Apical Prolapse

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Apical Prolapse

• Dr Samera F.AlBasri

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Overview

• Apical prolapse is one type of POP and refers to
  the downward displacement of the vaginal apex.
• Support of the vaginal apex is primarily derived
  from the integrity of the Uterosacral and
  cardinal ligaments, the continuity of the fibro
  muscular layer surrounding the vagina, and a
  neuromuscularly intact levator ani.
• 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 support defects of
  the anterior or posterior vaginal walls or an
  isolated apical defect since the defects in the
  connective tissue, neural pathways, and muscle
  are not confined to one small site Therefore, if
  an anterior or posterior prolapse is diagnosed,
  one should examine the patient carefully
  (preferably standing) to ensure that a
  concomitant apical defect is not present as well.
  
• Many experts believe that adequate suspension of
  the apex is the cornerstone of any successful
  prolapse repair. If the vaginal muscularis is
  intact and well suspended at the apex, many
  anterior and posterior defects will also resolve
• The most common risk factors for developing
  prolapse are vaginal delivery and previous
  hysterectomy
• The incidence of surgical repair for apical
  prolapse is increased in any woman who has had a
  prior hysterectomy, and even further increased in
  women who have had a hysterectomy for prolapse
  Therefore, some type of apical suspension should
  be done at the time of every hysterectomy.

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CLINICAL MANIFESTATIONS 

• The most common symptom of clinically significant
  apical prolapse is a protrusion of tissue from
  the vaginal opening.
• . Women with prolapse may also report a sensation
  of pelvic pressure, voiding difficulty, a need to
  splint to urinate or defecate, bowel symptoms,
  and pelvic or low back pain.
• The prolapsed vagina may protrude on standing,
  leading to chronic discharge and bleeding from
  chronic ulceration. Rare cases of vaginal
  evisceration have been reported in prolapse that
  has been chronically neglected.
• Traditionally, experts believed that these
  symptoms became progressively worse as the
  prolapse gradually increased over time.
• Several well-designed studies have shown that low
  back and pelvic pain are not associated with
  prolapse and that many pelvic floor symptoms,
  particularly bowel symptoms, do not increase with
  advanced stage prolapse

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DIAGNOSIS AND PREOPERATIVE EVALUATION 

• History   
• Women with symptomatic apical prolapse should
  undergo a careful history which focuses on
  related pelvic floor symptoms, given that pelvic
  floor disorders rarely occur in isolation.
• They should be questioned about concomitant
  urinary incontinence, voiding difficulties, fecal
  incontinence, and defecatory problems.
• Since prolapse is a quality of life disorder, it
  is also essential to determine which symptoms are
  most bothersome to the individual patient and to
  tailor a treatment plan accordingly

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DIAGNOSIS AND PREOPERATIVE EVALUATION

• Physical examination 
•  
• A thorough speculum and bimanual examination
  should be done.
• 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. It is often helpful to use
  half of the speculum, placed posteriorly to
  examine the anterior wall and apex, then placed
  anteriorly to examine the posterior wall.
• The anterior vaginal wall is frequently the most
  prolapsed vaginal segment, even in women with
  apical prolapse. It is important to identify the
  position of the apex.
• Women should also be examined in the standing
  strain position to maximize the prolapse and aid
  in identification of other defects in pelvic
  support that will require concomitant repair.
  Theoretically, an operation that corrects all
  existing defects may decrease the likelihood that
  a subsequent operation will be necessary
• The findings of the examination should be
  recorded using a quantitative and reproducible
  method for recording pelvic organ prolapse.
• The system currently recommended by the
  International Continence Society and the American
  Urogynecologic Society is the Pelvic Organ
  Prolapse Quantification (POP-Q) system

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DIAGNOSIS AND PREOPERATIVE EVALUATION
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DIAGNOSIS AND PREOPERATIVE EVALUATION

• Evaluation for urinary dysfunction 
•  
• Apical prolapse frequently coexists with lower
  urinary tract dysfunction urinary incontinence
  and urinary retention are common, so a thorough
  apical prolapse evaluation should assess for
  both.
• Urinary retention can be evaluated by checking a
  post void residual urine volume (PVR) within 10
  minutes of the patient voiding. In general, a PVR
  of less than 50 mL is considered adequate
  emptying, and a PVR greater than 200 mL is
  considered inadequate. Ninety percent of elevated
  post-void residual urine volumes normalize after
  surgical correction of prolapse.
• Many women with advanced apical prolapse remain
  continent despite loss of anterior vaginal and
  bladder/urethral support. However, 8 to 40
  percent of continent women develop symptoms of
  stress urinary incontinence after
• surgical correction of the prolapse.
• Urethral pressure measurements and
  electromyography performed during urodynamics in
  women with advanced prolapse suggest that the
  prolapse "kinks" or obstructs the urethra, thus
  maintaining continence.
• Therefore, to identify "occult" or "potential"
  stress incontinence, all women with apical
  prolapse should have a preoperative evaluation of
  stress continence with the prolapse reduced. In
  addition, all women having surgical
• correction of prolapse should be counseled
  regarding the potential for postoperative
  incontinence.
• In a large randomized trial, the Colpopexy and
  Urinary Reduction Efforts (CARE) trial, stress
  continent women with stage II to IV apical
  prolapse underwent preoperative urodynamics
  testing . When testing was performed without
  reduction of the prolapse, only 3.7 of
  participants exhibited SUI. Women who had SUI
  with prolapse reduction prior to surgery and then
  underwent sacral colpopexy alone (without
  concomitant incontinence surgery), had a
  significantly increased risk of postoperative
  SUI. The results of different methods of prolapse
  reduction (manual, pessary, speculum, swab,
  forceps) were variable a swab was the method
  most likely to predict postoperative stress
  incontinence, and a pessary was the least likely

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OPTIONS FOR SURGICAL THERAPY 

• Colpocleisis 
•  
• Women who do not desire future vaginal
  intercourse and/or are in poor general health may
  consider an obliterative procedure, such as
  Colpocleisis.
• Colpocleisis is highly effective with low
  morbidity for correcting apical prolapse in such
  women
• Procedure

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Colpocleisis 

• The procedure is performed under general or
  spinal anesthesia and can be done with the uterus
  in situ or after hysterectomy
• . Concomitant hysterectomy at the time of
  Colpocleisis increases morbidity without
  improving surgical success
• Using sharp and blunt dissection, the vaginal
  epithelium is dissected from the underlying
  muscularis. A total Colpocleisis removes all of
  the vaginal epithelium, while a partial
  Colpocleisis leaves a small portion of vaginal
  epithelium on each side to provide drainage
  tracts in women with a uterus
• The leading edge of the prolapse is identified
  and successive interrupted sutures are used to
  reduce the prolapse until it lies above the
  levator plate, effectively obliterating the
  vaginal canal. Care should be taken not to pull
  the posterior urethra down when suturing the
  anterior and posterior vagina.
• Finally, a wide perineorrhaphy is created by
  removing a large diamond shaped area of perineal
  skin and distal vaginal epithelium. The levator
  muscles are then approximated with non-absorbable
  sutures. The area from above the rectum to the
  urethrovesical junction should be closed

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Colpocleisis 

• Complications
• Significant postoperative complication rates
  occur in approximately 2 percent of patients and
  are frequently attributed to the older age and
  frail condition of patients selected for this
  procedure.
• Transfusion is the most commonly reported major
  complication related to the surgery itself.
• Some women develop stress urinary incontinence
  after Colpocleisis, which, as described, is
  likely secondary to "un-kinking" the urethra.
• Optimal management of potential stress
  incontinence is unclear. Most women choose
  Colpocleisis for its simplicity and quick
  recovery and wish to avoid the morbidity of an
  additional major continence procedure.
• Performance of a minimally invasive mid-urethral
  sling may be appropriate in these cases however,
  the role of this procedure at the time of
  Colpocleisis has not been studied.

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OPTIONS FOR SURGICAL THERAPY

• Vaginal versus abdominal procedures  
• In women who desire a reconstructive procedure,
  route of access should be determined based on
  risks, benefits, and complications of abdominal
  and vaginal surgery, as well as the use of
  synthetic meshes.
• This may be the most controversial area in the
  treatment of apical prolapse, subject to debate
  amongst experts with ample evidence from
  observational studies supporting both sides.
• In the past, gynecologic surgeons favored the
  vaginal approach for its low complication rates
  and quick recovery however, abdominal routes
  have gained popularity more recently
• Evidence from randomized trials has demonstrated
  that abdominal repairs are more durable, while
  vaginal repairs have fewer complications,
  including foreign body complications.
• Choosing a vaginal or abdominal route to correct
  apical prolapse must be individualized based on
  patient expectations, goals, and wishes. While
  the abdominal route seems to have increased
  durability, it comes at the expense of a longer
  recovery period and possibly more complications.
• A younger, active woman may choose the higher
  success of abdominal sacrocolpopexy, accepting
  the longer recovery and potential for foreign
  body erosion. In contrast, a frail, elderly woman
  may opt for a higher chance of recurrence in
  exchange for a quicker return to her daily
  activities
• Given these data, recommendations regarding
  surgical approach among pelvic surgeons differ
  dramatically based on their own experiences and
  biases

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VAGINAL APICAL SUSPENSION PROCEDURES 

• Sacrospinous ligament suspension
•  Sacrospinous ligament suspension is the
  best-studied vaginal procedure for treating
  apical prolapse. Anatomic cure rates after
  Sacrospinous ligament suspension range from 63
  to 97 percent.
• The failure rate is relatively low when the
  procedure is performed for apical prolapse 2 to
  11 percent, depending on criteria for failure,
  but is high when performed for anterior vaginal
  wall prolapse 4 to 40 percent.
• . Therefore, women with large anterior wall
  defects in addition to apical defects may benefit
  from another type of prolapse repair, which more
  directly addresses the anterior vagina.
• Randomized trials have shown that Sacrospinous
  ligament suspension is slightly inferior to
  abdominal sacrocolpopexy in anatomic restoration,
  but results in similar patient satisfaction
• Procedure
• Sacrospinous ligament suspension is generally
  performed unilaterally. Some surgeons have
  proposed bilateral Sacrospinous ligament
  suspension, although the value of this
  modification has not been proven
• . The bilateral technique depends upon adequate
  vaginal length and depth
• Am J Obstet Gynecol 1996 and 2004

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Cont. Sacrospinous ligament suspension

• Before starting the procedure, the surgeon must
  ensure that the vagina is long enough to reach
  the Sacrospinous ligament without a suture bridge
  since a vagina shortened from previous vaginal
  surgery may preclude Sacrospinous ligament
  suspension.
• Marking sutures are placed on the vaginal
  epithelium at the site where it is going to
  attach to the ligament.
• The posterior vagina is opened in the midline
  from the perineal body to the apex.
• The vaginal epithelium is then separated from the
  underlying muscularis and the dissection
  continued to the level of the ischial spine.
• The rectovaginal space is opened by gently
  pushing the rectum medially, and the rectal
  pillar is perforated.
• Once the perirectal space is entered, the ischial
  spine can be palpated and the ligament can be
  found medially.
• A long right angle retractor, e.g.,
  Briesky-Navratil, is placed on the ischial spine
  to protect the pudendal neurovascular bundle and
  another is used to retract the bladder superiorly
  and the rectum medially.
• Once the ligament is clearly visible, two to
  three permanent sutures are placed through the
  ligament approximately one and one-half
  finger-breadths medial to the ischial spine.
• Several techniques and devices are available to
  assist placing the suture through the ligament
  (Miya hook, Deschamps ligature carrier).
• 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.
• A common modification of this technique is the
  "Michigan Modification
• . In the Michigan Modification, all four vaginal
  walls are directly approximated to the
  Sacrospinous ligament (instead of just the
  posterior vaginal wall), theoretically decreasing
  the risk of anterior vaginal wall recurrence. The
  point on each vaginal wall that reaches the
  ligament is identified and the intervening vagina
  excised. The sutures are placed through the
  Sacrospinous ligament, as described above, then
  sewn to the anterior and posterior vagina and
  tied to the ligament.

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Cont. Sacrospinous ligament suspension

• Complications
• Complications after Sacrospinous ligament
  suspension are uncommon. Intraoperative
  hemorrhage from laceration of the pudendal
  vessels is the most frequent complication.
  Pudendal hemorrhage is best treated by tightly
  packing the ischiorectal fossa and waiting for
  homeostasis to occur. Cystotomy and enterotomy
  are rarely reported.
• Injury to the branches of the sciatic nerve that
  cross the coccygeus muscle-Sacrospinous ligament
  complex (C-SSL) is another possible source of
  postoperative pain or nerve dysfunction. One
  approach to decrease nerve entrapment is to
  perforate the Sacrospinous ligament with the
  needle in a vertical rather than a horizontal
  orientation
• However, if the sciatic nerve is entrapped in the
  suture despite careful surgical technique, the
  classic triad of sciatic entrapment occurs. The
  patient typically awakens with severe buttock
  pain radiating down the posterior leg. Delay in
  diagnosis and treatment can result in permanent
  neuropathy therefore, regional anesthesia of
  prolonged duration should not be used for this
  type of surgery and the patient should be taken
  back to the operating room immediately upon
  diagnosis to have the sutures removed.
• Postoperative bowel complications are rare as the
  procedure is meant to be extra peritoneal.

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Iliococcygeus suspension 

• Iliococcygeus suspension is performed similar to
  the Sacrospinous colpopexy, but uses the
  Iliococcygeus fascia over the levator plate
  instead of the Sacrospinous ligament. The
  literature on this operation is sparse however,
  subjective success rates appear to be similar for
  Sacrospinous and Iliococcygeus suspensions, while
  objective success after Sacrospinous ligament
  suspension is 14 higher than after Iliococcygeus
  suspension
• reported advantages of the Iliococcygeus
  suspension include less frequent anterior vaginal
  wall recurrence and injury to the pudendal
  neurovascular bundle, although these benefits are
  not supported by any data.
• Complications are similar to those described
  above for Sacrospinous ligament suspension.

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Uterosacral ligament suspension  

• Procedure
• The key to successful Uterosacral ligament
  suspension is simultaneous correction of all
  defects in the apical endopelvic fascia. In the
  most commonly performed modification of the
  Uterosacral ligament suspension , the anterior
  and posterior vaginal walls are opened in the
  midline and the enterocele sac identified. 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
• Three permanent sutures are placed 1.5
  centimeters medial and 1.5 centimeters posterior
  to the ischial spine through the Uterosacral
  ligament on each side
• The sutures are numbered sequentially, 1 through
  6, to facilitate vaginal placement. One arm of
  each permanent suture is placed through the
  anterior endopelvic fascia and the other through
  the posterior endopelvic fascia. The sutures are
  placed serially across the width of the vaginal
  apex. All sutures are then tied, re-approximating
  the anterior and posterior endopelvic fascia,
  closing any potential enterocele defect, and
  elevating the vaginal apex toward the sacrum
• Cystoscopy should be performed after tying the
  sutures due to a significant rate of ureteral
  kinking during this procedure

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Uterosacral ligament suspension
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Uterosacral ligament suspension Cont

• Complications
• Intra and postoperative complications after
  Uterosacral suspension are uncommon. Routine
  Cystoscopy should be done at the completion of
  each case before the patient leaves the operating
  room to prevent delayed recognition of ureteral
  injuries. Ureteral kinking from the Uterosacral
  suture is found during routine Intraoperative
  Cystoscopy in up to 11 percent of cases. 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 uretero-neocystectomy
  has been reported
• The sacral nerves can be ligated if Uterosacral
  ligament suspension sutures are placed lateral to
  the ligament fibers or too deep into the pelvic
  sidewall.

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Abdominal sacral colpopexyLaparoscopy and
Laparotomy  

• Abdominal sacral colpopexy is the most durable
  apical prolapse procedure
• The most common procedure is sacral colpopexy
  (attachment between the sacral promontory and the
  upper vagina) sacral hysteropexy (attachment
  between the sacral promontory and the lower
  uterus) and sacral cervicopexy (attachment
  between the sacral promontory and the cervix) are
  uncommon
• Anatomic success rates after sacral colpopexy
  range from 76 to 100
• Am J Obst Gynecol 2002

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sacral colpopexy
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Abdominal sacral colpopexy Laparoscopy and
Laparotomy  

• Procedure
• Abdominal sacral colpopexy involves attaching a
  permanent mesh to the anterior and posterior
  vagina, and then attaching the free end of the
  mesh to the anterior longitudinal ligament of the
  sacrum, which reestablishes a somewhat horizontal
  vaginal axis . A commonly performed technique is
  to carefully open the presacral space and expose
  the anterior longitudinal ligament of the sacrum.
  
• Two or three permanent sutures are placed through
  the anterior longitudinal ligament just below the
  promontory when sutures are placed lower on the
  sacrum, at the S3 to S4 level, presacral
  hemorrhage is more common.
• Next, a permanent mesh is attached to the
  posterior vagina to the level of the rectal
  reflection and to the anterior vagina for a
  distance of several centimeters. Two rows of
  permanent sutures should be used to widely attach
  the mesh to the vagina to distribute the tension.
  
• The free end of the mesh is attached to the
  anterior longitudinal ligament using the
  previously placed sutures. Failure to attach the
  mesh anteriorly results in anterior vaginal wall
  recurrence rates of almost 30 .
• prophylactic Burch colposuspension should be
  performed at the time of abdominal sacrocolpopexy
  in women without preoperative symptoms of stress
  incontinence

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Abdominal sacral colpopexy Laparoscopy and
Laparotomy  

• Complications
• Cystotomy (3.1 percent), enterotomy (1.6
  percent), incisional problems (4.6 percent),
  ileus (3.6 percent), thromboembolic event (3.3
  percent), and transfusion (4.4 )
• . Presacral hemorrhage is the most concerning
  intra-operative complication and can have
  life-threatening consequences. The presacral
  plexus of veins and the middle sacral artery can
  be lacerated during the presacral dissection,
  particularly if done at the S3-S4 level.
  Reconstructive surgeons should be prepared to
  manage presacral hemorrhage and have bone wax,
  concave thumbtacks, and thrombin immediately
  available.

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POSTOPERATIVE CARE 

• Postoperative care is similar regardless of
  surgical approach. However, recovery after sacral
  colpopexy may be slower due to the abdominal
  incision. Few data are available to guide
  postoperative care and most recommendations are
  based on the surgeon's experience and preferences
• Ambulation The woman can begin walking with
  assistance as soon as the day of surgery
• Diet Women undergoing vaginal approaches can
  frequently tolerate oral intake the evening of
  surgery, and those having abdominal surgery the
  morning after surgery
• Bladder drainage The urinary catheter placed
  preoperatively is left in place postoperatively
  as women frequently cannot empty their bladders
  immediately after pelvic and/or vaginal surgery,
  particularly if a concomitant continence
  procedure was done. The catheter can be removed
  on the first postoperative day in the absence of
  an intra-operative bladder injury, but a
  post-void residual urine volume should be checked
  to ensure complete bladder emptying. Continuous
  bladder drainage is not required
• Lifting Most surgeons place some lifting
  restrictions on patients after surgery, although
  these range dramatically from surgeon-to-surgeon.
  It is probably reasonable to suggest a moderate
  short-term lifting restriction, such as 10 pounds
  for two weeks, then resume-lifting activities as
  tolerated. This area has not been examined
  extensively, with a notable exception. One study
  found that there was no greater increase in
  intra-abdominal pressure with lifting 20 to 35
  pounds or doing jumping jacks than simply rising
  from a chair . Satisfaction after surgery
  correlates with patient goal achievement, many of
  which are related to life-style, thus long-term
  lifting restrictions are probably not necessary
  or advisable
• Nothing should be placed in the vagina (tampons,
  coitus) until complete healing occurs, typically
  in three to four weeks
• Return to normal activities Patients may resume
  normal activity (including sports) and return to
  work when they are no longer experiencing pain or
  fatigue related to surgery. A postoperative
  examination should be performed to ensure
  complete healing and assess outcome of the repair

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• Thank you