What are the surgical options for pelvic organ prolapse?

From the Guidelines

Surgical options for pelvic organ prolapse include both reconstructive and obliterative procedures, with the choice of surgery depending on several factors including the patient's age, sexual activity status, desire for future pregnancies, severity of prolapse, previous surgeries, and overall health. Reconstructive surgeries aim to restore normal anatomy and include vaginal approaches such as anterior colporrhaphy for cystocele repair, posterior colporrhaphy for rectocele repair, and vaginal vault suspension procedures like sacrospinous ligament fixation 1. Abdominal approaches include sacrocolpopexy, which uses mesh to suspend the vaginal apex to the sacrum, providing excellent long-term support. Obliterative procedures like colpocleisis close off the vaginal canal and are typically reserved for older women who are no longer sexually active. Minimally invasive techniques including laparoscopic and robotic approaches offer the benefits of smaller incisions, less pain, and faster recovery while achieving similar outcomes to open procedures.

Some key considerations in choosing a surgical approach include:

• The patient's age and surgical risk
• Coexisting functional symptoms (including incontinence or constipation)
• Surgeon’s familiarity with a particular surgical approach 1
• The need for future pregnancies
• The severity of the prolapse
• Previous surgeries
• Overall health

Recovery typically requires 6-8 weeks of restricted activity with avoidance of heavy lifting (nothing over 10 pounds), and pelvic floor physical therapy is often recommended post-operatively to strengthen supporting muscles and improve long-term outcomes. The goal of any treatment strategy is to improve the patient’s quality of life, because the condition primarily causes morbidity but is not life threatening 1.

In terms of specific procedures, some options include:

• Anterior colporrhaphy for cystocele repair
• Posterior colporrhaphy for rectocele repair
• Vaginal vault suspension procedures like sacrospinous ligament fixation
• Sacrocolpopexy
• Colpocleisis
• Laparoscopic and robotic approaches

It's worth noting that the debate about the optimal approach continues, and there is no agreement in literature whether the abdominal approach is better than the perineal one, or vice-versa 1. However, the choice of surgery should be individualized to each patient's specific needs and circumstances.

From the Research

Surgical Options for Pelvic Organ Prolapse

The surgical options for pelvic organ prolapse (POP) can be categorized into two main types: obliterative and reconstructive surgery 2. The choice of surgical approach depends on various factors, including the patient's health status, goals, and desired outcomes.

Obliterative Surgery

• Obliterative surgeries, such as colpocleisis, result in an inability to have sexual intercourse postoperatively 2.
• This type of surgery is often used for patients who are not sexually active or who have a high risk of recurrence.
• Colpocleisis has been shown to have a low risk of recurrence, but it is not suitable for all patients 2.

Reconstructive Surgery

• Reconstructive procedures, such as sacrospinous ligament fixation (SSLF) and uterosacral vaginal vault suspension (USVS), aim to preserve vaginal length and function 2.
• These procedures can be performed through vaginal or abdominal approaches.
• Abdominal sacrocolpopexy (ASC) is a reconstructive procedure that has been shown to have a distinct advantage over vaginal approaches in terms of symptom recurrence, sexual function, and quality of life 2.

Other Surgical Options

• Sacrocolpopexy is considered a reference operation for pelvic organ prolapse repair, but its indications and technical aspects are not standardized 3.
• Uterosacral ligament suspension and sacrospinous ligament fixation are other surgical options for POP repair 4.
• Anterior and posterior prolapse procedures, such as anterior vaginal repair and posterior vaginal repair, can also be used to treat POP 4.

Factors to Consider

• Patient age, health status, and lifestyle should be taken into account when choosing a surgical approach 5.
• The patient's expectations and goals should also be considered, as different approaches can result in different outcomes in terms of sexual function and quality of life 2, 5.
• The surgeon's experience and expertise in performing the procedure should also be considered 5.