Pelvic organ prolapse in women: Surgical repair of apical prolapse (uterine or vaginal vault prolapse)

INTRODUCTION — Apical prolapse is the descent of uterus, cervix, or vaginal vault. Pelvic organ prolapse (POP) affects millions of women; approximately 200,000 inpatient surgical procedures for prolapse are performed annually in the United States [1,2]. Eleven to 19 percent of women will undergo surgery for POP or incontinence by age 80 to 85 years, and 30 percent of these women will require an additional POP or incontinence surgery [3,4]. Anterior vaginal wall prolapse without concomitant apical prolapse is uncommon [5], and apical prolapse repair should be included in the majority of pelvic reconstructive surgery procedures.

Reconstructive procedures for prolapse of the vaginal apex are reviewed here. Evaluation of women with POP, conservative management, and choosing a primary surgical procedure are discussed separately. Obliterative procedures for POP (colpocleisis) are also discussed separately. (See "Pelvic organ prolapse in females: Epidemiology, risk factors, clinical manifestations, and management" and "Vaginal pessaries: Indications, devices, and approach to selection" and "Pelvic organ prolapse in women: Choosing a primary surgical procedure" and "Pelvic organ prolapse in women: Obliterative procedures (including colpocleisis)".)

TERMINOLOGY — The International Continence Society defines apical vaginal prolapse as any descent of the vaginal cuff scar or cervix, below a point which is 2 cm less than the total vaginal length about the plane of the hymen [6]. The clinical significance of apical descent that is not beyond the hymen is unclear, as half of asymptomatic women presenting for routine gynecologic care have prolapse to the hymen [7]. Similarly, studies suggest that prolapse becomes symptomatic when the leading edge protrudes beyond the vaginal opening [8]. However, isolated anterior vaginal wall defects are uncommon. Therefore, if the anterior vaginal wall protrudes beyond the hymen, the apex likely has inadequate support, as well [5,9].

ANATOMY AND MECHANISMS OF INJURY — Apical prolapse refers to the downward displacement of the vaginal apex (figure 1). The vaginal apex is either the uterus and cervix or, in women who have undergone subtotal or total hysterectomy, the cervix or vaginal cuff.

Support of the vaginal apex is primarily derived from the integrity of the uterosacral and cardinal ligaments, the continuity of the endopelvic fascia, and a neuromuscularly intact levator ani muscle (figure 2). The etiology of apical prolapse is likely related to connective tissue, neural, and/or muscular defects in these normal supports.

It is rare to find isolated apical prolapse or isolated prolapse of the anterior or posterior vaginal walls, since the defects in the connective tissue, neural pathways, and muscle are not confined to one site [9,10].

The anatomy of the female pelvic floor is discussed in detail separately. (See "Pelvic organ prolapse in females: Epidemiology, risk factors, clinical manifestations, and management", section on 'Anatomy of pelvic support'.)

RISK FACTORS — The risk factors for developing apical prolapse are generally the same as for developing anterior or posterior vaginal wall prolapse. (See "Pelvic organ prolapse in females: Epidemiology, risk factors, clinical manifestations, and management", section on 'Risk factors'.)

●Prior hysterectomy – The most common risk factors associated with apical prolapse are vaginal parity (number of vaginal deliveries) and previous hysterectomy [11,12]. The risk of prolapse after hysterectomy was illustrated in a case-control study in which 160,000 women who underwent hysterectomy were significantly more likely than age-matched controls to require subsequent pelvic floor repair (3.2 versus 2 percent) [13]. Women who have prolapse at the time of hysterectomy have an even higher risk of subsequent surgery for POP.

●Prior vaginal delivery or POP surgery – A case-control study of women who underwent hysterectomy reported that the risk of subsequent POP repair was 5-fold in those who had a history of vaginal delivery, 8-fold in those who had prior surgery for POP or urinary incontinence, and almost 13-fold in those who had grade 2 or higher prolapse at the time of hysterectomy [14]. Surgeons should resuspend the vaginal apex when performing hysterectomy for nonprolapse indications to minimize this risk.

●Risk factors for post-operative POP recurrence – A Dutch trial comparing sacrospinous hysteropexy to vaginal hysterectomy with uterosacral ligament suspension for individuals with ≥stage 2 prolapse reported five-year prolapse outcomes using a composite measure of prolapse beyond the hymen, bothersome bulge symptoms, repeated surgery, or pessary use for recurrent prolapse. The risk of failure was increased with smoking (odds ratio [OR] 2.88, 95% CI 1.12-7.40), more anterior compartment prolapse (preoperative POP-Q point Ba [OR 1.23 per 1 cm; 95% CI 1.01-1.50]), and higher body mass index (OR 1.10 per 1 kg/m^2, 95% CI 1.02-1.19) [15]. These risks should be addressed when counseling patients regarding vaginal prolapse repair.

CANDIDATES FOR APICAL PROLAPSE REPAIR — Indications for apical prolapse repair are generally the same as for other POP repair procedures (ie, symptomatic prolapse in women who decline or fail conservative therapy and who can tolerate surgery). Prolapse is not typically symptomatic until the vagina protrudes through the hymen. (See "Pelvic organ prolapse in women: Choosing a primary surgical procedure", section on 'Candidates for surgical treatment' and "Pelvic organ prolapse in females: Epidemiology, risk factors, clinical manifestations, and management", section on 'Clinical manifestations'.)

PREOPERATIVE EVALUATION AND PREPARATION — In women planning surgical repair of apical prolapse, surgeons should assess each vaginal compartment (apical, anterior, and posterior) for the presence of support defects or prolapse. In addition, POP often coexists with urinary and/or anal incontinence. During the history and physical examination, the presence and severity of each of these disorders should be assessed, as this information may alter surgical decision making.

Aspects of preoperative evaluation and preparation that are specific to apical prolapse repair are discussed in this section. General principles of evaluation of women undergoing POP repair are discussed in detail separately. (See "Pelvic organ prolapse in women: Diagnostic evaluation".)

Informed consent and patient goals — Shared decision making is crucial when discussing surgical options for prolapse to align the patient's goals for treatment with surgical risks and outcomes. Surgeons should discuss with each woman the pelvic symptoms that are bothersome to her and their effects on her quality of life. This helps to set realistic goals for reconstructive surgery and assess postoperative improvement. Patient satisfaction after surgery for POP and urinary incontinence correlates highly with achievement of self-described preoperative surgical goals but poorly with objective outcome measures [16-18].

Informed consent for repair of apical prolapse should include a discussion of the risk of persistent or recurrent prolapse at the apex, anterior, or posterior vaginal walls, as well as the efficacy of the procedure in reducing or eliminating the patient's pelvic symptoms. Since some women develop stress urinary incontinence (SUI) following apical prolapse repair, surgeons should also discuss the risk of developing incontinence, as well as the risks and benefits of performing a prophylactic incontinence procedure versus deferring an incontinence procedure until symptoms develop. (See 'Evaluation of urinary dysfunction' below.)

Other important items to discuss with women planning apical POP surgery include potential postoperative changes in sexual function and mesh-related complications if mesh will be used for the repair. In our practice, we counsel all women undergoing pelvic surgery that there is a risk of postoperative dyspareunia. (See "Transvaginal synthetic mesh: Complications and risk factors", section on 'Complications by procedure'.)

History — The most common clinical manifestation of prolapse of the vaginal apex is a bulge or protrusion from the vagina (picture 1). Protrusion of the vagina may result in vaginal discharge and/or bleeding from ulceration. Other symptoms commonly reported by women with apical prolapse are voiding difficulty and constipation; some women need to reduce the prolapse using a finger in the vagina (ie, splint) to urinate or defecate.

Women with advanced anterior or posterior vaginal wall prolapse may have similar symptoms and pelvic examination is needed to ascertain the site(s) and stage of prolapse. Investigators demonstrated that restoration of the vaginal apex during prolapse examination fixes anterior vaginal wall defects 50 percent of the time and posterior vaginal wall defects 30 percent of the time [19].

Physical examination — A thorough speculum and bimanual pelvic examination are performed. We perform apical prolapse assessment initially with the woman standing and straining. Each vaginal compartment (apical, anterior, and posterior) should then be examined with the women supine. The apical prolapse can be visualized during speculum examination with the woman straining as the speculum is slowly withdrawn from the upper third of the vagina. In some women with advanced apical prolapse, protrusion of the apex is visible at or beyond the vaginal introitus before the speculum is inserted (picture 1).

Since isolated apical prolapse is rare, careful assessment of the anterior and posterior wall is important [9].

The findings of the examination should be recorded using a quantitative and reproducible method for recording POP. The system currently recommended by the International Continence Society and the American Urogynecologic Society is the Pelvic Organ Prolapse Quantitation System (POP-Q) (figure 3 and figure 4) [20]. (See "Pelvic organ prolapse in women: Diagnostic evaluation", section on 'Speculum and bimanual examination'.)

Evaluation of urinary dysfunction — Apical prolapse frequently coexists with urinary incontinence or urinary retention, and women planning apical prolapse repair should be evaluated for these conditions.

Urinary incontinence — Women with symptoms of both POP and SUI are treated with a combined prolapse repair and continence procedure. Women with POP but no SUI symptoms are challenging because they can have stage II or greater apical prolapse and remain continent despite loss of anterior vaginal and bladder/urethral support but then become incontinent after POP repair. Studies have reported 13 to 65 percent of continent women develop symptoms of stress incontinence after surgical correction of the prolapse [7,21-23]. This likely occurs because the prolapse kinks and obstructs the urethra; this obstruction is alleviated when the prolapse is repaired. This is referred to as "occult" or "potential" stress incontinence. Women with stage I POP are unlikely to have urethral obstruction and resultant occult stress incontinence [7,21-23].

To detect occult incontinence, we perform a preoperative evaluation for occult stress incontinence during which the prolapse is reduced. Stress testing can be done via a basic office evaluation with full-bladder cough stress test or urodynamic testing. (See "Urogynecologic surgery: Perioperative care issues", section on 'Urodynamic studies'.)

While we perform preoperative evaluation for occult SUI, we recognize that the ability of preoperative prolapse reduction testing to predict postoperative urinary incontinence is limited. In study of stress-continent women undergoing preoperative urodynamic testing prior to sacrocolpopexy, nearly 4 percent of women had urodynamic stress incontinence when the prolapse was not reduced, which increased to 27 percent of women with prolapse reduction [24]. When all methods of prolapse reduction were combined, the positive and negative predictive values of preoperative prolapse reduction stress testing were 37 and 80 percent, respectively. While the positive predictive value of preoperative reduction stress tests is low, it appears to be helpful in surgical planning. In a multicenter trial of continent women undergoing vaginal prolapse repair who were randomly assigned to concomitant midurethral sling or sham incision, women with a positive cough stress test had more benefit from prophylactic sling than those without a positive stress test [25]. (See "Pelvic organ prolapse and stress urinary incontinence in females: Surgical treatment", section on 'Occult SUI'.)

For continent women with stage II or greater POP who undergo abdominal sacrocolpopexy or vaginal native tissue repairs, high-quality data indicate that bothersome stress incontinence is less likely to develop in women who undergo a concomitant procedure for SUI rather than an apical prolapse procedure alone. Concomitant SUI procedure at the time of prolapse repair is discussed in detail separately. (See "Pelvic organ prolapse and stress urinary incontinence in females: Surgical treatment", section on 'Symptomatic POP without symptomatic SUI'.)

Urinary retention — Urinary retention is evaluated by measuring a postvoid residual urine volume (PVR) within 10 minutes after the patient has voided. In general, a PVR of less than 50 to 100 mL is considered adequate emptying, and a PVR greater than 200 mL is considered inadequate. An elevated preoperative PVR normalizes after surgical correction of prolapse in over 90 percent of women [26,27].

Evaluation of defecatory dysfunction — Women with POP should be asked about symptoms of defecatory dysfunction (eg, constipation, the need to place pressure on, or "splint," the posterior vaginal wall to defecate, anal incontinence). Such symptoms should be evaluated prior to surgery, as appropriate. (See "Pelvic organ prolapse in females: Epidemiology, risk factors, clinical manifestations, and management", section on 'Defecatory symptoms' and "Fecal incontinence in adults: Etiology and evaluation".)

SURGICAL PLANNING — When planning surgery for quality of life disorders, such as apical prolapse, factors beyond simple anatomic outcomes are discussed by each woman with her surgeon. Such factors include the woman's goals for surgery, concerns for symptom recurrence and reoperation, ability to tolerate surgery, preferences regarding recovery time and complication profile of each surgery, and concerns regarding sexual function (algorithm 1). Key issues for discussion include the choice of surgical route (abdominal [open, laparoscopic, robotic] or vaginal) and the risks and benefits of that route, the need for repair of other pelvic defects, and the presence of urinary incontinence. In addition, women undergoing intraperitoneal surgery must further decide if they desire hysterectomy as part of the repair, elective or risk-reducing bilateral salpingo-oophorectomy, or prophylactic salpingectomy for ovarian cancer risk reduction. (See "Pelvic organ prolapse in women: Choosing a primary surgical procedure", section on 'Concomitant hysterectomy' and "Opportunistic salpingectomy for ovarian, fallopian tube, and peritoneal carcinoma risk reduction", section on 'Candidates'.)

Issues specific to planning repair of apical prolapse are discussed in this section. General principles of surgical decision-making regarding POP (eg, obliterative versus reconstructive surgery) are discussed separately. (See "Pelvic organ prolapse in women: Choosing a primary surgical procedure", section on 'Candidates for surgical treatment'.)

Abdominal versus vaginal approach

Summary — To repair apical vaginal prolapse, the surgeon must decide between abdominal or vaginal surgical routes. Data suggest that abdominal surgery, typically with an abdominal sacrocolpopexy (ASC) or sacrospinous hysteropexy, provides better objective anatomic outcomes than native tissue vaginal apical support procedures for most women [28-32]. However, vaginal procedures are a reasonable alternative because of similar rates of postoperative prolapse symptoms, reoperation, and adverse events compared with ASC [28-30,33,34]. The uterus or fallopian tubes can be removed by either route.

While the majority of studies on ASC outcomes used an open technique, laparoscopic and robot-assisted approaches are now more commonly performed. Laparoscopic and robotic approaches appear to offer the improved vaginal support associated with open procedures and the shorter recovery of vaginal procedures [30]. One trial of 112 women randomly assigned to laparoscopic or open ASC reported no difference between the procedures for recurrence of apical prolapse (none in either group), surgical complications, or mesh exposures at a mean of 41 months of follow-up, although there were significantly more anterior compartment recurrences in the laparoscopic group compared with the abdominal group (18 versus 2 percent) [35]. None of the women with recurrent prolapse had symptoms or required repeat surgery.

Benefits of abdominal repair — ASC appears to provide improved anatomic support without a large increase in morbidity compared with vaginal repairs [36]. A 2016 meta-analysis of 30 trials concluded that open sacrocolpopexy had superior outcomes compared with a variety of vaginal procedures, including sacrospinous ligament suspension (SSLS), uterosacral ligament suspension (ULS), and transvaginal mesh, but the open approach also resulted in longer operating times and greater delay in resumption of activities. The longer time to resumption of activities can be mitigated by the use of laparoscopy or robot-assisted surgery to perform the abdominal procedure. (See 'Laparoscopic or robotic procedures' below.)

Therefore, ASC may be more appropriate for women with risk factors for prolapse recurrence, including young age, obesity, stage III or IV POP, prone to high-impact activities or heavy lifting, and previous failed POP repair [37-40]. Rare risk factors for recurrent prolapse are bladder exstrophy or spina bifida [41,42]. Other reasons to choose an abdominal approach include insufficient vaginal length for transvaginal repair or other indications for abdominal surgery (eg, ovarian cystectomy).

Benefits of vaginal repair — Transvaginal apical repair may benefit women who do not want the risks associated with open abdominal procedures [36]; although, most abdominal procedures are now done using minimally invasive techniques, which have a different risk profile compared with open surgery.

●Reduced risk of complication compared with open abdominal surgery – A retrospective analysis of Medicare data from 2002 to 2011 reported that women age 65 years or older undergoing sacrocolpopexy had higher rates of 30-day readmissions (7.4 versus 3.5 to 4.5 percent), 30-day gastrointestinal complications (6 versus 1 percent), and surgical site infections (5.9 versus 3.1 to 3.7 percent) compared with women undergoing native tissue vaginal repairs (uterosacral ligament and SSLS); however, there was no difference in prolapse recurrence at 12 months amongst the groups [43]. A major limitation of this study is that most sacrocolpopexies were done using an open technique, which is associated with more complications and longer recoveries than laparoscopic and robotic approaches. For comparison, a large retrospective cohort study of over 450 women undergoing laparoscopic or robotic sacrocolpopexy reported a gastrointestinal complication rate of only 2.6 percent [44]. In addition, vaginal surgery has a shorter operative duration and recovery compared with open ASC and avoids abdominal incisions.

●Potential avoidance of synthetic mesh – Vaginal surgery with native tissue repair eliminates the risk of mesh-related complications associated with abdominal support procedures or vaginal mesh procedures. The elimination of mesh-related complications can be particularly important in women at higher risk of mesh or graft exposure (eg, women who smoke or are immunosuppressed). (See "Transvaginal synthetic mesh: Complications and risk factors", section on 'Complications by procedure'.)

●Ability to correct other vaginal support defects at same time – Transvaginal surgery is performed in 80 to 90 percent of prolapse surgeries in the United States [2,3,45]. This may be secondary to the minimally invasive nature of vaginal surgery and the ease of addressing the anterior and posterior compartments more easily at the time of vaginal surgery; however, outcome data after ASC suggest that simply addressing the apex often corrects both anterior and posterior defects as well.

Surgical comparators — The majority of outcome data comes from studies comparing ASC and SSLS. Additional vaginal procedures can include ULS and iliococcygeus suspension.

●Anatomic outcome – ASC is associated with improved objective anatomic support compared with vaginal prolapse repairs, mainly SSLS. In two systematic reviews and meta-analyses that defined anatomic failure as ≥Stage 2 prolapse, postoperative anatomic success was more likely with ASC compared with vaginal repairs (failure rate 6 versus 20 percent, relative risk [RR] 0.29, 95% CI 0.09-0.97 [28] and odds ratio [OR] for success 2.04, 95% CI 1.12-3.27 [29]). There was some, but not complete, overlap in the studies selected by the two reviews.

●Postoperative prolapse symptoms – While ASC may have improved objective anatomic support, postoperative prolapse symptoms are similar for ASC compared with SSLS. A meta-analysis of three trials reported a statistically insignificant trend toward lower risk of postoperative prolapse symptoms for ASC compared with vaginal repairs (RR 0.53, 95% CI 0.25-1.09, n = 169 women) [28].

●Reoperation rates – Reoperation rates appear similar between ASC and SSLS. One meta-analysis reported a statistically insignificant lower reoperation rate for ASC compared with SSLS (7 versus 16 percent, RR 1.46, 95% CI 0.19-1.11, n = 169). A different meta-analysis reported no difference in reoperation rates between ASC with mesh compared with a combined group of native tissue vaginal repairs, although the data were limited by small sample size, short duration of follow-up, and a combination of surgical procedures [29].

●Complication rates – While a definitive conclusion regarding complication rates between abdominal and vaginal repairs is limited by study heterogeneity, surgical heterogeneity, and inconsistent reporting of adverse events, there does not appear to be a difference in overall complication rates between the two approaches. In a meta-analysis of 100 trials and studies (n = 13,466 women) that addressed the severity of complications in ASC and native tissue transvaginal apical suspension procedures, total complication rates were similar for abdominal compared with vaginal procedures (complication rate 17.1 percent [CI 16.1-18.1] for abdominal procedures versus 15.3 percent [CI 14.7-16.3] for vaginal procedures) [46]. A systematic review and meta-analysis of 79 studies reported that total complication rates were similar for the vaginal and abdominal approaches, but bowel and mesh complications were more common with ASC than the combined group of vaginal repairs [29].

●Risk of mesh or suture complications – Native tissue vaginal prolapse repairs do not use synthetic mesh, and therefore cannot have mesh-related complications. Suture complications can occur with either procedure. A meta-analysis of trials and cohort studies reported more mesh or suture complications after ASC than a combined group of vaginal procedures (OR 3.26, 95% CI 1.62-6.56) [29]. (See "Transvaginal synthetic mesh: Complications and risk factors", section on 'Complications by procedure'.)

●Risk of postoperative dyspareunia – The conflicting results among trials and meta-analyses suggest that a large difference in postoperative dyspareunia rates is unlikely; however, ASC may be associated with slightly less dyspareunia than native tissue vaginal suspensions. As an example, in a meta-analysis of three randomized trials, postoperative dyspareunia was less likely in women who underwent ASC compared with SSLS (RR 0.39, 95% CI 0.18-0.86, n = 106 women) [28]. By contrast, a different meta-analysis reported no difference in dyspareunia in two trials and two cohort studies between the surgical approaches [29] yet also included one trial that reported a decreased rate of dyspareunia with ASC compared with vaginal repair [47].

●Length of surgery – Comparison of surgical operating time between vaginal and abdominal procedures varies based on type of abdominal approach (open, laparoscopic, and robot-assisted). In a meta-analysis of three trials, ASC was associated with longer operating time (an average of 21 minutes longer), longer recovery time (an average of eight days longer), and greater expense [28]. In contrast, a different meta-analysis of three trials and three cohort studies reported no difference in hospital length of stay between the abdominal and vaginal approaches, but the data were limited.

While the majority of studies have compared ASC with SSLS, other transvaginal apical support procedures have been assessed as well. Studies comparing high ULS [48] and iliococcygeus suspension [49] with ASC suggest similar outcomes to the SSLS data. While the sample size and duration of follow-up are limited in these studies, these procedures are established apical support surgeries and are reasonable alternatives to SSLS in women who wish to avoid abdominal surgery or the risk of pudendal nerve and vascular injury associated with SSLS. (See 'Uterosacral ligament suspension' below and 'Iliococcygeus suspension' below.)

Concomitant repair of other sites of prolapse — Apical prolapse almost always coexists with other sites of POP (anterior or posterior). It is controversial whether repair of apical prolapse is sufficient to support the anterior and posterior vaginal walls or if additional procedures are required to address anterior and/or posterior prolapse. If the vaginal muscularis is well suspended at the apex, many anterior and posterior defects will also resolve; conversely, correction of anterior or posterior prolapse does not repair apical descent. Anterior vaginal wall prolapse, in particular, is highly correlated with apical prolapse. The approach to concomitant repair of multiple sites of prolapse varies by surgical route and by site of prolapse. A detailed discussion of the concomitant repair of multiple sites of prolapse can be found separately. (See "Pelvic organ prolapse in women: Choosing a primary surgical procedure", section on 'Concomitant repair of apical and anterior or posterior prolapse'.)

Uterus preservation — With growing emphasis on patient-centered outcomes and shared decision making, surgeons and patients are reconsidering uterine preservation versus hysterectomy at the time of apical POP repair. In two studies totaling over 300 women that assessed opinions on uterine preservation versus hysterectomy at the time of POP repair, 36 to 60 percent of women indicated they would prefer uterine preservation in the scenario of equal surgical outcomes between the two approaches [50,51]. In the scenario of superior surgical results with hysterectomy, 21 percent of women indicated they would still decline a hysterectomy and elect uterine preservation instead. Women with a history of cervical pathology, abnormal uterine bleeding, or other risk factors for uterine malignancy are not typically candidates for uterine preservation. Uterine preservation necessitates ongoing surveillance for cervical and uterine pathology, which may be more technically challenging following prolapse repair.

While hysterectomy has traditionally been performed with POP repair, there are few data to support that practice. Comparison of study outcomes between hysteropexy and hysterectomy are confounded by anatomic variables (isolated apical prolapse or multiple compartment prolapse), hormonal status (premenopausal, postmenopausal on hormone therapy, and postmenopausal without hormone therapy), surgical approach (vaginal, open abdominal, laparoscopic, and robotic), and use of synthetic mesh or native tissue. In addition, the number of women who subsequently undergo hysterectomy after a uterus-sparing prolapse surgery is not known.

In general, despite the multiple surgeries and approaches that limit direct comparison of data, uterus-preserving surgery appears to have similar success rates and shorter surgical times compared with hysterectomy. Thus, the decision to preserve or remove the uterus is heavily based on the patient's preferences, risks for future cervical or uterine pathology, and the potential for subsequent uterine surgery, including hysterectomy. Supporting data include the following:

●Transvaginal mesh hysteropexy compared with vaginal hysterectomy and ULS – A multicenter trial comparing transvaginal mesh hysteropexy using Uphold LITE with vaginal hysterectomy with ULS in 183 women with symptomatic uterovaginal prolapse collected data at three and five years [31,52]. While the five-year data favored the mesh hysteropexy procedure, the mesh product used in the original surgery was removed from the market in 2019.

•Three-year data – The 36-month incidence failure rates were similar between the two groups (26 versus 38 percent, adjusted hazard ratio 0.62, 95% CI 0.38-1.02) [52]. Failure was defined as retreatment for prolapse, anatomic prolapse beyond the hymen, or bothersome symptoms of vaginal bulge. Not surprisingly, adverse events rates and operative times differed between the surgeries. Transvaginal mesh hysteropexy had a higher rate of mesh exposure (8 versus 0 percent) while hysterectomy had a higher rate of prolonged (>12 weeks) granulation tissue (11 versus 1 percent) and permanent suture exposure (21 versus 3 percent), although none required operative intervention. Mean operative time for hysterectomy was 45 minutes longer. Patients undergoing hysterectomy also had higher rates of ureteral kinking that were managed intraoperatively (7 versus 0 percent). The Uphold LITE is not currently available for clinical use, and these data may not be generalizable to other types of mesh hysteropexy.

•Five-year data – Five-year follow-up data were available for 156 women (89 percent). The primary outcome, a composite of retreatment of prolapse, prolapse beyond the hymen, or prolapse symptoms, occurred less often in the mesh hysteropexy group than the vaginal hysterectomy group (37 versus 54 percent, adjusted hazard ratio 0.58, 95% CI 0.36-0.94) [31]. At the five-year comparison of the mesh hysteropexy and vaginal hysterectomy with ULS groups, the initial differences in adverse events persisted (mesh exposure in 8 versus 0 percent, granulation tissue after 12 weeks in 1 versus 12 percent, and suture exposure after 12 weeks in 3 versus 21 percent, respectively).

●Sacrospinous hysteropexy compared with vaginal hysterectomy and SSLS – Five-year follow-up of a randomized trial comparing sacrospinous hysteropexy (with no mesh) with vaginal hysterectomy and SSLS reported that hysteropexy had lower rates of apical failure (1 versus 8 percent, difference -6.7 percent, 95% CI -12.8 to -0.7 percent) and better composite success (87 versus 76 percent) [53]. Apical failure was defined as apex at or beyond the hymen with bothersome bulge symptoms or repeat surgery for apical prolapse. Overall anatomic failure, defined as recurrent stage 2 prolapse of any compartment, was similar between the groups (45 percent for hysteropexy versus 50 percent for hysterectomy, difference -4.8 percent, 95% CI -18.5 to 8.9 percent).

●A systematic review of retrospective studies, meta-analysis of two trials and four studies, and a nonrandomized prospective trial reported that sacrospinous hysteropexy was as effective as vaginal hysterectomy with apical repair [54-56]. Uterine preservation was associated with less blood loss and shorter operating times.

●A trial including 82 women that compared vaginal hysterectomy with ULS to open sacrohysteropexy with mesh reported similarly high apical success rates (95 percent) and subjective outcomes between the groups; however, women in the sacrohysteropexy arm were more likely to undergo reoperation in the first year after surgery [57].

●A multicenter parallel cohort study comparing vaginal mesh hysteropexy and laparoscopic sacral hysteropexy reported no differences between the groups in anatomic, symptomatic, or composite outcomes at one year of follow-up [58]. Two women in the vaginal hysteropexy arm underwent reoperation in the first year after surgery compared with none in the laparoscopic sacral hysteropexy group.

●A prospective cohort study compared outcomes in women who had laparoscopic sacrocolpopexy with or without hysterectomy and reported similar anatomic or functional outcomes [59].

A detailed discussion of uterus conservation at the time of prolapse repair is presented elsewhere. (See "Pelvic organ prolapse in women: Choosing a primary surgical procedure", section on 'Concomitant hysterectomy'.)

Concomitant surgery for stress urinary incontinence — Many women with apical prolapse have coexisting urinary incontinence, as noted above. (See 'Evaluation of urinary dysfunction' above.)

Burch colposuspension performed concurrently with ASC is discussed below. (See 'Concomitant Burch colposuspension' below.)

Women with symptomatic urinary incontinence — Women with symptoms of both POP and stress incontinence are treated with a combined prolapse repair and continence procedure. (See "Pelvic organ prolapse and stress urinary incontinence in females: Surgical treatment", section on 'Symptomatic POP and symptomatic SUI'.)

Women at risk for occult urinary incontinence — For women with stage II or greater POP who are undergoing ASC, high-quality data support a concomitant Burch colposuspension rather than sacrocolpopexy alone. For continent women undergoing transvaginal prolapse repair, the decision of whether to perform a concomitant midurethral sling depends upon patient preference regarding the risk of developing stress urinary incontinence (SUI) compared with the risk of perioperative complications. Addition of a midurethral sling to native tissue vaginal repair reduces SUI symptoms but is associated with increased risk of postoperative voiding dysfunction. (See "Pelvic organ prolapse and stress urinary incontinence in females: Surgical treatment", section on 'Symptomatic POP without symptomatic SUI'.)

Combined surgery for POP and stress incontinence is discussed in detail separately. (See "Pelvic organ prolapse and stress urinary incontinence in females: Surgical treatment", section on 'Symptomatic POP without symptomatic SUI' and "Pelvic organ prolapse and stress urinary incontinence in females: Surgical treatment", section on 'Summary and recommendations'.)

EVALUATING APICAL PROLAPSE PROCEDURES — Surgical outcomes of POP treatments have ranged over the years from patients' reports that they are "happy or cured" to strict anatomic criteria for cure regardless of patient satisfaction. Improvement in objectively measured outcomes after surgery do not always correspond to patient satisfaction [16,17]. More recently, experts agree that outcomes literature should include both a measure of subjective cure (based upon the patient's report of cure or improvement) and a measure of objective cure using a validated POP measuring system. A study looked at cure rates using a variety of anatomic and subjective definitions in a cohort of women two years after abdominal sacrocolpopexy [60]. Reported cure rates range widely, from 19 percent to 97 percent, depending on the definition used with patient reports of no bulge beyond the hymen being most associated patients' own assessment of improvement. These data should not be over-interpreted to mean objective outcomes are not valuable, as the follow-up period in this study was short (only two years) and anatomic outcomes tend to worsen over time.

ABDOMINAL SACROCOLPOPEXY — Abdominal repair of apical prolapse is performed by securing the anterior and posterior vaginal walls via surgical mesh to the anterior longitudinal sacral ligament just below the sacral promontory (figure 5). This reestablishes a nearly horizontal vaginal axis [61]. The ventral abdominal wall and round ligaments should never be used because of the high risk of recurrent prolapse.

Abdominal sacrocolpopexy (ASC; attachment between the sacral promontory and the vagina vault in women who have undergone total hysterectomy) is the most commonly performed procedure. Uterine or cervix sparing procedures include: sacral hysteropexy (attachment between the sacral promontory and the lower uterus) and sacral cervicopexy (attachment between the sacral promontory and the cervix).

Typically, a hysterectomy is done at the time of apical POP repair in women with uterovaginal prolapse. While no prospective comparative studies are available to determine if outcomes are improved with concomitant hysterectomy, several small studies suggest that POP outcomes are not worse and operating times are shorter with uterine preservation [62-64]. A retrospective cohort study compared three groups (hysterectomy plus sacrocolpopexy, sacral hysteropexy, and hysterectomy plus uterosacral suspension) and showed a sixfold increase in POP recurrence in the uterosacral suspension group [65].

Concomitant hysterectomy at the time of prolapse repair is discussed in detail separately. (See "Pelvic organ prolapse in women: Choosing a primary surgical procedure", section on 'Concomitant hysterectomy'.)

Laparoscopic or robotic procedures — Although sacrocolpopexy was traditionally performed through a laparotomy, most surgeons perform sacrocolpopexy through conventional and robot-assisted laparoscopic approaches. Laparoscopic and robot-assisted ASC are less invasive and have shorter lengths of stay after surgery [66]. In addition, single port laparoscopic procedures have been reported [67]. (See "Robot-assisted laparoscopy" and "Abdominal access techniques used in laparoscopic surgery", section on 'Single-incision laparoscopic surgery'.)

Data suggest that the conventional laparoscopic and robot-assisted routes result in a shorter hospital stay (eg, one to two versus three to four days), faster time to recovery, and less postoperative pain than laparotomy, with comparable short-term efficacy [46,68-72]. Some retrospective studies have also found a significant decrease in blood loss (eg, 60 to 150 mL less) with laparoscopic procedures [68,70]. A large retrospective cohort study of 450 women undergoing laparoscopic and/or robotic sacrocolpopexy reported high anatomic success rates and few complications [44]. A disadvantage of laparoscopic procedures is a longer operative duration (eg, one to two hours longer). In addition, robotic procedures are more costly than laparotomy or conventional laparoscopy [73,74]. A United Kingdom multicenter randomized equivalence trial compared open with laparoscopic sacrocolpopexy. At one year, there were no differences in anatomic or subjective pelvic floor outcomes; however, blood loss, postoperative hemoglobin values, and hospital stay were better in the laparoscopic arm [75]. Many surgeons initially adopted a higher sacral fixation point when performing laparoscopic and robotic procedures. Case reports of vertebral discitis [76] and cadaveric and magnetic resonance imaging studies suggest that to avoid disc complications, sutures should be placed inferior to the promontory to avoid the intravertebral disc [77,78].

Performing sacrocolpopexy requires suturing, which is more difficult to do with conventional than during robot-assisted laparoscopy. For this reason, some surgeons prefer robotic-assisted laparoscopy. However, two randomized trials have found that robotic compared with conventional laparoscopic sacrocolpopexy has a longer operative duration (24 to 67 minutes longer) and higher costs, with similar complication rates and short-term outcomes [79,80].

Although further studies are necessary to ascertain the role for robotic versus laparoscopic sacrocolpopexy, current data suggest that the laparoscopic route may be more cost effective and confer some benefits to the patients.

Procedure — Open ASC used to be performed through a lower abdominal Pfannenstiel incision; however, most sacrocolpopexies are now done with traditional or robotic-assisted laparoscopy. Minimally invasive procedures have equivalent prolapse outcomes and adverse events to open procedures with decreased recovery times.

Regardless of route of access, the technique is to attach a permanent mesh to the posterior vagina to the level of the rectal reflection and to the anterior vagina for a distance of 4 cm, or just above the bladder trigone. It is acceptable to use a mesh fashioned into a Y configuration or to use two separate strips of mesh. Alternatively, the posterior mesh may extend to the perineal body, adding support to this area (sacral colpoperineopexy). Two rows of sutures are then used to widely attach the mesh to the vagina to distribute the tension; the sutures should approximate the mesh to the vaginal walls for a distance of several centimeters. Permanent sutures are typically used to attach the mesh to the vagina and sacrum. Secondary to concern about vaginal erosion of permanent sutures, some surgeons are starting to use delayed absorbable sutures. In the Colpopexy and Urinary Reduction Efforts (CARE) trial (a randomized trial that compared ASC with and without Burch colposuspension) of 322 women undergoing ASC with permanent sutures, only three participants had a vaginal erosion of the permanent suture in the first two years after surgery [81]. The suture was simply removed in all three patients; two healed without further problem, and the other was lost to follow-up. Given the lack of high-quality data supporting comparable anatomic and/or symptomatic outcomes with use of delayed absorbable sutures and the minimal risks associated with permanent suture, patients should be counseled appropriately if nonpermanent sutures are used.

Failure to attach the mesh anteriorly results in anterior vaginal wall recurrence rates of almost 30 percent [82]. The optimal approach for posterior vaginal wall attachment is unclear; however, simply attaching the mesh to the rectovaginal septum to maintain continuity with the perineal body results in high success rates [83]. The mesh exposure rates reported from abdominovaginal attachment of the mesh to the perineal body have varied widely (7 to 40 percent) [84,85].

After exposing the presacral space, the free end of the mesh is attached to the anterior longitudinal ligament just below the sacral promontory using two or three nonbraided permanent sutures.

Avoiding presacral hemorrhage — Laceration of the presacral venous plexus leads to profuse hemorrhage. Careful dissection must be used near the sacrum. The sutures are placed through the sacral (anterior longitudinal) ligament just below the sacral promontory since placement lower on the sacrum, at the S3 to S4 level, is more likely to result in presacral hemorrhage. Additionally, suture placement on the promontory may deviate the vaginal axis too far forward or result in discitis.

Choosing a surgical mesh — Simple suturing of the apical vaginal skin to the sacrum is regarded as insufficient fixation and likely to result in recurrent prolapse. The best type of mesh and suture material remains controversial, but most surgeons agree that synthetic nonabsorbable materials should be used. Synthetic mesh sacrocolpopexy has consistently outperformed the biologic graft materials (autologous, allogeneic, xenograft) in randomized trials but at the expense of higher mesh exposure rates [61,86,87]. In a systematic review of 65 studies (3 were randomized trials), the average rate of synthetic mesh exposure was 3.4 percent; the lowest rate was for polypropylene (0.5 percent) compared with other types of synthetic mesh, such as polyethylene or polytetrafluoroethylene (3.1 to 5.0 percent) [86]. At least one study of a lightweight mesh has reported lower mesh exposure rates [88].

On rare occasions, a surgeon may also face an intraoperative decision on whether to use synthetic or biologic mesh in the face of a bowel injury or concomitant sigmoid resection with reanastomosis for the treatment of rectal prolapse. Since it is often not advisable to place synthetic nonabsorbable materials during procedures contaminated by bowel contents, these choices should be determined by carefully weighing the risk and benefits for an individual patient.

Outcome — A systematic review of studies from 1966 to 2004 reported that anatomic success rates after ASC ranged from 76 to 100 percent with a 4 percent (range 0 to 18 percent) reoperation rate for prolapse (follow-up interval of six months to three years) [86].

The need for concomitant anterior or posterior vaginal wall repairs at the time of sacrocolpopexy is controversial. This topic is discussed in detail separately. (See "Pelvic organ prolapse in women: Choosing a primary surgical procedure", section on 'Abdominal route'.)

One-year outcomes of the CARE trial showed that ASC performed with or without posterior vaginal wall repair resulted in statistically and clinically significant improvements in bowel symptoms, including obstructive defecation and posterior vaginal wall topography regardless of concomitant posterior repair [8]. Likewise, there was no difference in anterior vaginal wall support in women who had a concomitant paravaginal repair and those who did not. Another study of 149 women with advanced prolapse who underwent sacrocolpopexy without any concomitant repairs demonstrated excellent anatomic outcomes one year after surgery [89].

Two-year outcomes of the CARE trial showed that 95 percent of women had support of the vaginal apex within 2 cm of the total vaginal length and 3 percent had undergone reoperation for prolapse [90]. Women reported significant improvement in pelvic floor symptoms and sexual function using validated questionnaires. In addition, correction of apical prolapse via ASC with or without Burch colposuspension significantly reduced bladder symptoms other than incontinence, both irritative (eg, urgency, frequency, nocturia) and obstructive (eg, intermittent flow, straining to void, sensation of incomplete emptying, poor stream) [91]. At one-year, participants reported a significant decrease in obstructive defecatory symptoms, fecal incontinence and anorectal pain [8]. New onset fecal incontinence with activity, as well as pain prior to and with defecation, were more likely to be reported by women who had a concomitant posterior repair procedure than by those who did not.

A prospective study of consecutive patients undergoing robot-assisted laparoscopic sacrocolpopexy using a very lightweight polypropylene Y-shaped mesh reported five-year surgical success rates of 89 percent, with no apical failures and no mesh exposures [88]. Four percent underwent reoperation for prolapse, and all were anterior or posterior repairs. Seven-year outcomes of the CARE trial showed that the estimated probabilities of treatment failure for the urethropexy group and the no urethropexy group, respectively, were 0.27 and 0.22 for anatomic POP and 0.29 and 0.24 for symptomatic POP [92]. Mesh exposure/erosion probability at seven years was 10.5 percent; however, approximately one-half of the synthetic mesh inserts were older multifilament products with known higher risk of exposure. Long-term studies reported that, at 10 to 14 years after ASC, 2 to 26 percent of women had undergone reoperation for prolapse [93].

Few studies have specifically reported the impact of sacrocolpopexy on pain. In a 2020 planned secondary analysis of a trial comparing 200 women undergoing sacrocolpopexy with a lightweight polypropylene mesh, 97 percent of women with baseline pain had resolution of pain or dyspareunia symptoms one year after surgery [94]. Four percent of patients reported de novo pain one year after surgery.

Complications — The most frequently reported intraoperative and postoperative complications of open and minimally invasive sacrocolpopexy include [86,95]:

●Open

•Incisional problems – 4.6 percent

•Blood transfusion – 4.4 percent

•Ileus – 3.6 percent

•Thromboembolic event – 3.3 percent

•Cystotomy – Approximately 3 percent

•Enterotomy – 1.6 percent

●Minimally invasive

•Cystotomy – Approximately 3 percent

•Small bowel obstruction – 0.7 percent

•Port site hernia – 0.3 percent

•Enterotomy – 0.3 percent

Specific complications by type include:

●Gastrointestinal – Studies consistently report that gastrointestinal complications, such as small bowel obstruction or ileus, occur after approximately 0.1 to 5.0 percent of open ASC procedures [86,96,97] and 0.7 to 2.5 percent of minimally invasive sacrocolpopexies [44,80,95]. In the CARE trial, 4 of 322 women (1.2 percent) required reoperation for small bowel obstruction, and all were associated with incisional problems. No intraoperative bowel injuries were reported [96]. Studies of laparoscopic and robotic sacrocolpopexy report similarly low rates of bowel complications. A large database study of women undergoing hysterectomy and/or apical prolapse surgery reported a rate of gastrointestinal injury <1 percent and the majority (73 percent) were diagnosed within one month of surgery [98].

●Presacral hemorrhage – Presacral hemorrhage is the most concerning intraoperative complication and can have life-threatening consequences. Reconstructive surgeons should be prepared to manage presacral hemorrhage and have bone wax, concave thumbtacks, and thrombin immediately available. (See "Management of hemorrhage in gynecologic surgery" and "Management of hemorrhage in gynecologic surgery", section on 'Presacral bleeding'.)

●Mesh exposure – Mesh exposure rates vary depending on the type of mesh used. Synthetic nonabsorbable mesh is typically used and, as noted above, a systemic review found that the average rate of exposure for all types of synthetic mesh was 3.4 percent, with a rate of 0.5 percent for polypropylene mesh [86]. (See 'Choosing a surgical mesh' above.)

•Impact of concomitant hysterectomy – Several studies report higher mesh exposure rates when sacrocolpopexy is performed with concomitant total hysterectomy, but this is not universally reported [81,99].

-Any hysterectomy – In a multicenter study of 322 women undergoing ASC, concomitant total hysterectomy was more common in women who developed a mesh or suture exposure (60 percent versus 24 percent), resulting in a nearly fivefold increased risk of mesh exposure in women with a concomitant hysterectomy [81].

-Supracervical or total hysterectomy – A study including nearly 3500 patients reported similar rates of mesh complications after sacrocolpopexy with supracervical hysterectomy compared with sacrocolpopexy with total hysterectomy (adjusted hazard ratio [aHR] 0.83, 95% CI 0.4-1.6) and without hysterectomy (aHR 1.7, 95% CI 0.9-3.0) [100].

-Ultralightweight synthetic mesh – There are few data reporting mesh exposure rates at the time of total hysterectomy with ultra-lightweight polypropylene meshes. A multicenter study, which included 204 women who had total laparoscopic hysterectomy and sacrocolpopexy with ultra-lightweight polypropylene mesh, reported a 5 percent mesh exposure rate in the first year after surgery [101]. A study including nearly 3500 patients reported a similar rate of mesh complications after sacrocolpopexy with supracervical hysterectomy compared with sacrocolpopexy with total hysterectomy (aHR 0.83, 95% CI 0.4-1.6) and without hysterectomy (aHR 1.7, 95% CI 0.9-3.0) [100].

•Other mesh exposure risk factors – Some data suggest that smoking and use of ePTFE mesh (Gore-Tex) are also risk factors for mesh exposure following sacrocolpopexy [81,102].

Concomitant Burch colposuspension — Burch colposuspension (also referred to as retropubic urethropexy) is an effective procedure for the treatment and prevention of stress urinary incontinence (SUI). This procedure had been widely used but has now been largely replaced by midurethral sling procedures. This is due to the increased operative duration and risk of complications for a Burch procedure compared with a midurethral sling. Efficacy of Burch colposuspension compared with other procedures is reviewed in detail elsewhere. (See "Female stress urinary incontinence: Choosing a primary surgical procedure", section on 'Comparison of efficacy'.)

In current practice, Burch colposuspension is typically performed mostly in combination with an ASC in women with symptomatic SUI or as a prophylactic procedure in women with advanced prolapse who are likely to develop SUI after sacrocolpopexy. The two procedures are both performed via an abdominal incision, and thus, traditionally have been done together. However, some surgeons prefer to perform a midurethral sling procedure even for women undergoing ASC.

Combined prolapse and continence surgery and choice of a concomitant procedure are discussed in detail separately. (See "Pelvic organ prolapse and stress urinary incontinence in females: Surgical treatment" and "Female stress urinary incontinence: Choosing a primary surgical procedure", section on 'Coexistent anatomic or functional abnormality'.)

VAGINAL SURGICAL APPROACH

Choice of procedure — As there is no clearly superior vaginal approach, procedure selection should be centered on patient factors and goals.

Procedure comparisons

●Comparison of vaginal procedures – The principal choice of vaginal procedures is between uterosacral ligament suspension (ULS) and sacrospinous ligament suspension (SSLS). As discussed in greater detail in the subsections below, ULS potentially improves anterior vaginal wall support compared with SSLS. On the other hand, the risk of ureteral injury and need for cystoscopy for ULS are potential disadvantages of this procedure. When the vaginal route is used to repair apical prolapse the vaginal apex is suspended to a ligament in the pelvis; of these, only the sacrospinous is a true ligament.

Vaginal repairs are typically performed in individuals who have undergone total hysterectomy, although cervix- and uterine-sparing procedures are possible [103]. In general, United States surgeons perform ULS at the time of concomitant vaginal hysterectomy, while SSLS is performed more commonly for posthysterectomy prolapse repair. However, both procedures may be performed in women with a prior hysterectomy or at the time of concomitant hysterectomy.

One potential limitation is that vaginal procedures require a sufficient vaginal length to reach the supporting ligament.

●Vaginal procedures versus abdominal sacrocolpopexy (ASC) – One major point of consideration is the higher anatomic surgical failure rates for these native tissue vaginal procedures compared with ASC using synthetic mesh (anatomic failure rate approximately 20 to 25 percent at seven years of follow-up) [92].

Efficacy and related data — The main source of data is the Operations and Pelvic Muscle Training in the Management of Apical Support Loss (OPTIMAL) randomly assigned trial comparing ULS and SSLS in 374 women with Pelvic Organ Prolapse Quantitation System (POP-Q) stage II to IV apical vaginal prolapse; all participants had stress incontinence and had concomitant retropubic midurethral sling procedures [104].

●In a 2018 study of OPTIMAL trial data that compared time to surgical failure among women with vaginal apical prolapse who underwent either ULS (n = 188) or SSLS (n = 186), the two surgical groups had similarly high estimated surgical failure rates (ULS 61.5 percent and SSLS 70.3 percent) five years after surgery; however, the risk and benefits of the procedures differed slightly [105].

●In the initial 2014 trial, primary surgical outcome was a composite measure of success defined as the absence of all of the following at two years: vaginal apical descent to more than one-third the vaginal length, anterior and posterior wall descent beyond the hymen, bothersome vaginal bulge symptoms, and surgical or nonsurgical retreatment of prolapse. At two years, 59 percent of ULS and 61 percent of SSLS met this definition of success (odds ratio [OR] 0.9, 95% CI 0.6-1.5). However, these numbers declined to 44 and 33 percent, respectively, by five years. In other words, the estimated proportion of women with anatomic failure was 47.5 and 61.8 percent, respectively. Approximately one-third of women failed based on anatomy alone, one-third based on symptoms alone, and one-third based on anatomy and symptoms. The final rates are estimates because not all women had all data points.

There were no significant differences between ULS and SSLS in most perioperative outcomes, including blood loss and severe intraoperative or postoperative adverse events. However, women who had ULS had significantly lower rates of neurologic pain requiring intervention (6.9 versus 12.4 percent, OR 0.5, 95% CI 0.2-1.0). Pain also persisted to the four- to six-week postoperative visit in fewer women following ULS (0.5 versus 4.3 percent). Ureteral obstruction occurred in six women in the ULS group (3.2 percent) and none in the SSLS group. In a planned secondary analysis, there were no clinically meaningful or statistically significant differences between the SSLS and ULS groups for the outcomes of quality of life, sexual function, de novo dyspareunia, and body image [106]. Risk factors for anatomic failure up to five years from surgery included Hispanic ethnicity, higher preoperative perineal body length, and higher pretreatment Pelvic Organ Prolapse Distress inventory [107].

It is important to note that the OPTIMAL trial also compared perioperative behavioral therapy with pelvic floor muscle training with usual care [104]. In a subgroup analysis of the usual care group, at two-year follow-up, ULS had a significantly lower rate of apical descent than SSLS (8.6 versus 20.8 percent, OR 0.3, 95% CI 0.1-0.9). Among women who received usual care, bothersome vaginal bulge symptoms were also lower in the ULS group (15.4 versus 21.1 percent), although the statistical significance was not reported. Rates of retreatment were not reported for this subgroup analysis. This raises the question of whether ULS is the superior procedure for most women since most women receive usual care. The pelvic floor muscle training aspect of the trial is discussed in detail below. (See 'Pelvic floor muscle training' below.)

Uterus preservation — Uterine conservation at the time of prolapse repair is discussed in detail above. (See 'Uterus preservation' above.)

Sacrospinous ligament suspension — SSLS (also referred to as sacrospinous ligament fixation) is the most commonly studied transvaginal procedure for treating vaginal vault prolapse.

Although SSLS may also improve anterior vaginal wall prolapse, it is less effective for this indication. Thus, women with large anterior wall defects in addition to apical defects may benefit from another type of prolapse repair, which better supports the anterior vagina or concomitant anterior colporrhaphy. (See "Pelvic organ prolapse in women: Choosing a primary surgical procedure", section on 'Concomitant repair of apical and anterior or posterior prolapse'.)

SSLS is generally performed unilaterally. Most surgeons prefer the right side since the bowel enters the rectum on the left side [108]. Some surgeons have proposed bilateral SSLS, although the value of this modification has not been proven [109-111]. Use of the bilateral technique depends upon adequate vaginal length and width.

Procedure — Before starting the procedure, the patient is examined to ensure that the vagina is long enough to reach the sacrospinous ligament. Women who do not have sufficient vaginal length for SSLS may be candidates for sacrocolpopexy.

The sacrospinous ligament extends from the ischial spines to the lower portion of the sacrum and coccyx (figure 6 and figure 7). The coccygeus muscle follows the same path as the sacrospinous ligament; together they are referred to as the coccygeus muscle-sacrospinous ligament complex (figure 8). The ligament can be identified on pelvic examination by palpating the ischial spine and tracing posteriorly and medially to the sacrum [112]. Marking sutures are placed on the vaginal epithelium at the site where it will attach to the sacrospinous ligament.

Several techniques are commonly used when performing a SSLS. In one modification, the perirectal space is entered by opening the posterior vagina in the midline from the perineal body to the apex. The vaginal epithelium is then separated from the underlying muscularis. The dissection is continued to the level of the ischial spine. The rectovaginal space is opened by gently pushing the rectum medially then perforating the rectal pillar (areolar tissue that extends from the rectum to the arcus tendineus fascia pelvis and overlies the levator muscle) (figure 9) [113].

Once the perirectal space is entered, the ischial spine can be palpated and the ligament found medially. A long right angle retractor (eg, Breisky-Navratil) is placed on the ischial spine to protect the pudendal neurovascular bundle and two others are used to retract the bladder superiorly and the rectum medially.

With the ligament clearly visible, two to three sutures are placed through the ligament approximately one and one-half fingerbreadths medial to the ischial spine. Several techniques and devices are available to assist placing the suture through the ligament (eg, Miya hook, Deschamps ligature carrier, laparoscopic or Capio suturing devices) [108].

After securing the sutures to the ligament complex, each of the sutures is placed through the muscularis on the undersurface of the posterior vaginal epithelium and tied by a pulley stitch, while the free end of the suture is held. Traction on the free end of the suture draws the vaginal apex directly onto the sacrospinous ligament and the suture is tied.

Another common modification of the SSLS is the "Michigan Modification" technique [114,115]. In the Michigan Modification, all four vaginal walls are directly approximated to the sacrospinous ligament (instead of just the posterior vaginal wall). The point on each vaginal wall that reaches the ligament is identified, and the intervening diamond of vaginal epithelium is excised. The sutures are placed through the sacrospinous ligament, as described above, then sewn through to both the anterior and posterior vagina and tied to the ligament. A long-lasting absorbable suture is used. The goal of this modification is to decrease the risk of an anterior vaginal wall recurrence; although it has not been evaluated in comparative studies with standard SSLS, case series report high long-term satisfaction rates after the procedure. A single-site study reported that 76 percent of women were "completely or very" satisfied at least five years after SSLS [115]. The largest randomized trial comparing ULS and SSLS used this technique.

Avoiding nerve entrapment — There are several techniques to decrease the risk of entrapment of the sciatic nerve or its branches when the sutures are placed. One approach is to perforate the sacrospinous ligament with the needle in a vertical rather than horizontal orientation, thereby attempting to place the suture parallel to the course of these nerves. Also, since these nerves did not travel in the lateral third segment of the sacrospinous ligament, placement of the fixation sutures within this region is another approach to decrease the risk of nerve injury. Regional anesthesia of prolonged duration should not be used postoperatively in women undergoing SSLS, since this may mask the symptoms of nerve entrapment. (See 'Complications' below.)

Treating hemorrhage — Significant hemorrhage has been reported in 0.2 to 2 percent of SSLS procedures [116,117]. Controlling hemorrhage is challenging because of the small space, lack of visualization, and close approximation of vessels and nerves. Techniques to control bleeding include pressure, topical hemostatic agents, direct repair, vaginal packing, and embolization. (See "Management of hemorrhage in gynecologic surgery".)

Based on cadaveric study, vessels at risk for injury include the superior gluteal, inferior gluteal, internal pudendal, vertebral, middle sacral, lateral sacral, and circumflex femoral [118]. Among these vessels, the inferior gluteal artery and its coccygeal branch appear to be the arteries at greatest risk for injury [118,119]. Bleeding encountered during SSLS can typically be managed conservatively with surgical clips, pressure, and/or hemostatic agents. A laparoscopic clip applier can facilitate visualization in this deep space when a discrete vessel is identified. Alternatively, use of hemostatic agents and packing for 5 to 10 minutes will control most bleeding. Computed tomography angiography and vessel embolization can be performed when bleeding cannot be controlled with more conservative measures [117,120-122]. Exploratory laparotomy is rarely indicated secondary to inability to access this space from an abdominal approach.

Outcome — In a literature review of mostly observational studies, cure rates of prolapse-related symptoms ranged from 70 to 98 percent (only four studies reported subjective results), and the range of objective cure rates was 67 to 97 percent [108]. However, newer data with five-year follow-up reported subjective failure rates of 41.8 percent (cure of 58.2) and objective failure rates of 61.8 percent (cures of 38.2 percent) [105]. Eight percent of women underwent retreatment for prolapse within five years. Recurrence of apical prolapse after SSLS has been reported in 2 to 19 percent of women and of anterior vaginal wall prolapse in 6 to 29 percent [114,116,123-131]. Therefore, as noted above, women with large anterior wall defects in addition to apical descent may benefit from an additional type of prolapse repair, which more directly addresses support of the anterior vagina. A study that followed women for 2 to 15 years reported that 16 percent had prolapse symptoms [132].

Regarding bowel symptoms, relief of constipation was reported in several studies [108]. Data regarding fecal incontinence were inconsistent, with some studies reporting improvement in patients with preoperative symptoms, and others reporting de novo incontinence in some patients.

Complications — Serious complications are uncommon following SSLS. A literature review of mostly observational studies that included 1922 SSLS procedures reported the following complication rates [108]:

●Cystitis – 4.5 percent

●Fever, secondary wound healing, abscess, or septicemia – 4.1 percent

●Ureteral kinking, problems with urination – 2.9 percent

●Pain (unclassified, gluteal, or bladder) – 2.0 percent

●Hemorrhage/blood transfusion – 1.9 percent

●Nerve damage (eg, sciatic nerve) – 1.8 percent

●Injury to pelvic organs – 0.8 percent

●Pelvic or vaginal vault hematoma – 0.4 percent

Infectious complications are the most common type of adverse event, and are generally mild (eg, cystitis).

Lower urinary tract complications involving ureteral impingement or injury may also occur; cystotomy is infrequent [116]. Enterotomy and postoperative bowel complications are rare, as the procedure is meant to be extraperitoneal. A discussion of lower urinary tract injury in gynecologic surgery can be found separately. (See "Urinary tract injury in gynecologic surgery: Identification and management".)

Hemorrhage during SSLS is most commonly due to laceration of the inferior gluteal or pudendal vessels [118]. Pudendal hemorrhage is best treated by tightly packing the ischiorectal fossa and waiting for hemostasis. Further discussion of hemorrhage during gynecologic surgery can be found separately. (See "Management of hemorrhage in gynecologic surgery".)

Postoperative pain or nerve dysfunction is likely due to injury to the branches of the sciatic nerve that cross the sacrospinous ligament, based on anatomic studies in cadavers [133]. If the sciatic nerve is entrapped in the suture, the classic triad of nerves entrapment will present (paresthesias, pain, temporary relief with injection of local anesthetic). The patient typically awakens with severe buttock pain radiating down the posterior leg. Delay in diagnosis and treatment can result in permanent neuropathy; therefore, as noted above, regional anesthesia of prolonged duration should not be used for this type of surgery. Upon diagnosis of nerve entrapment, the patient should be taken back to the operating room immediately to have the sutures removed.

The effect of SSLS on sexual function has not been well studied. Many studies have not evaluated this outcome and some women who undergo apical prolapse repair are not sexually active [108]. The rate of dyspareunia was 36 percent in pooled data from three randomized trials in which SSLS was compared with ASC [28] (see 'Abdominal versus vaginal approach' above). By contrast, observational studies have reported dyspareunia in 3 to 10 percent of women who underwent SSLS [108].

Uterosacral ligament suspension — ULS has increased in popularity. The uterosacral ligaments are thought to be one of the main connective tissue supports for the upper vagina.

Procedure — This procedure is typically performed transvaginally, but it can also be done laparoscopically. The uterosacral ligaments are made of smooth muscle, connective tissue, and nerves. They originate from the S1 to S4 vertebrae to insert near the cervix (figure 10).

The key to successful ULS is simultaneous correction of all defects in the apical endopelvic fascia. The anterior and posterior vaginal muscularis [134] near the apex should be directly approximated to ensure the continuity of the vaginal muscularis.

In the most commonly performed ULS technique, the anterior and posterior vaginal walls are opened in the midline; the enterocele sac is identified, if present [135]. The peritoneal cavity is entered and the uterosacral ligaments identified. An Allis clamp can be used to tent the uterosacral ligament, making it easier to identify. The rectum is retracted medially.

Two or three permanent sutures are passed through the uterosacral ligament on each side. These are placed 1.5 centimeters medial and 1.5 centimeters posterior to the ischial spine. The sutures are numbered sequentially with labeled Kelly clamps, one through six, to facilitate vaginal placement. In serial fashion, one arm of each suture is passed through the anterior muscularis surrounding the vaginal apex and the other through the posterior endopelvic fascia. The sutures thereby cross the width of the vaginal apex. All sutures are then tied, re-approximating the anterior and posterior vaginal muscularis, closing any potential enterocele defect, and elevating the vaginal apex toward the sacrum.

Retrospective chart review of 248 procedures found that 1 percent with permanent sutures had loss of support beyond the hymen versus 6 percent in delayed absorbable group [136].

Avoiding or detecting ureteral injury — The average distance from the lateral aspect of the suspension sutures to the medial border of the ureters was 14 mm in a cadaver study [137]. Cystoscopy should be performed after tying the sutures due to a significant rate of ureteral kinking during this procedure.

Avoiding nerve entrapment — Cadaveric studies suggest a higher risk of sacral nerve entrapment when uterosacral sutures are placed using a deep, dorsal, posterior technique and suggest that sacral nerve injury may be minimized by tenting the ligament ventrally prior to placing sutures [138].

Outcome — A meta-analysis of 10 observational studies evaluated ULS in 930 women; a successful anatomic outcome was defined as POP-Q stage 0 or 1 [139]. The rates of a successful outcome for each compartment were apical (98 percent), anterior (81 percent), and posterior (87 percent). Meta-analysis of subjective outcomes was not possible due to methodologic differences across studies; relief of prolapse symptoms was reported by 82 to 100 percent of patients (this outcome was only reported by five studies). Reoperation for symptomatic prolapse was reported in 9 percent of women (reported by four studies). A large multicenter trial reported success rates at five years to be less promising [105]. Objective failure at five years was 47.5 percent, and subjective failure (bulge symptoms) was 37.4 percent. Twelve percent of women underwent retreatment for prolapse by five years.

Complications — Complications of ULS are uncommon. The meta-analysis described in the preceding section reported the following complications rates [139]:

●Ureteral obstruction – 1.8 percent

●Blood transfusion – 1.3 percent

●Pelvic organ injury – 0.4 percent

Ureteral obstruction is the most common complication. Cystoscopy should be done routinely at the completion of each case to prevent delayed recognition of ureteral injury. Ureteral kinking from the uterosacral suture is found during routine intraoperative cystoscopy in up to 11 percent of cases [140,141]. If both ureters do not efflux briskly, the most lateral suture (closest to the ureter) on that side should be removed. Typically, removing this suture is sufficient to restore brisk ureteral efflux without further sequelae, although ureteral injury requiring ureteroneocystostomy has been reported. (See "Diagnostic cystourethroscopy (cystoscopy) for gynecologic conditions", section on 'Indications'.)

The sacral nerves can be ligated if ULS sutures are placed lateral to the ligament fibers or too deep into the pelvic sidewall [137,142,143]. In a retrospective case series, 7 of 182 women who had undergone a ULS developed sensory neuropathy and pain in the S2 to S3 dermatomes immediately postoperatively [143]. Three of these women had reduction of pain when suspension sutures were removed within four days after surgery.

Iliococcygeus suspension — Iliococcygeus suspension is similar to the SSLS, but uses the iliococcygeus fascia over the levator plate instead of the sacrospinous ligament. Proposed advantages of the iliococcygeus suspension compared with SSLS are lower risks of anterior vaginal wall recurrence and injury to the pudendal neurovascular bundle, but these benefits remain unproven. There are few data regarding this procedure. In a case-control study of 128 women, one- to two-year follow-up, subjective success rates were similar for iliococcygeus suspension and SSLS (91 versus 94 percent), but objective success occurred significantly more frequently in women who underwent SSLS (53 versus 67 percent) [144]. Perioperative complications were similar for the two procedures. Some data suggest that vaginal length may be longer following iliococcygeus suspension compared with SSLS [145].

Vaginal mesh kits — Most vaginal mesh kits are no longer commercially available. (See "Transvaginal synthetic mesh: Use in pelvic organ prolapse".)

One systematic review of articles reporting outcomes of vaginal mesh procedures for apical prolapse concluded that vaginal mesh seemed to effectively cure apical POP; however, long-term anatomic and functional data were needed, as well as comparative studies to traditional POP repairs [146]. High complication rates were found with apical mesh procedures (up to 17.6 percent) with mesh exposure and dyspareunia most common. In contrast, authors of another systematic review of vaginal mesh procedures for POP concluded that there were insufficient data to determine efficacy of vaginal mesh procedures for apical POP [147]. This systematic review also found high complication rates associated with vaginal mesh placement, including graft exposure in up to 30 percent, urinary tract infections in up to 19 percent, and visceral injury in up to 3 percent. A randomized trial compared a total vaginal mesh procedure (Prolift; this device has now been removed from the market) with laparoscopic sacrocolpopexy [148]. At two-year follow-up, women in the sacrocolpopexy group had a significantly higher objective success rate (77 versus 43 percent) and a lower reoperation rate (5 versus 22 percent). This study was limited by methodologic issues. Safety issues regarding transvaginal placement of mesh or biografts are discussed in detail separately. (See "Transvaginal synthetic mesh: Use in pelvic organ prolapse".)

POSTOPERATIVE CARE — Postoperative care is similar for both vaginal and abdominal approaches. The postoperative course will also vary according to whether concomitant procedures were performed (eg, hysterectomy, surgery for stress urinary incontinence). We give patients standard instructions regarding postoperative pain control, bleeding, signs of infection, and gastrointestinal function. We advise no sexual intercourse for six weeks to avoid disruption of the repair. (See "Urogynecologic surgery: Perioperative care issues", section on 'Postoperative'.)

We see patients at two weeks postoperatively for routine follow-up. We perform a wound check and speculum examination. Few data are available to guide postoperative care and most recommendations are based on the surgeon's experience and preferences.

Routine discharge instructions can be found separately. (See "Patient education: Care after gynecologic surgery (Beyond the Basics)".)

Pelvic floor muscle training — Pelvic floor muscle training is often used as an initial treatment for POP or stress urinary incontinence (SUI). Many clinicians also advise patients to perform these exercises following pelvic floor reconstructive surgery. However, there is not high-quality evidence to support the efficacy of perioperative use. This was investigated in the Operations and Pelvic Muscle Training in the Management of Apical Support Loss (OPTIMAL) randomized trial (n = 374) that compared sacrospinous ligament suspension with uterosacral ligament suspension, as well as perioperative behavioral therapy with pelvic floor muscle training (BPMT) with usual care; behavioral therapy included education on behavioral strategies to reduce urinary and colorectal symptoms [104]. All participants also had SUI and underwent a concomitant retropubic midurethral sling procedure. BPMT compared with usual care did not result in a significant difference in urinary symptoms at six months or prolapse outcomes at two years.

The surgical outcomes of the trial are discussed in detail above.

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Pelvic organ prolapse" and "Society guideline links: Gynecologic surgery".)

SUMMARY AND RECOMMENDATIONS

●Definition and symptoms – Apical prolapse is the descent of uterus, cervix, or vaginal vault (figure 1). Common symptoms of apical prolapse are a vaginal bulge, difficulty voiding, or constipation. (See 'Anatomy and mechanisms of injury' above.)

●Surgical indications – Surgical candidates for apical prolapse include symptomatic women who have failed or declined conservative management. Prolapse is typically a chronic problem, and women often prefer surgery to conservative therapy since successful surgery does not require ongoing maintenance to control symptoms. (See 'Candidates for apical prolapse repair' above.)

●Abdominal sacrocolpopexy – Apical prolapse repair via sacrocolpopexy is more effective at restoring vaginal topography than traditional vaginal repairs, although subjective outcomes are similar after the two types of procedures. We suggest abdominal sacrocolpopexy (ASC) rather than transvaginal repair for most women undergoing apical prolapse repair (Grade 2C). (See 'Abdominal versus vaginal approach' above.)

•Laparoscopy rather than open surgery – Laparoscopic sacrocolpopexy is as effective as open sacrocolpopexy but results in decreased blood loss and shorter hospital stays. As a result, minimally invasive routes are preferred to open sacrocolpopexy in most patients. (See 'Laparoscopic or robotic procedures' above.)

•Mesh selection – For women with apical prolapse undergoing ASC, we recommend ultra-lightweight synthetic polypropylene mesh over biografts (Grade 1B). Synthetic mesh use in sacrocolpopexy reduces the risk of recurrent apical prolapse. (See "Transvaginal synthetic mesh: Use in pelvic organ prolapse".)

●Transvaginal surgery – A vaginal surgical approach is a reasonable alternative to an abdominal approach for women who cannot tolerate abdominal surgery, have no risk factors for prolapse recurrence (risk factors include young age, obesity, stage III or IV POP, previous failed POP repair), are having concomitant vaginal surgery, or have risk factors for mesh-related complications (eg, concomitant hysterectomy, smoking, immunosuppression, obesity). (See 'Abdominal versus vaginal approach' above and 'Choice of procedure' above.)

•Vaginal procedures – Transvaginal apical repair procedures include sacrospinous ligament suspension and uterosacral ligament suspension. The efficacy of these two procedures appears comparable, but each procedure is associated with different risks of complications. (See 'Choice of procedure' above.)

●Concomitant continence surgery – For women undergoing repair of apical prolapse, a concomitant continence procedure is often performed to treat or prevent stress urinary incontinence. Midurethral slings are the preferred concomitant procedure if a vaginal route is used for prolapse repair; some surgeons also place a midurethral sling at the time of ASC. (See 'Concomitant surgery for stress urinary incontinence' above.)

For women undergoing Burch colposuspension, we suggest a laparoscopic rather than open approach (Grade 2A). Open colposuspension should be performed if the surgeon is not experience in the laparoscopic technique for this procedure. (See 'Concomitant Burch colposuspension' above.)