4th Annual Jefferson Urology Symposium: Focus on Urinary Incontinence

© The Canadian Journal of Urology TM : International Supplement, August 2021 Murphy ET AL. chosen, the cornerstone of any good vaginal prolapse repair is solid support of the apex. 16 Vaginal obliterative repair Colpocleisis is the standardforvaginal obliterative repair. Atotal colpocleisis removes all of the vaginal epithelium, while a Le Fort colpocleisis leaves a portion of the epithelium to allow for a drainage tract for womenwho still have a uterus. It is a highly effective procedurewith very low risk of POP recurrence on the order of < 5%. 17 It also has the advantage of shorter operating time, less blood loss and decreased perioperative morbidity. Since it eliminates the possibility of vaginal intercourse, colpocleisis is reserved for womenwho no longer desire vaginal intercourse. Preoperative counseling before a colpocleisis must be thorough and ensure that woman understand the obliterative nature of the procedure. Vaginal reconstruction Two of the best-studied vaginal reconstructive repairs are sacrospinous ligament fixation (SSLF) and uterosacral vaginal vault suspension (USVS). They can be performed concomitantly with a hysterectomy or with a uterine sparing technique. SSLF is an extraperitoneal procedure that supports the vaginal apex by suspending to the sacrospinous ligament with either absorbable or permanent sutures. In a systematic review, anatomic cure rates range from69%- 100%. 18 Common complications reported following SSLF include dyspareunia, recurrence in the anterior compartment, and gluteal pain. The USVS procedure can be performed both vaginally and laparoscopically. Unlike SSLF, this procedure is intraperitoneal. The vaginal apex is sutured to the uterosacral ligament bilaterally. In one cohort study, USVVS was shown to reduce recurrence rate to 13.7%. 19 Abdominal reconstruction Abdominal sacrocolpopexy (ASC) is themainstay of the abdominal approach to POP repair and has been well studied since its first introduction by Lane et al in 1962. ASC can be done by an open, laparoscopic, or robotic assistedmethod. 20 ASC is considered the gold standard for women desiring a restorative repair of an apical POP. 21 The procedure entails the placement of synthetic mesh on the anterior andposterior aspects of the vagina. Themesh is then suspended to the anterior longitudinal ligament as it passes over the sacral promontory. 22 There is growing evidence that sufficient support for the vaginal apex is imperative in sustaining the structural integrity of the anterior and posterior compartments, and without adequate apical support, vaginal repairs run an increased risk of failure. 23,24 When compared to vaginal reconstructive surgery, ASC has unique advantages. Acomprehensive review by Nygaard et al found that 78%-100% of patients had no apical prolapse postoperatively, and 58%-100%had no prolapse at all. 25 A systematic review conducted by Maher et al found that ASC is associated with a significantly lower risk of awareness of prolapse, recurrent prolapse on examination, and repeat surgery for prolapse. 24 The use of synthetic mesh was associated with superior anatomic outcomes when compared to cadaveric fascia. ASC may also confer some advantage over the vaginal approach with respect to postoperative sexual function. ASChas been shown to conservemore vaginal length in comparison to vaginal approaches. 26,27 A study by Siddiqui et al, which evaluated postoperative sexual function following ASC, reported a “relatively high” sexual function score of 40 based on the Pelvic Organ Prolapse/Urinary Incontinence Sexual Function Questionnaire short form. 28 Several studies have shown that postoperative dyspareunia was significantly less with ASC compared to a vaginal POP repair. 24,26 Based on these findings, sexually active patients or patients with shorter vaginal lengthmay benefit fromASC over a vaginal POP repair. With respect to different minimally invasive approaches to abdominal reconstruction, two randomized trials demonstrated that both laparoscopic and robotic techniques result in a similar duration of operation. However, laparoscopy resulted in less postoperative pain compared to robotic assisted surgery. 36,37 The laparoscopic approach has also been shown to have reduced blood loss when compared to the open approach. 24 The robotic approach with ASC is also associated with a faster learning curve, with Geller et al reporting that after 20 cases, the overall time needed to perform the cases decreases dramatically. 38 Although intraoperative complications are rare, ASC comes with risks which must be carefully weighed when considering the procedure. Nygaard et al discusses the median rates of such complications as: cystotomy (3.1%), enterotomy or proctotomy (1.6%), and ureteral injury (1.0%). Median rates for postoperative events included urinary tract infection (10.9%), wound problems (4.6%), and hemorrhage or transfusion (4.4%). 25 Mesh erosion was 3.4%, and varied depending on the materials used as follows: Teflon (5.5%), Marlex (5%), Mersiline (3%), Gortex (3%), polypropylene (0.5%). Moreover, mesh erosion was a factor which increased over time, suggesting a need for long term follow up of such patients. Vaginal suture erosion also presented as a rare complication which was managed by excision in the office. 24