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S P E C I A L I S S U E S I N G E N I TA L P R O L A P S E
SURGICAL MANAGEMENT OF PELVIC ORGAN PROLAPSE
IN WOMEN: HOW TO CHOOSE THE BEST APPROACH
http://www.lebanesemedicaljournal.org/articles/61-1/review4.pdf
Nadine EL KASSIS , David ATALLAH , Maroun MOUKARZEL , Wadih GHANAME
3
2
1
1
Charbel CHALOUHY , Joseph SUIDAN , Richard VILLET , Delphine SALET-LIZEE
1
2
El Kassis N, Atallah D, Moukarzel M, Ghaname W, Chalouhy C,
Suidan J, Villet R, Salet-Lizee D. Surgical management of pelvic
organ prolapse in women : How to choose the best approach.
J Med Liban 2013 ; 61 (1) : 36-47.
ABSTRACT : Although benign, pelvic organ prolapse is a
real public health problem, affecting mostly women above
sixty-five. Eighty-year-old women have an 11.1% lifetime
risk of undergoing surgery for prolapse or stress urinary
incontinence and 29%will need a second procedure.
Surgical approach may be abdominal (sacrocolpopexy
by laparotomy, laparoscopy or robot-assisted) or vaginal
(autologous, or prosthetic reinforcement). In addition to
anatomical correction, surgical objectives include • improvement of the patient’s quality of life • prolapse symptoms relief • normal urinary, digestive and sexual functions and especially • avoiding iatrogenic sequelae.
Thus, the choice of the surgical approach does not only
depend upon the site and the severity of the prolapse.
Urogynecological surgeons should take into consideration
the patient’s expectations and life style, her age – a determinant factor in deciding upon the best approach –,
and her relapse risk factors. They should master both
approaches, and the management of surgical complications. Therefore, an apprenticeship in a reference pelviperineology center is a must. In addition, surgeons should
be aware of and consider contraindications to each procedure, for instance contraindications to transvaginal
prosthesis reinforcement like risk factors of bad healing
or infection. Urogynecology specialists have to take into
consideration known anatomical and functional results of
each technique as cited in the medical literature and act
in accordance with international recommendations. The
surgery’s main objective is to ameliorate the patient’s
discomfort and her quality of life without causing iatrogenic dysfunctional symptoms (urinary, digestive, sexual).
The pelvic organ prolapse being a benign pathology, the
patient’s satisfaction is the main marker of the procedure
success.
In short, regarding the surgical management of pelvic
organ prolapse in women the answer to the question How
to choose the best approach? is not binary. It depends
on several factors, and regardless of the choice, it must
remain a minimally invasive act, at an acceptable cost.
Visceral & Gynecological Surgery Dept., Groupe hospitalier
Diaconesses Croix Saint-Simon, Paris, France; 2Gynecology &
Obstetrics Dept., CHU Hôtel-Dieu de France (HDF), St Joseph
University (USJ), Faculty of Medicine (FM), Beirut, Lebanon;
3
USJ-FM, Urology Department, CHU- HDF; 4FM, The Holy
Spirit University of Kaslik (USEK), Jounieh, Lebanon.
Correspondence: Nadine el Kassis, MD.
e-mail: [email protected]
1
36 Lebanese Medical Journal 2013 • Volume 61 (1)
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4
El Kassis N, Atallah D, Moukarzel M, Ghaname W, Chalouhy C,
Suidan J, Villet R, Salet-Lizee D. Traitement chirurgical du
prolapsus des organes pelviens de la femme : le choix de la
meilleure voie d’abord. J Med Liban 2013 ; 61 (1) : 36-47.
RÉSUMÉ : Le prolapsus des organes pelviens de la
femme est un réel problème de santé publique, touchant surtout les femmes âgées de plus de 65 ans.
À 80 ans, la femme présente un risque de 11,1% d’être
opérée pour un prolapsus ou une incontinence urinaire à l’effort, avec un risque de réopération de 29%.
La voie d’abord peut être abdominale (promontofixation par voie ouverte, laparoscopie ou robotique)
ou vaginale (autologue ou prothétique). Les objectifs de
l’opération ne comprennent pas seulement la correction
anatomique du prolapsus, mais aussi l’amélioration de
la qualité de vie de la patiente, le soulagement de la gêne
occasionnée par ce prolapsus, le rétablissement ou la
préservation des fonctions urinaire, digestive et sexuelle,
et surtout éviter les complications iatrogènes.
Le choix de la voie d’abord ne dépend pas seulement
du site et de la sévérité du prolapsus. Le chirurgien
en urogynécologie doit prendre en considération les
attentes de la patiente, son style de vie, son âge – un
facteur déterminant du choix de la voie d’abord –
ainsi que ses facteurs de risque de récidive, maîtriser les
différentes approches chirurgicales et savoir gérer leurs
complications ; c’est pourquoi un apprentissage dans
un centre de référence en pelvipérinéologie est indispensable.
Le chirurgien doit prendre en considération les
contre-indications de chaque procédure, par exemple
les contre-indications au renfort prothétique vaginal :
les facteurs de risque d’une mauvaise cicatrisation vaginale ou d’infection prothétique. Il doit aussi connaître
les résultats anatomiques et fonctionnels des différentes
techniques tels que cités dans la littérature médicale,
faire le choix en fonction et suivre les recommandations
internationales concernant le traitement chirurgical des
prolapsus. L’objectif ultime de l’intervention chirurgicale est l’amélioration de la gêne de la patiente et de sa
qualité de vie sans créer de nouveaux dysfonctionnements (urinaire, digestif et sexuel). Puisque le prolapsus
des organes génitaux est une pathologie fonctionnelle,
la satisfaction de la patiente est le marqueur le plus
important de la réussite de la technique chirurgicale
utilisée.
En résumé, la réponse à la question Comment choisir la meilleure voie d’abord ? pour le traitement chirurgical du prolapsus dépend de plusieurs facteurs.
Quel que soit le choix, elle doit être la moins invasive
possible et d’un coût abordable.
with intraanal rectal invagination and normal sphincter function.
Several techniques exist and are regularly adapted, as
knowledge in physiopathology expands and new materials appear. The question that arises is thus: Which technique and which approach for which patient?
We will try in the course of this exposé to provide a
detailed review of the different factors influencing the
choice of the appropriate surgical technique.
INTRODUCTION
Pelvic organ prolapse is a real public health problem. This
benign pathology, often asymptomatic, can affect 50% of
parous women [1] but does not always require surgical
treatment.
The prevalence of pelvic organ prolapse is steadily
increasing due to increasing life expectancy with a resulting increase in the number of cases over 65 years [2].
In a retrospective cohort study on 376 women, Olsen et
al. [3] estimated that by the age of 80, women have a
11.1% lifetime risk of undergoing a surgical operation for
pelvic organ prolapse and/or stress urinary incontinence
(SUI), and a 29% rate of reoperation. Moreover, the risk
of relapse increases among second hand patients (17%
against 12% for first hand patients) [3]. These results
emphasize the need to offer the most appropriate surgical
technique from the beginning.
Prolapse surgery has long been a subject of dichotomy
between the school of the abdominal approach and that
of the vaginal approach. Over time, the controversy increased with the advent of new technologies: laparoscopy
and robotics.
The conflict persists due to the lack of randomized
prospective studies comparing sacrocolpopexy and vaginal meshes; however, the goal is to restore the woman’s
functional anatomy regardless of the surgical approach.
Every surgeon should master the different approaches,
because the choice of the most appropriate one is similar
to selecting a set of golf clubs during a tournament: there
is a different club for every shot.
The possible approaches are the following:
• Vaginal approach: autologous or prosthetic surgery
• Abdominal approach: sacrocolpopexy
– by laparoscopy, which has become the gold standard of prolapse surgery;
– by laparotomy, which has become a rare surgical
procedure, in case of contraindications to laparoscopy and if the vaginal approach is undesirable,
for instance in complex prolapse with multiple
relapses;
– robotically assisted, another mini-invasive approach
currently being evaluated and compared to laparoscopy.
• Endoanal approach: this approach is rather exceptional, as in case of rectocele producing dyschezia
REMINDERS
Definitions
Pelvic organ prolapse is an abnormal migration or permanent or transitory hernia of one or several pelvic
organs modifying the form and/or the location of the
vaginal walls that may advance until their protrusion
through the urogenital cleft [4].
The different forms of prolapse are:
– Prolapse of the anterior vaginal wall: cystocele.
– Prolapse of the uterus or remaining cervix: hysteroptosis or cervical ptosis.
– Prolapse of the vaginal vault following hysterectomy:
colpoptosis.
– Prolapse of the posterior vaginal wall that can be
caused by a bulge of a part of the rectum in the vagina
(rectocele) and/or the posterior cul-de-sac (elytrocele),
and/or small intestine (enterocele).
Anatomical reminder
There are three anatomical levels at the pelvic floor
level [5] (Table I):
• Level I concerns the cervical, upper vaginal support
and high posterior digestive compartment, corresponding to the insertion of cardinal and uterosacral
ligaments into the vaginal fundus and into the uterine
isthmus. Clinical manifestations of level I support
defects include hysteroptosis, and post-hysterectomy
colpoptosis, proximal rectocele and/or an enterocele
posteriorely.
Level
II, or mid-vaginal support, the largest one, con•
cerns the anterior compartment, where the vagina is
in direct contact with the bladder, and the posterior
compartment where the rectum is in direct contact
with the vagina. Its deterioration leads to a cystocele
and/or a middle rectocele.
TABLE I
PELVIC ORGAN CLASSIFICATION USING DE LANCEY THEORY [5]
Level 1 / Superior
Level 2 / Medial
Level 3 / Inferior
ANTERIOR
Urinary
Cystocele
Urethral segment prolapse
MIDDLE
Gynecological
Hysteroptosis
Post-hysterectomy colpoptosis
N. EL KASSIS et al. – Surgical management of pelvic organ prolapse
POSTERIOR
Digestive
Proximal rectocele or
Enterocele
Middle rectocele
Distal rectocele
(destruction of the perineal body)
Lebanese Medical Journal 2013 • Volume 61 (1) 37
• Level III, corresponding anteriorely, to the urinary
Prevalence of prolapse
The prevalence of prolapse is somewhere between 2.9%
and 97.7% depending on the studies. It varies between
2.9% and 11.4% when a questionnaire for detecting prolapse is used or between 31.8% and 97.7% when conducting clinical examinations with the Baden classification system or the Pelvic Organ Prolapse (POP-Q) classification. It should be emphasized that the first two stages
of the POP-Q and Baden classification correspond to prolapses that are intravaginal or at the level of vaginal introitus and therefore extremely limited, thus explaining the
very high prevalence figures.
Swift observes a progressive aggravation of prolapse
with increasing age, showed by a statistically significant
reduction of the proportion of stage 1 at the expense of
stages 2 and 3 (Table II) [11].
Concerning the type of prolapse, the study of the compartments of prolapse in the literature reveals a predominance of the anterior compartment prolapse compared to
the posterior compartment which is itself more frequent
than the middle compartment [12-14].
Often, cystocele is associated with hysteroptosis (in
20% of cases according to Hendrix [15]).
The posterior colpocele is often secondary to hysterectomy or other pelvic surgery (Burch Procedure, cystopexy, etc.). An isolated rectocele is fairly infrequent (7%)
[6], and is often related to chronic constipation and increasing parity. A prolapse of the vaginal vault is often
associated with a history of hysterectomy.
compartment and to the sub-urethral vaginal segment,
and posteriorly, to the anal cap behind the perineal
body. This level support defect can result in distal rectocele or perineal descent.
The pelvic viscera are held in place by a fixation system
formed by the visceral “ligaments” containing vascular
and nervous elements of the viscera, and by a system that
supports the pelvic floor including the endopelvic fascia
and the different muscles of the pelvic floor, in particular
the levator ani with a static part, the iliococcygeal muscle,
and a dynamic part, the puborectal sling that passes behind
the urogenital diaphragm and the rectum. Pelvic floor defects result from damage to these muscular, neurological,
and connective tissue elements. There currently exists no
way to directly repair these elements. Additionally, reconstruction of the perineum and its reinforcement are ensured
by the native tissues that can either be repaired (raphae), or
reinforced with autologous, heterologous or especially
synthetic tissue [6-7].
Prolapse risk factors
Multiple mechanisms can cause pelvic prolapse, resulting
from deterioration of the anatomical structures and from
excessive pressure exerted upon them [8]. The essential
factor is obstetrical trauma, or pregnancy itself, specially
in the presence of fetal macrosomia regardless of the
mode of delivery [9]; delivery is responsible for pelvic
and perineal damage resulting from stretching, tearing or
even avulsion of the muscular and conjunctive tissues
and/or pudendal nerves [10].
The other factors include: congenital predisposition
(caucasoid, ligamentous laxity, connective tissue anomalies), ageing, menopausal hormone deficiency, lumbar
lordosis, abdominal wall muscles atrophy, excessive intraabdominal pressure (asthma, chronic bronchitis, severe
constipation, strenuous physical efforts), increasing body
mass index, iatrogenic factors (hysterectomy, treatment
of stress urinary incontinence and other pelvic surgery,
specifically prolapse surgery) [4].
STUDY
VERSI 2001 [12]
Patients
N
OBJECTIVES OF TREATMENT FOR PROLAPSE
Pelvic organs prolapse in women is above all a functional
pathology. Its surgical correction must improve the functional symptoms and the quality of life in a sustainable
manner.
Thus, there are four main outcomes to consider in prolapse surgery:
1) To relieve symptoms related to prolapse (perineal
heaviness, vaginal bulging, loss of self-esteem due
to a change in body image);
TABLE II
PREVALENCE OF PROLAPSE BY ANATOMICAL COMPARTMENT (POP-Q)
Age
(years)
285
Post menopause
HANDA 2004 [13]
412
50-79
BLAIN 2008 [14]
954
17-90
Anatomical
compartment
Cystocele
Hysterocele
Rectocele
Cystocele
Hysterocele
Rectocele
Cystocele
Hysterocele
Rectocele
Stage 0
%
Stage I
%
Stage II
%
85.4
96.2
87.1
27
78
35
14.4
3.3
7.8
32
15
34
9.5
0.6
5.1
23
5
26
POP-Q : Pelvic Organ Prolapse Quantification
Stage III
%
6
0
0
0.7
0
0
18
3
5
Total
%
51
20
27
24.6
3.8
12.9
73
23
65
N° of cases
per year/100 women
9.3
1.5
5.7
2) To correct the anatomical deteriorations by raising
the prolapsed organ (correction of the ptosis) and by
supporting it in its ideal position;
3) To avoid creating new anatomical deteriorations or
new functional disorders such as chronic urinary or
genital infections, dysuria or dyschezia, urinary or
fecal incontinence, dyspareunia;
4) To allow normal urination, defecation, and as the
case may be, normal sexual activity or in some
cases, pregnancy.
The question that follows is how to make the best
choice, taking into consideration the above objectives, in
order to have lasting results at the least cost and with the
least morbidity.
Unfortunately, the answer is neither binary nor does it
comply with any mathematical formula.
The choice of the approach depends upon many factors:
– patient’s expectations
– patient’s age and physical activity
– patient’s risk factors of relapse
– contraindications of procedure(s)
– surgeon’s experience and practice
– anatomical results of the different procedures
– surgery effects on the functional symptoms
– results concerning the quality of life and level of
satisfaction.
“natural” and relatively painless vaginal approach,
details about synthetic implants, description of the
complications and risk of reoperation and within
what time limit.
One must know how to listen to patients and respond
to their requests, even if there is no single answer.
2. Patient’s age
Pelvic organ prolapse concerns women of all ages. Its
prevalence increases with age up until approximately
50 years (4.1% between 30 and 39 y, 6.2% between 40
and 49 y) to subsequently remain stable (11.8 % between
50 and 59 y; 12.2% between 60 and 69 y; and 11%
between 70 and 79 y) [16]. Nygaard et al. find lower
prevalences, but with the same tendency to stagnate after
menopause [17].
Following menopause, prolapse severity appears to be
age correlated, marking the continuation of the degenerative process [11, 13] (Table III).
n Young women prolapse
Among very young women, prolapse concerns usually
one compartment taking the form of a hysteroptosis secondary to collagen disease, or especially following a difficult labor [9, 18].
The treatment must take into consideration the fertility
desires of these women.
The standard treatment was the Manchester technique
that has fallen into disuse because of its poor results, in
1. Patient’s expectations
particular regarding the preservation of fertility and pregThey are numerous:
nancy complications. The other standard technique was
Richardson’s sacrospinous uterine fixation [19-20], later
• Relief of the inconvenience caused by the prolapse,
in particular vaginal bulging or heaviness and disreplaced by modern techniques using implants (laparocomfort;
scopic sacrohysteropexy).
Resumption
of
daily
activities
(sports,
dance,
walkProlapse in young women before menopause involves
•
ing, travelling, gardening, professional activities);
often several compartments. Treatment must be comprehensive and sustainable in light of life expectancy, for the
• Precise information on the different surgical possibilities as a complement to those already gathered on
preservation of the uterus is not systematic. It thus calls
the Internet: advantages of laparoscopy, number of
for prosthetic repair.
trocars and abdominal incisions, advantages of the
The current gold standard is laparoscopy or robot-assisted sacrocolpopexy by setting a vesico-vaginal
mesh and another recto-vaginal one.
TABLE III
The vaginal prosthetic approach is not preferred
PREVALENCE OF PROLAPSE
BY POP-Q STAGE, AGE AND MENOPAUSE STATUS [11]
among young women because it has been associated to dyspareunia and painful prosthetic retraction
Age
Stage 0
Stage I
Stage II Stage III Stage IV in 10% of operated women [21]. It is indicated in
(%)
(%)
(%)
(%)
(%)
(years)
stage 3 and 4 prolapse, and in the case of one-compartment recurrences.
18-82
6.4
43.3
47.7
2.6
0
n Elderly women
27.3
0
0
18-29
22.7
50.0
Among elderly women over 70 seeking treat30-39
6.9
50.9
41.4
0.9
0
ment
for their prolapse, vaginal approach with
40-49
2.6
44.2
51.9
1.3
0
native tissue is the best option. It includes hysterec50-59
3.2
38.9
55.8
2.1
0
tomy, anterior and/or posterior repair and preserved
0
27.7
59.6
8.5
60-69
4.3
vaginal permeability if necessary for multicompart≥ 70
0
26.3
52.6
21.1
0
mental prolapse. Recto-vaginal fascia plication with
Pre-menopause
8.9
47.3
43.1
0.7
0
levator ani low myorrhaphy is the optimal operation
Post-menopause HRT+ 3.7
35.8
56.0
4.5
0
for an isolated rectocele, the sacrospinofixation for
0
6.1
50.0
41.5
Post-menopause HRT– 2.4
the ptosis of the vaginal vault, and culdoplasty for
POP-Q : Pelvic Organ Prolapse Quantification
elytrocele.
Abdominal surgery (promontofixation) is theoretically
possible at this age but it carries more significant risks of
intra- and postoperative complications than the autologous vaginal approach.
Prosthetic vaginal surgery is theoretically possible at
this age but related studies are lacking. It is indicated
in the event of recurrence of prolapse at the level of the
anterior and/or medial compartment following prior estrogenic vaginal preparation.
n Menopausal women between 60 and 70 years
With regard to patients in the 60 to 70 age bracket,
the choice of the approach is contingent upon other factors
because age alone is no longer determinant. Abdominal
and transvaginal prosthetic reinforcement are valid options
as well as native tissue repair in some cases.
3. Relapse risk factors
According to Olsen et al. 29% of patients operated for
prolapse and/or urinary incontinence are likely to be reoperated for recurrence in the operated compartment or in
another [3].
The different relapse risk factors are:
• Severe prolapse with a POP-Q stage greater than or
equal to 3 [22].
Congenital
or acquired collagen disease, polymor•
phism of the progesterone receptors [23].
• Age under 60 years in light of life expectancy [24-25].
• Body mass index greater than 30 capable of causing
permanent damage to the pelvic tissues [26]. However, the functional and anatomical results would be
comparable to the non-obese according to Bradley
et al. [27].
Chronic
cough (asthma, chronic obstructive pulmo•
nary bronchopathy) resulting in chronic excessive
abdominal pressure [28].
• Occupations and sports generating chronic excessive
abdominal pressure with excessive use of abdominal
muscles (ballet dancers, carrying heavy loads, etc.).
• Quick recurrence following well executed surgical
treatment for prolapse.
In the presence of one or several relapse risk factors or
following prolapse recurrence, one must know how to
choose the best technique and approach. In such cases, a
prosthetic reinforcement of the prolapse is recommended,
by laparoscopy or by vaginal approach, especially in the
case of a prolapse of the anterior and/or middle compartment(s), while taking into consideration the other factors
affecting the choice of the approach.
4. Absolute & relative contraindications of the different
approaches
They can help in the choice of the best approach.
The contraindications for sacrocolpopexy are those of
laparoscopy:
• Contraindication to general anaesthesia (respiratory
failure, severe heart failure, etc.).
True
obesity with a BMI greater than 30-35. The risk
•
of conversion to laparotomy is increased, and can
reach 10% [29]. In addition to that, obese patients
may experience more complications than non-obese
patients (14% v/s 2.6%, p < 0.05) [30].
• A history of multiple laparotomies with a risk of morbidity of 0.32% by laparoscopy and 0.11% already
upon patient installation.
• A progressive spinal pathology, for instance spondylodiscitis.
The contraindications to the transvaginal prosthesis
approach are related to a risk of poor vaginal healing or
infection:
• Poorly controlled diabetes, extended corticosteroid
therapy, immunodepression.
Poor
quality of the vaginal mucosa: severe vaginal
•
atrophy (hence the importance of a prior vaginal
preparation with local hormones).
Tobacco
intoxication multiplying the risk of prosthet•
ic exposure by three [31].
• History of pelvic radiation.
• A history of exposure or infection of prosthesis by
vaginal approach represents a high risk of complication in the event of insertion of a new prosthesis.
• Placing the patient in lithotomy position for vaginal
surgery with autologous or prosthetic tissue may
prove impossible in the event of severe pathology
that prevents hip flexion.
The patient must be informed of operative risks in the
presence of these key predictors of intra- or postoperative
technical complications, as well as of possible alternatives.
5. The surgeon’s experience and practice
As with any surgery, and particularly in prolapse management, the surgeon himself is a factor of choice of the
approach. Surgeons are even referred to by the approach
they adopt: a “vaginalist”, an “abdominalist”, or more recently “laparoscopist” or even “robotist.”
Ideally, a surgeon specialized in urogynecology should
master all approaches: vaginal repair with native tissues
and prosthetic, and abdominal (laparoscopic and robotassisted).
The promontofixation by laparoscopy requires a longer
operating time than by laparotomy. The learning curve is
quite long; for it is necessary to master laparoscopic surgical techniques and female pelvic anatomy, and to learn to
perform the different technical steps as quickly as possible
with low morbidity and as effectively as possible. The
Strasbourg team stabilized its operating time at 211 min
after 18 to 24 operations (maximum of 360 min, minimum
of 150 min) with objective and subjective success rates of
95.8% and 94% respectively [32]. They attribute the reduction in the operating time to training on one hand and
to the introduction of several tricks that facilitate performance of the operation on the other hand.
As for trocar-guided tension-free vaginal mesh technique (Prolift™), its learning curve is shorter than the
one for laparoscopic promontofixation: 10 operations for
the anterior mesh procedure in roughly 40 min and 18 for
the posterior mesh procedure, going down from 60 to
24 min [33].
Consequently, in order to master both approaches, the
learning curve is hardly negligible.
The surgeon who wants to manage pelvic organ prolapses must be an experienced laparoscopist as well as
an expert in the vaginal approach in order to reduce operating time, morbidity and operating costs, and to improve
results. To achieve these goals, an apprenticeship in a reference centre for urogynecology is recommended. Furthermore, the surgeon has to remain up to date with the latest
techniques, new materials (vaginal meshes and other),
medical literature and medico-legal aspects.
6. Anatomical results
Anatomical correction is one of the goals of prolapse
treatment; however, it is not necessarily correlated with
functional symptoms, the patient’s quality of life and level
of satisfaction. Furthermore, failure rates vary depending
on the definition used for assessing the anatomical success
[34].
When the prolapse is unicompartmental, the treatment
may only concern the affected compartment, or overall
treatment of the three compartments, taking into account
the common physiopathology (see table I).
Concerning isolated cystocele, a level 2 prolapse, it is
secondary to a lateral detachment of the arcus tendinous
of the pelvic fascia and/or to a medial defect by alteration
of the vesico-vaginal fascia.
Surgical possibilities are:
Vaginal approach with native tissue: plication of the
vesico-vaginal fascia (of Halban) by non-absorbable suture, with colpotomy upon request. This option shows a
high rate of recurrence (43% of relapses one year after the
surgery according to Sand) [35-36].
Paravaginal repair of the arcus tendinous of the pelvic
fascia has not proven its effectiveness [37-40].
This option can only be considered for older women
who are not very active, with no sexual activity, or when
prosthetic reinforcement is impossible. Moreover, it must
always be associated with hysterectomy and ligament
repair for reinforcing the level 1.
Transvaginal prosthesis: reinforcement of the vesicovaginal space with a polypropylene prosthesis with a transobturator anchoring system by keeping the Halban’s fascia
flat against the vagina. This method has proven effective
over the long term on the anatomical correction of cystoceles, with success rates of 81% to 95% after one to three
years’ follow-up, compared to the traditional anterior colporrhaphy in the different randomized trials [41-43].
According to Nieminen et al., recurrence rate was assessed at 12% against 41% after simple colporrhaphy three
years after surgery [44-45].
However, anterior prosthetic reinforcement could specifically expose the patient to risk of prolapse of another
compartment in 23% of cases according to Withagen et
al., nevertheless only 4% of the patients were reoperated
[46].
Abdominal prosthesis: promontofixation by laparoscopy or by robot by anchoring a retrovesical prosthesis
to the promontory, with or without posterior retrovaginal
prosthesis, with or without supracervical hysterectomy.
Criticism of this technique targets the absence of correction of the paravaginal defect without major consequences on the functional result, the possible elongation
of the cervix that may subsequently require an act of trachelectomy if it causes patient discomfort, and the development of a low rectocele due to a posterior dissection that
does not reach the level of the perineal body.
Furthermore, a relapse in the previously unaffected
posterior compartment may occur following the insertion
of a single anterior prosthesis, hence the importance
of insertion of retrovaginal prosthesis without anchoring
it to the promontory, even in the absence of a rectocele
[47-48].
Prolapse of the median compartment or level 1 that
may touch the uterus in place, or the cervix or the vaginal
apex post hysterectomy is due to the destruction of the
uterosacral and cardinal ligaments.
Surgical possibilities are:
Vaginal approach with native tissue: ligamentous repair associated to hysterectomy. This option may be considered in the case of isolated hysteroptosis among rather
young patients (with uterosacral and adnexal ligaments of
good quality). Fatton et al. [49] achieved good anatomical
results after two years of extraperitoneal suspension of the
uterosacrals to the vaginal vault (85.5%) [50-51].
Among older women, especially among patients having had previous hysterectomy, the gold standard for correction of a prolapse of the medial compartment is by
sacro-spinous fixation (Richter technique), consisting of
attaching the vaginal vault to the uni- or bilateral sacrospinal ligament with non-absorbable sutures. This technique has a risk of relapse in the form of an anterior prolapse ranging from 25% to 30% [52-53].
For women who wish to become pregnant, vaginal
approach by fixation of the uterosacral ligaments to the
sacrospinous ligament is another option (Richardson’s
technique).
Transvaginal prosthesis: It consists of approaching
the sacrospinous ligament by an anterior or posterior route
with prosthetic reinforcement either by anterior or posterior Elevate (AMS) or by posterior ProliftTM (Gynecare) or
Apogee or other vaginal meshes. In case of an anterior- or
posterior-associated prolapse, an anteroposterior prosthesis kit is a therapeutic possibility.
Abdominal prosthesis: Another alternative is the
abdominal approach by promontofixation (laparoscopic
or robot-assisted) with the insertion of two pre- and retrovaginal prostheses with or without supracervical hysterectomy according to the patient’s desire. The anterior prosthesis is fixed to the upper part of the vagina till its middle part and to the uterine isthmus, and fixed posteriorely
to the anterior sacral ligament.
An exhaustive review of the literature conducted by
Maher et al. demonstrates that promontofixation gives the
best anatomical results and less dyspareunia than sacrospinous fixation of the vaginal vault [54].
Another prospective randomized study conducted by
Maher et al. compares objective and subjective results of
laparoscopic promontofixation and anteroposterior vaginal prosthetic reinforcement for the treatment of vaginal
vault prolapse. Two years after surgery, promontofixation
patients presented a higher rate of objective success (77%
vs. 41% p < 0.001), with a lower rate of reoperation (5%
vs. 22% p < 0.006); adding to that, they were more satisfied overall than those operated by transvaginal prosthesis
approach [55].
Yet another review of the literature conducted by
Diwadkar et al. in 2009, comparing standard autologous,
prosthetic vaginal approaches and promontofixation for
treatment of vaginal vault prolapse reveals that the rate of
reoperation for recurrence was the least for transvaginal
prosthesis, followed by promontofixation and then by the
standard vaginal approach (3.9 vs. 2.2 vs. 1.3%), knowing
that the monitoring period for transvaginal prosthesis
(17 months) was the shortest. Meanwhile, the rate of reoperation was the highest in the vaginal prosthesis group to
manage complications (8.5%) [56].
As for the repair of an isolated rectocele, surgical possibilities are:
– Plication of prerecti fascia by vaginal approach, with
low myorrhaphy;
– Mesh augmented posterior repair (posterior Prolift or
posterior Elevate, etc.) in case of a total length stage
3 or 4 rectocele or especially in case of relapse;
– Promontofixation with fitting a tension-free prosthesis
between the vaginal wall and rectum, attached to the
elevators inferiorly and to the posterior vaginal wall.
Promontofixation has a success rate of approximately
92% at three years, while autologous repair by vaginal
approach has a 76% to 90% success rate according to
medical literature [57-58]. Meanwhile, vaginal prosthetic
reinforcement doesn’t add much to anatomical results
while leading to increased morbidity risks (mesh exposure, vaginal erosion, prosthetic shrinkage, dyspareunia)
[57], unless it’s a relapse or stage 3 or 4 rectocele. Vaginal
approach with autologous tissue is also superior to the
endoanal approach [59-60]. In short, vaginal repair with
native tissue by plication of the prerecti fascia by nonabsorbable suture is the consensual treatment for isolated
rectoceles.
7. Results on functional symptoms
The associated functional symptoms, often the leading
reason for consultation, are threefold: urinary, digestive
and sexual. They should be taken into consideration when
establishing operative indication.
Urinary results
Stress urinary incontinence
Treatment of genuine stress urinary incontinence (SUI)
associated with prolapse does not interfere with the choice
of the approach. “Gold standard” treatment for stress urinary incontinence is the suburethral support system with a
retropubic or transobturator sling. This intervention may
be performed in association with laparoscopic promontofixation as with vaginal surgical treatment with autologous tissue or synthetic mesh with no difference regarding
results and secondary effects. In the case of occult urinary
incontinence upon clinical assessment, there is yet no consensus for treating SUI at the same time as prolapse regardless of the approach, since 35% to 60% of these
women remain dry following surgical treatment of prolapse without associated SUI treatment [61].
Overactive bladder
Furthermore, genitourinary prolapses, especially cystoceles, are often associated with overactive bladder symptoms specially urgencies or with obstructive symptoms
(dysuria, incomplete bladder emptying, need to reduce the
prolapse by using their fingers to push the prolapse up to
aid urinary voiding, etc.). This association is above all statistical, by pure coincidence or through a causal link, and
that by denervation of the pelvic floor, or by obstruction
mean (myogenic lesion) [62].
The causal relationship between prolapse and overactive bladder is more plausible because anatomical prolapse correction by surgery or by insertion of a pessary
improves the irritative and obstructive urinary signs. De
Boer et al. (2010) and Basu et al. demonstrated that overactive bladder incidence increased among patients having
a pelvic organ prolapse, with a significant reduction of
this incidence following surgical correction of the prolapse regardless of the approach [63-64]. Obstructive
symptoms are likewise associated with the degree of prolapse, and correction of the latter should reduce the severity of this obstruction [65].
Digestive results
Rectocele is often associated with digestive disorders
especially terminal constipation or dyschezia. Correction
of rectocele will reduce the obstruction and theoretically
correct digestive complaints. Surgical treatment by vaginal
approach is superior to endoanal approach from this standpoint [54]. According to a study conducted by Bradley et
al., promontofixation seems to improve obstructive digestive symptoms in 75% to 86% of patients after 12 months
[66]. It also resolves the problem of fecal incontinence in
76% of cases, one year after surgery. By contrast, de novo
fecal incontinence seems to occur among 1% to 5% of
patients. However, Forsgren et al. find more pronounced
dyschezia among women operated of promontofixation
[67]. In fact, few authors deal with this subject in the literature. In principle, until proof of the contrary, and from
the moment we no longer anchor the posterior prosthesis
to the anterior sacral ligament, sacrocolpopexy and vaginal
approach are comparable regarding improvement of
obstructive digestive symptoms.
In case of a descending perineum associated with prolapse and obstructive digestive complaints, anchoring of
the different pelvic viscera by laparotomy or especially by
laparoscopy, thus a promontofixation with placing two or
even three prostheses (retrovesical, retrovaginal et retrorectal) seems to be the best solution [68].
Results on sexual activity
For sexually active women at the preoperative stage,
the surgical operation must not have any deleterious
effects upon their sexuality. For those for whom prolapse
might hinder normal sexual activity by physical or rather
emotional impact, one of the objectives of the surgical
operation is to improve it [69-70].
Data deriving from the literature concerning sexuality
following surgical treatment of prolapse are contradictory:
the “pathology” treated (prolapse and/or urinary incontinence) primarily concerns women over the age of 60, a
population among whom sexuality is not always an essential criterion. It often alters sexuality, not as much from
a purely “organic” perspective as much as indirectly by
the psychological repercussion and the loss of self-respect
that it causes. Thus, there is usually an overall improvement in sexuality following surgery explained in great
part by the disappearance of the “intravaginal ball” and/or
the urinary incontinence [71]. This improvement is hardly dependent upon the type of surgery itself as long as it is
properly performed. In fact, Bouchet et al., in a retrospective study comparing repercussions from abdominal and
vaginal approaches on sexuality, demonstrated that the
only factor influencing sexuality was age, independently
of the approach [72].
The treatment of prolapse by large colpectomy of the
Lefort type is obviously contraindicated among sexually
active women, except in the absence of other surgical
options.
Prolapse treatment by vaginal approach with native tissue, contrary to common belief, is both a reliable surgery
and capable of preserving sexuality. Surgical treatment of
rectocele has often been suspected of causing dyspareunia
and sexual dysfunction due to myorraphy that is too tight,
that raises too high and/or causes excessive narrowing of
the introitus [73-74].
Therefore, consensual surgical attitude limits myorraphy, if necessary, to the lower part and limits the extent
of the perineorraphy and is based on the folding of the prerecti fascia.
As for the treatment of cystocele, the data available in
the literature is rather reassuring with regard to the quality of sexual relations following plication of the prevesical
fascia (Halban) and colpotomy [74].
Regarding the surgical correction of prolapse of the
medial compartment, Maher et al. (2001) report a low rate
and comparable rate of dyspareunia whether the patient
has a uterine sacrospinofixation or a sacrospinofixation of
the vaginal fundus associated to vaginal hysterectomy
[75]. A review of the literature conducted by Fatton et al.
reveals that the risk of dyspareunia remains limited in
the absence of prior reconstructive surgery on condition of
respecting good practice rules [76]. Regardless of the chosen technique, it is important to respect the length of the
vaginal wall and to avoid funnel-like strictures of the last
third of the vagina facilitated by large colpectomies and
asymmetrical fixations.
The treatment of prolapse by transvaginal prosthesis
that potentially targets a population of sexually active
women would entail an average rate of de novo dyspareunia of 12.8% in case of using mixed synthetic/biological
prostheses and 7.1% in case of using synthetic prostheses
[77]. Correlation between painful retraction, a major problem of synthetic prostheses by vaginal approach, and dyspareunia is probably not linear: Fatton et al. find in a
series of 125 patients operated by the Prolift technique
a 15% rate of painful retraction on clinical examination
between 6 and 12 months following surgery and a 3.4%
rate of de novo dyspareunia. Of the 13 sexually active
patients experiencing painful retraction, eight had no dyspareunia, illustrating the discordance between the two
entities [76]. Feiner et al. describe the clinical presentation
then the treatment of 17 patients referred to their centre,
after being operated by anterior or total Prolift, Apogee or
Perigee and presenting symptomatic prosthesis retraction,
14 among them having disabling dyspareunia. These patients were reoperated (mobilization, partial or total resection of the prosthesis). 88% of patients presented a clear
reduction of pain, and 64% showed improvement in dyspareunia [78].
As for sacrocolpopexy, a surgery that concerns especially “young” women and therefore sexually active ones,
it offers an improvement in their sex life following surgery [79]. Price et al. reveal a rate of 8% of de novo dyspareunia, while Handa et al. find a rate of 14.5% [80].
Nevertheless, in this latter series, 44.7% of women who
weren’t sexually active prior to the operation resumed
sexual activity after surgery. Generally speaking, studies
are reassuring concerning the impact of promontofixation
on patients’ sexual life.
The comparative studies currently at our disposal
show that promontofixation is comparable to the vaginal
approach with native tissue [81], yet superior to sacrospinal fixation regarding the impact on sexuality [54].
Sacrospinal fixation of the uterosacral ligaments is equivalent to simple vaginal hysterectomy [81]. Vaginal repair
with native tissue is comparable to transvaginal prosthesis
in improving the PSIQ-12 sexuality score [82-85].
A prospective randomized clinical trial would be necessary to compare promontofixation and transvaginal prosthesis: more and more women under 60 years of age are
subject to high grade prolapse requiring prosthetic reinforcement, and in most cases, the literature does not allow
us to opt for vaginal prosthetic surgery among sexually
active women.
8. Results concerning patients’ quality of life and level
of satisfaction
Let us not forget, in our review, that the ultimate goal of
the prolapse surgical cure is “improvement in patients’
quality of life.” Consequently, a preoperative assessment
of the impact of the prolapse and associated symptoms on
patients’ quality of life is recommended together with a
review of the repercussions of the surgical correction on
the quality of life of these patients with the help of the
appropriate questionnaires.
Maher et al. deduce in their literature review in Cochrane Database that vaginal approach repercussions on the
quality of life are identical to those of the abdominal
approach, although sacrospinal fixation presents a rate of
anterior and middle relapse greater than that of promontofixation, and a higher rate or dyspareunia [54].
The level of satisfaction is in fact correlated with
hymeneal cutoff. Indeed, a study conducted by Barber
et al. shows that two years after promontofixation with or
without Burch, the rate of anatomical failure is 45% for a
POP-Q greater than stage I and 9% for a prolapse that protrudes from the hymen, 4% for a new treatment (pessary
or reoperation) (Figure 1) [34, 86].
In other words, the patients were satisfied with their
surgery when the corrected prolapse did not protrude
from the hymen (the equivalent of a Baden-Walker stage
0 to 2). Indeed, Barber et al. found that the absence of sensation of a vaginal bulging (90% of the population) is the
best appropriate criteria measuring satisfaction and improvement of the patient’s quality of life, while anatomical success alone is not sufficient [34].
Concerning the treatment of the medial compartment,
an exhaustive review of the literature between 1985 and
2008 conducted by Diwadkar comparing vaginal approach
with native tissue (sacrospinal fixation of the vaginal vault
or uterosacral ligaments, or McCall culdoplasty), transvaginal prosthesis and promontofixation, demonstrates
that transvaginal prosthesis carries with it more complications (fistulae and prosthetic exposures) and reoperations,
while the vaginal approach with autologous tissue produced the most recurrences [56]. In fact, the vaginal
approach with native tissue displayed 15.3% of complications at 32.6 months, of which only 1.9% required revision
surgery. Promontofixation (laparotomy or laparoscopy)
had a rate of complications of 17.1% at 26.5 months,
including 2.2% of prosthesis erosion. Only 4.9% of patients had to be revised for complications. The group of
patients operated by transvaginal prosthesis presented
14.5% of complications at 17.1 months, 5.8% of which
involved infection or prosthetic erosion; 8.5% of patients
FIGURE 1. Venn diagram of failure rates using four definitions of
success: two anatomic definitions (National Institutes of Health
[NIH] “satisfactory” anatomic outcome [pelvic organ prolapse
quantification / POP-Q stage 0 or 1] and “no descent beyond the
hymen”), subjective cure, and no re-treatment.
From: Barber MD, Brubaker L, Nygaard I et al. Defining success
after surgery for pelvic organ prolapse. Obstet Gynecol 2009;
114: 600-9. (Used with permission).
were surgically revised, essentially for managing complications, but only 1.3% were revised for recurrent prolapse.
Lawndi et al. in a cohort study evaluating the impact
of pelvic organ prolapse surgery on the quality of life, find
that only 10% of patients operated, all approaches combined, are dissatisfied after their surgery, and that this
is especially due to de novo overactive bladder symptoms
[87].
Advantages and disadvantages:
In short, both vaginal (native and prosthetic) and abdominal approaches have a high rate of satisfaction and
positive functional and anatomical results if the indications are well established and the surgery properly carried
TABLE IV
LAPAROSCOPIC PROMONTOFIXATION AND TRANSVAGINAL PROSTHESIS
Promontofixation
Visual quality
Codified technique
Follow-up > 10 years
Preserves vaginal permeability
Treats all possible cases
Pelvic organ prolapse II to IV •
Relapses •
± Subtotal hysterectomy •
Long procedure
Invasive
Costly
General anesthesia only
Serious complications ≈ 4%
Ileus
Post-op occlusion
Approach
ADVANTAGES
DISADVANTAGES
Transvaginal prosthesis
Minimally invasive
Selective local anesthesia
or regional anesthesia
Operation of short duration
Targeted indication
• Pelvic organ prolapse and stage III-IV
• ± other compartment relapse
Operation with limited visibility
Short follow-up (< 5 years)
Ideal prosthesis is not available (size and material)
Serious complications are rare (< 2.6%)
Specific complications:
Erosion: 3 x the rate of mesh erosion in promontofixation
Retraction: 16% to 20%
out. A rapid comparison can be drawn between laparoscopic promontofixation and transvaginal prosthesis from
Table IV.
CONCLUSION
Prolapse of the pelvic organs is thus a functional pathology that does not jeopardize the patient’s vital prognosis.
Its management is always subject to controversy regarding
the ideal approach from the beginning. As we have exposed above, the choice of the approach depends in fact
upon several criteria: the patient’s age, her physical activity and expectations, the surgeon’s training and experience,
the contraindications to each approach, the risk factors for
relapse, anatomical mapping and severity of the lesions,
the accompanying functional symptoms and the economic
cost of the procedure.
The choice of the approach is not binary. Urogynecology is a multidisciplinary entity. The surgeon treating
pelvic organ prolapse must master the standard vaginal,
prosthetic, and abdominal approaches, especially laparoscopy or robotics nowadays, and must of course know how
to manage the complications arising from both of these
approaches.
Evidence-based medicine favors the abdominal approach which, according to randomized studies, is the
most solid over the long term, while the standard vaginal
approach has the most elevated rate of recurrence at the
level of the anterior compartment. The transvaginal prosthesis technique, meanwhile, is effective over the long
term according to the different existing studies. The rate of
exposure of the prosthesis has clearly declined since the
spread of this technique and growing awareness of the risk
factors of this complication. Risk factors and solutions of
painful prosthetic retraction and dyspareunia remain subjects to controversy.
Lest we forget, standard vaginal approach still has certain indications and advantages, especially when done by
expert hands.
Ultimately, prolapse surgery remains a functional surgery with the initial goal of improving the quality of life
of our patients and, regardless of the approach, it must
remain minimally invasive and at an acceptable cost.
REFERENCES
1. Maher C, Baessler K, Glazener CM et al. Surgical management of pelvic organ prolapse in women. Cochrane
Database Syst Rev 2004: CD004014.
2. Luber KM, Boero S, Choe JY. The demographics of pelvic floor disorders: current observations and future projections. Am J Obstet Gynecol 2001; 184: 1496-501; discussion 1501-3.
3. Olsen AL, Smith VJ, Bergstrom JO et al. Epidemiology
of surgically managed pelvic organ prolapse and urinary
incontinence. Obstet Gynecol 1997; 89: 501-6.
4. Delcroix M. Prolapsus génital. In: Delcroix M, Guérin du
Masgenet B, ed. Décision en gynécologie obstétrique.
Paris : Vigot 1996: 496-506.
5. DeLancey JO. Structural anatomy of the posterior pelvic
compartment as it relates to rectocele. Am J Obstet
Gynecol 1999; 180: 815-23.
6. Villet R. Rectocèles et colpocèles postérieures. Aspects
cliniques et thérapeutiques. Med Chir Di 1987; 16: 583-8.
7. Villet R. Principes du traitement chirurgical des prolapsus génitaux. e-mémoires de l’Académie nationale de
chirurgie 2006; 5: 11-13.
8. Jacquetin B, Amblard J. Statique pelvienne. Prolapsus.
In : Fernandez H, Chapron C, Pouly JL, ed. Traité de
gynécologie. Paris : Médecine-Sciences, Flammarion,
2005 : 310-21.
9. Deval B, Rafii A, Poilpot S et al. [Prolapse in the young
woman: study of risk factors]. Gynecol Obstet Fertil
2002; 30: 673-6.
10. Tinelli A, Malvasi A, Rahimi S et al. Age-related pelvic
floor modifications and prolapse risk factors in postmenopausal women. Menopause 2010; 17: 204-12.
11. Swift SE. The distribution of pelvic organ support in a
population of female subjects seen for routine gynecologic health care. Am J Obstet Gynecol 2000; 183: 27785.
12. Versi E, Harvey MA, Cardozo L et al. Urogenital prolapse and atrophy at menopause: a prevalence study. Int
Urogynecol J Pelvic Floor Dysfunct 2001; 12: 107-10.
13. Handa VL, Garrett E, Hendrix S et al. Progression and
remission of pelvic organ prolapse: a longitudinal study
of menopausal women. Am J Obstet Gynecol 2004; 190:
27-32.
14. Blain G, Dietz HP. Symptoms of female pelvic organ prolapse: correlation with organ descent in women with single compartment prolapse. Aust N Z J Obstet Gynaecol
2008; 48: 317-21.
15. Hendrix SL, Clark A, Nygaard I et al. Pelvic organ prolapse in the Women’s Health Initiative: gravity and gravidity. Am J Obstet Gynecol 2002; 186: 1160-6.
16. Tegerstedt G, Maehle-Schmidt M, Nyren O et al. Prevalence of symptomatic pelvic organ prolapse in a Swedish
population. Int Urogynecol J Pelvic Floor Dysfunct
2005; 16: 497-503.
17. Nygaard I, Barber MD, Burgio KL et al. Prevalence of
symptomatic pelvic floor disorders in US women. JAMA
2008; 300: 13111-6.
18. Strohbehn K, Jakary JA, Delancey JO. Pelvic organ prolapse in young women. Obstet Gynecol 1997; 90: 33-6.
19. Onwude J. Genital prolapse. Clin Evid 2005; 13: 2360-4.
20. Maher C, Baessler K, Glazener CM et al. Surgical management of pelvic organ prolapse in women: a short version Cochrane review. Neurourol Urodyn 2008; 27: 3-12.
21. Delarue E, Collinet P, Sabban F et al. [Treatment of genital prolapse in young women: sacrohysteropexy or vaginal route?]. Gynecol Obstet Fertil 2008; 36: 1043-9.
22. Salvatore S, Athanasiou S, Digesu GA et al. Identification of risk factors for genital prolapse recurrence.
Neurourol Urodyn 2009; 28: 301-4.
23. Salvatore S, Siesto G, Serati M. Risk factors for recurrence of genital prolapse. Curr Opin Obstet Gynecol
2010; 22: 420-4.
24. Carey M, Slack M, Higgs P et al. Vaginal surgery for pelvic organ prolapse using mesh and a vaginal support
device. BJOG 2008; 115: 391-7.
25. Miedel A, Tegerstedt G, Morlin B et al. A 5-year prospective follow-up study of vaginal surgery for pelvic organ
prolapse. Int Urogynecol J Pelvic Floor Dysfunct 2008;
19: 1593-601.
26. Kudish BI, Iglesia CB, Sokol RJ et al. Effect of weight
27.
28.
29.
30.
31.
32.
33.
34.
35.
36.
37.
38.
39.
40.
41.
42.
43.
change on natural history of pelvic organ prolapse.
Obstet Gynecol 2009; 113: 81-8.
Bradley CS, Kenton KS, Richter HE et al. Obesity and
outcomes after sacrocolpopexy. Am J Obstet Gynecol
2008; 199: 690. e1-8.
Blandon RE, Bharucha AE, Melton LJ 3rd et al. Risk
factors for pelvic floor repair after hysterectomy. Obstet
Gynecol 2009; 113: 601-8.
Vaccaro CA, Vaccarezza H, Rossi GL et al. Body surface
area: a new predictor factor for conversion and prolonged
operative time in laparoscopic colorectal surgery. Dis
Colon Rectum 2012 Nov; 55 (11): 1153-9.
Morgan-Ortiz F, Soto-Pineda JM, López-Zepeda MA et
al. Effect of body mass index on clinical outcomes of
patients undergoing total laparoscopic hysterectomy. Int
J Gynaecol Obstet 2013 Jan; 120 (1): 61-4.
Withagen MI, Vierhout ME, Hendriks JC, Kluivers KB,
Milani AL. Risk factors for exposure, pain, and dyspareunia after tension-free vaginal mesh procedure. Obstet
Gynecol 2011 Sep; 118 (3): 629-36.
Akladios CY, Dautun D, Saussine C et al. Laparoscopic
sacrocolpopexy for female genital organ prolapse: establishment of a learning curve. Eur J Obstet Gynecol
Reprod Biol 2010; 149: 218-21.
Bafghi A, Iannelli A, Verger S et al. [Transvaginal repair
of genital prolapse with Prolift: evaluation of safety and
learning curve]. J Gynecol Obstet Biol Reprod (Paris)
2009; 38: 77-82.
Barber MD, Brubaker L, Nygaard I et al. Defining success
after surgery for pelvic organ prolapse. Obstet Gynecol
2009; 114: 600-9.
Sand PK, Koduri S, Lobel RW et al. Prospective randomized trial of polyglactin 910 mesh to prevent recurrence of cystoceles and rectoceles. Am J Obstet Gynecol
2001; 184: 1357-62; discussion 1362-4.
Dwyer PL, O’Reilly BA. Transvaginal repair of anterior
and posterior compartment prolapse with Atrium polypropylene mesh. BJOG 2004; 111: 831-6.
Demirci F, Ozdemir I, Somunkiran A et al. Abdominal
paravaginal defect repair in the treatment of paravaginal
defect and urodynamic stress incontinence. J Obstet
Gynaecol 2007; 27: 601-4.
Shippey SH, Quiroz LH, Sanses TV et al. Anatomic outcomes of abdominal sacrocolpopexy with or without
paravaginal repair. Int Urogynecol J 2010; 21: 279-83.
Viana R, Colaco J, Vieira A et al. Cystocele - vaginal
approach to repairing paravaginal fascial defects. Int
Urogynecol J Pelvic Floor Dysfunct 2006; 17: 621-3.
Morse AN, O’Dell KK, Howard AE et al. Midline anterior repair alone vs anterior repair plus vaginal paravaginal repair: a comparison of anatomic and quality of life
outcomes. Int Urogynecol J Pelvic Floor Dysfunct 2007;
18: 245-9.
Rane A, Kannan K, Barry C et al. Prospective study of
the Perigee system for the management of cystocoelesmedium-term follow-up. Aust N Z J Obstet Gynaecol
2008; 48: 427-32.
Moore RD, Beyer RD, Jacoby K et al. Prospective multicenter trial assessing type I, polypropylene mesh placed
via transobturator route for the treatment of anterior
vaginal prolapse with 2-year follow-up. Int Urogynecol J
2010; 21: 545-52.
Culligan PJ, Littman PM, Salamon CG et al. Evaluation
of a transvaginal mesh delivery system for the correction
44.
45.
46.
47.
48.
49.
50.
51.
52.
53.
54.
55.
56.
57.
58.
59.
60.
of pelvic organ prolapse: subjective and objective findings at least 1 year after surgery. Am J Obstet Gynecol
2010; 203: 506. e1-6.
Nieminen K, Hiltunen R, Takala T et al. Outcomes after
anterior vaginal wall repair with mesh: a randomized,
controlled trial with a 3-year follow-up. Am J Obstet
Gynecol 2010; 203: 235. e1-8.
Lucot JP, Bot-Robin V, Giraudet G et al. [Vaginal mesh
for pelvic organ prolapse repair]. Gynecol Obstet Fertil
2011; 39: 232-44.
Withagen MI, Vierhout ME, Milani AL. Does trocar-guided tension-free vaginal mesh (Prolift) repair provoke prolapse of the unaffected compartments? Int Urogynecol J
2010; 21: 271-8.
Villet R, Mandron E, Salet-Lizee D et al. [Surgical treatment of genito-urinary prolapse by abdominal approach
with promotofixation and setting of an anterior subvesical
prosthesis combined with retropubic colpopexia: anatomical and functional results in 104 patients]. Chirurgie 1997;
122: 353-8; discussion 358-9.
Antiphon P, Elard S, Benyoussef A et al. Laparoscopic
promontory sacral colpopexy: is the posterior, rectovaginal, mesh mandatory? Eur Urol 2004; 45: 655-61.
Fatton B, Dwyer PL, Achtari C et al. Bilateral extraperitoneal uterosacral vaginal vault suspension: a 2-year follow-up longitudinal case series of 123 patients. Int Urogynecol J Pelvic Floor Dysfunct 2009; 20: 427-34.
McCall ML. Posterior culdeplasty; surgical correction of
enterocele during vaginal hysterectomy; a preliminary
report. Obstet Gynecol 1957; 10: 595-602.
Yazdany T, Bhatia N. Uterosacral ligament vaginal vault
suspension: anatomy, outcome and surgical considerations. Curr Opin Obstet Gynecol 2008; 20: 484-8.
Sze EH, Meranus J, Kohli N et al. Vaginal configuration on MRI after abdominal sacrocolpopexy and sacrospinous ligament suspension. Int Urogynecol J Pelvic
Floor Dysfunct 2001; 12: 375-9; discussion 379-80.
Meschia M, Bruschi F, Amicarelli F et al. The sacrospinous vaginal vault suspension: Critical analysis of
outcomes. Int Urogynecol J Pelvic Floor Dysfunct 1999;
10: 155-9.
Maher C, Feiner B, Baessler K et al. Surgical management of pelvic organ prolapse in women. Cochrane
Database Syst Rev 2010: CD004014.
Maher C, Feiner B. Laparoscopic removal of intravesical
mesh following pelvic organ prolapse mesh surgery. Int
Urogynecol 2011; 22: 1593-5.
Diwadkar GB, Barber MD, Feiner B et al. Complication
and reoperation rates after apical vaginal prolapse surgical repair: a systematic review. Obstet Gynecol 2009;
113: 367-73.
Paraiso MF, Barber MD, Muir TW et al. Rectocele repair:
a randomized trial of three surgical techniques including
graft augmentation. American Journal of Obstetrics and
Gynecology 2006; 195: 1762-71.
De Ridder D. Should we use meshes in the management
of vaginal prolapse? Current Opinion in Urology 2008;
18: 377-82.
Nieminen K, Hiltunen KM, Laitinen J et al. Transanal or
vaginal approach to rectocele repair: a prospective, randomized pilot study. Diseases of the colon and rectum
2004; 47: 1636-42.
Kahn MA, Stanton SL. Techniques of rectocele repair and
their effects on bowel function. International Urogynecol-
61.
62.
63.
64.
65.
66.
67.
68.
69.
70.
71.
72.
73.
74.
ogy Journal and Pelvic Floor Dysfunction 1998; 9: 37-47.
Fatton B, Nadeau C. Urinary incontinence and genital prolapse. Journal de Gynécologie Obstétrique et Biologie de
la Reproduction 2009; 38: S239-S251.
Patil A, Duckett JR. Effect of prolapse repair on voiding
and bladder overactivity. Curr Opin Obstet Gynecol
2010; 22: 399-403.
de Boer TA, Salvatore S, Cardozo L et al. Pelvic organ
prolapse and overactive bladder. Neurourol Urodyn
2010; 29: 30-9.
Basu M, Duckett J. Effect of prolapse repair on voiding
and the relationship to overactive bladder and detrusor
overactivity. Int Urogynecol J Pelvic Floor Dysfunct
2009; 20: 499-504.
Romanzi LJ, Chaikin DC, Blaivas JG. The effect of genital prolapse on voiding. J Urol 1999; 161: 581-6.
Bradley CS, Nygaard IE, Brown MB et al. Bowel symptoms in women 1 year after sacrocolpopexy. Am J Obstet
Gynecol 2007; 197: 642. e1-8.
Forsgren C, Zetterstrom J, Zhang A et al. Anal incontinence and bowel dysfunction after sacrocolpopexy for
vaginal vault prolapse. Int Urogynecol J 2010; 21: 107984.
Villet R, Ayoub N, Salet-Lizee D et al. [Descending perineum in women]. Gastroenterol Clin Biol 2006; 30:
681-6.
Handa VL, Harvey L, Cundiff GW, Siddique SA,
Kjerulff KH. Sexual function among women with urinary incontinence and pelvic organ prolapse. Am J
Obstet Gynecol 2004; 191: 751-6.
Lukacz ES, Whitcomb EL, Lawrence JM, Nager CW,
Contreras R, Luber KM. Are sexual activity and satisfaction affected by pelvic floor disorders? Analysis of a
community-based survey. Am J Obstet Gynecol 2007;
197 (1): e1-6.
Rogers RG, Kammerer-Doak D, Darrow A et al. Does
sexual function change after surgery for stress urinary
incontinence and/or pelvic organ prolapse? A multicenter prospective study. Am J Obstet Gynecol 2006; 195:
e1-4,
Bouchet P, Crenn D, Deleflie M et al: [Influence of genital prolapse surgery on patient sexual life]. Gynecol
Obstet Fertil 2010; 38: 373-9.
Kahn MA, Stanton SL. Posterior colporrhaphy: its effects
on bowel and sexual function. Br J Obstet Gynaecol 1997;
104: 82-6.
Weber AM, Walters MD, Piedmonte MR. Sexual function and vaginal anatomy in women before and after
75.
76.
77.
78.
79.
80.
81.
82.
83.
84.
85.
86.
87.
surgery for pelvic organ prolapse and urinary incontinence. Am J Obstet Gynecol 2000; 182: 1610-15.
Maher CF, Cary MP, Slack MC et al. Uterine preservation or hysterectomy at sacrospinous colpoexy for uterovaginal prolapse? Int Urogynecol J Pelvic Floor
Dysfunct 2001; 12: 381-4; discussion 384-5.
Fatton B. [Sexual outcome after pelvic organ prolapse
surgery]. Prog Urol 2009; 19: 1037-59.
Jia X, Glazener C, Mowatt G et al. Efficacy and safety of
using mesh or grafts in surgery for anterior and/or posterior vaginal wall prolapse: systematic review and metaanalysis. BJOG 2008; 115: 1350-61.
Feiner B, Maher C. Vaginal mesh contraction: definition,
clinical presentation, and management. Obstet Gynecol
2010; 115: 325-30.
Price N, Slack A, Jackson SR. Laparoscopic sacrocolpopexy: an observational study of functional and anatomical outcomes. Int Urogynecol J 2011; 22: 77-82.
Handa VL, Zyczynski HM, Brubaker L et al. Sexual function before and after sacrocolpopexy for pelvic organ prolapse. Am J Obstet Gynecol 2007; 197: 629.e1-6.
Jeng CJ, Yang YC, Tzeng CR et al. Sexual functioning
after vaginal hysterectomy or transvaginal sacrospinous
uterine suspension for uterine prolapse: a comparison.
J Reprod Med 2005; 50: 669-74.
Paraiso MF, Barber MD, Muir TW et al. Rectocele
repair: a randomized trial of three surgical techniques
including graft augmentation. Am J Obstet Gynecol
2006; 195: 1762-71.
Nieminen K, Hiltunen R, Heiskanen E et al. Symptom
resolution and sexual function after anterior vaginal wall
repair with or without polypropylene mesh. Int Urogynecol J Pelvic Floor Dysfunct 2008; 19: 1611-16.
Nguyen JN, Burchette RJ. Outcome after anterior vaginal
prolapse repair: a randomized controlled trial. Obstet
Gynecol 2008; 111: 891-8.
Sivaslioglu AA, Unlubilgin E, Dolen I. A randomized
comparison of polypropylene mesh surgery with sitespecific surgery in the treatment of cystocele. Int Urogynecol J Pelvic Floor Dysfunct 2008; 19: 467-71.
Barber MD, Spino C, Janz NK et al. The minimum important differences for the urinary scales of the Pelvic Floor
Distress Inventory and Pelvic Floor Impact Questionnaire.
Am J Obstet Gynecol 2009; 200: 580.e1-7.
Lawndy SS, Kluivers KB, Milani AL et al. Which factors
determine subjective improvement following pelvic
organ prolapse 1 year after surgery? Int Urogynecol J
2011; 22: 543-9.

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