervical fibromuscularis towards the midline. 5 It has been performed with both plication along or augmented repair with a biologic graft. In 2019, the FDA halted the use of surgical mesh for transvaginal repair of anterior prolapse. 6 Many studies have been performed comparing native and augmented anterior repairs. In a prospective randomized trial of 160 women with anterior prolapse who underwent anterior colporrhaphy by Sand et al, they demonstrated recurrence at 1 year in 43% of patientswho underwent anterior colporrhaphywithout mesh compared to only 25% recurrence in patients with mesh (p = 0.02). 7 Another study by Weber et al compared anterior colporrhaphy, mesh augmented anterior colporrhaphy and ultra-lateral anterior colporrhaphy techniques, and found similar anatomic cure rates (between 30%-46%) and symptomresolution. 8 Their definition of cure was stage 0 or 1 (optimal and satisfactory respectively) as defined by the International Continence Society (ICS) POP Quantification (POP-Q) System. 9 In a 2016 Cochrane reviewbyMaher et al, they found that augmented biological graft or absorbable mesh repair providedmarginal benefit over a traditional colporrhaphy repair. 10 While anterior colporrhaphywith mesh demonstrated better anatomic success, it came at the cost of more surgical complications. 11 Some of the challengeswith traditional suture-based repair identified by the Cochrane review include lack of surgical technique standardization, lack of robust clinical studies, and the question of how success/failure is defined. Nearly three quarters of women with POP suffer from posterior prolapse. 12 Three methods of repairing posterior prolapse are posterior colporrhaphy, site- specific rectocele repair, or site-specific rectocele repair augmented with a porcine small intestinal submucosa graft. Paraiso et al conducted a randomized trial comparing these three methods, all of which resulted in significant improvements in symptoms, quality of life, and sexual functions. There was no improvement in anatomic outcomes when using the porcine-derived graft. 12 Defining success and failure Failure after a POP repair surgery can be defined by need for reoperation, recurrence of symptoms, or anatomic recurrence (e.g. beyond hymen, stage 2+, stage 3+ etc.). In the Pelvic Organ Support Study (POSST), 1,004 women between age 18 to 83 were examined and over 50% of them had stage 2 or 3 POP. 13 If we extrapolate this data, then over half the population fall into that category. Perhaps a strict anatomic definition of failure is too stringent. The presence of a vaginal bulge is a valuable screening tool for POP. 14 The absence of a vaginal bulge postoperatively has a significant relationship with a patient’s assessment of treatment success and Healthcare Related Quality of Life (HRQoL) while anatomic success does not directly correlate with QoL. 15 In a randomized control trial of 322 woman undergoing POP repair by Barber et al, the success rate was approximately 94% when success was defined as absence of prolapse beyond the hymen. Furthermore, subjective cure was associated with improvement in both the patient’s assessment of success and overall improvement (p < 0.001 and p < 0.001 respectively). Therefore, using anatomic criteria alone as the definition for success may be too strict andmany times not clinically relevant. The NIHPelvic Floor Disorders Network has put forth a recommendation regarding clinically relevant criteria for defining success after POP surgery: no prolapse beyond the hymen, no vaginal bulge symptom, and no retreatment of POP. 15 Apical prolapse Apical POP repairs can be divided vaginal and abdominal approaches. The advantage to the vaginal approach is that theperitoneal cavitydoes not need tobe entered for patients with an extensive surgical history. When compared to obliterative repairs, reconstructive repairs correct prolapse while preserving vaginal length to allow for sexual function. Patients need to be aware of the benefits and drawbacks of each option to come to an informed decision on the approach that best meets their needs. Whatever approach is ultimately