What are the treatment options for vaginal apex descent?

Treatment Options for Vaginal Apex Descent

For vaginal apex prolapse, laparoscopic or robotic sacrocolpopexy with mesh is the recommended surgical approach when intervention is indicated, as it demonstrates superior outcomes compared to vaginal procedures in terms of lower recurrence rates, reduced awareness of prolapse, and decreased need for repeat surgery. 1

When to Offer Treatment

Surgery should be offered when: 1

• Conservative options fail to meet patient expectations
• Symptoms are disabling and directly related to the prolapse
• Prolapse is stage 2 or greater on physical examination

Treatment Algorithm

Step 1: Conservative Management

For patients not ready for surgery or with minimal symptoms: 2

• Observation - appropriate for patients with minimal bother or not interested in active intervention
• Pelvic floor muscle training - formal referral is more beneficial than self-directed Kegel exercises 3
• Continence pessary - effective non-surgical option for those medically unfit for surgery or declining surgical intervention 2

Step 2: Surgical Intervention Selection

Primary Recommendation: Sacrocolpopexy

Sacral colpopexy (abdominal approach with mesh) is superior to vaginal procedures based on the following evidence: 4

• Awareness of prolapse: 2.11 times more common after vaginal procedures (7% after sacrocolpopexy vs 14% after vaginal procedures)
• Repeat surgery for prolapse: 2.28 times more likely after vaginal procedures (4% vs 5-18%)
• Recurrent prolapse on examination: 1.89 times more common after vaginal procedures (23% vs 41%)
• Stress urinary incontinence: 1.86 times more common after vaginal procedures
• Dyspareunia: 2.53 times more common after vaginal procedures

Minimally invasive approach (laparoscopic/robotic) should be prioritized over open sacrocolpopexy, as robotic and laparoscopic techniques demonstrate equal efficacy with the advantage of smaller incisions, though they are associated with longer operative times (median 174-192 minutes vs 95-127 minutes for vaginal approaches). 3, 5

Alternative: Vaginal Procedures

Vaginal approaches should be considered when: 3

• Patient declines laparotomy
• Patient is not a candidate for minimally invasive surgery
• Medical comorbidities preclude longer operative times

Specific vaginal techniques include: 4

• Uterosacral ligament suspension - equal efficacy to sacrospinous ligament suspension at 1 year
• Sacrospinous ligament suspension - acceptable alternative to sacrocolpopexy

Step 3: Mesh Considerations

For vaginal procedures, mesh augmentation is NOT recommended based on current evidence: 4

• No clear benefit in reducing recurrent prolapse (RR 0.36,95% CI 0.09-1.40, with serious inconsistency)
• No difference in awareness of prolapse or repeat surgery rates
• Most evaluated transvaginal meshes are no longer available
• National trends show decreased use of mesh-augmented vaginal suspensions over time 5

For sacrocolpopexy, mesh use is standard and recommended. 1, 4

Critical Assessment Requirements

Before surgery, ensure comprehensive evaluation: 1, 6

• Multi-compartment assessment - lateral vaginal wall defects often coexist with apical prolapse
• Levator muscle integrity evaluation - defects predict surgical recurrence and should influence surgical planning
• Imaging when indicated - transperineal ultrasound preferred for detecting levator muscle avulsion; MR defecography for comprehensive multi-compartment evaluation 1, 6

Common Pitfalls to Avoid

• Failing to assess all pelvic compartments - multi-compartment involvement is common, particularly with lateral wall defects 1
• Overlooking levator muscle defects - these predict surgical recurrence and require long-term monitoring 1
• Using transvaginal mesh without clear indication - current evidence does not support routine use 4
• Choosing vaginal approach in younger patients - older age is predictive of vaginal route selection, but younger patients may benefit more from the durability of sacrocolpopexy 5

Special Populations

For patients with uterine prolapse: 4

• Limited evidence comparing hysterectomy versus uterine-preserving surgery
• One RCT found awareness of prolapse was less likely after hysterectomy than abdominal sacrohysteropexy (RR 0.38)
• Decision should incorporate patient preference regarding uterine preservation

Postoperative Considerations

Long-term follow-up is essential: 1

• Monitor for recurrence, particularly in patients with levator defects
• Continued surveillance by primary care or specialist physician
• Operative time for sacrocolpopexy is longer (174-192 minutes) but complication rates are equivalent to vaginal approaches 5