Guideline No. 413: Surgical Management of Apical Pelvic Organ Prolapse in Women

Abstract

Objective

To compare success and complication rates of apical suspension procedures for the surgical management of symptomatic uterine or vaginal vault prolapse.

Target population

Women with symptomatic uterine or vaginal vault prolapse seeking surgical correction.

Options

Interventions included abdominal apical reconstructive repairs (sacrocolpopexy, sacrohysteropexy, or uterosacral hysteropexy) via open, laparoscopic, or robotic approaches; vaginal apical reconstructive repairs (vault suspensions or hysteropexy, sacrospinous, uterosacral, iliococcygeus, McCall's, or Manchester types); and vaginal obliterative procedures (with or without uterus in situ). Individual procedures or broad categories of procedures were compared: (1) vaginal versus abdominal routes for reconstruction, (2) abdominal procedures for reconstruction, (3) vaginal procedures for reconstruction, (4) hysterectomy and suspension versus hysteropexy for reconstruction, and (5) reconstructive versus obliterative options.

Outcomes

The Urogynaecology Committee selected outcomes of interest: objective failure (obtained via validated pelvic organ prolapse [POP] quantification systems and defined as overall objective failure as well as failure rate by compartment); subjective failure (recurrence of bulge symptoms determined subjectively, with or without use of a validated questionnaire); reoperation for POP recurrence; complications of postoperative lower urinary tract symptoms (de novo or postoperative stress urinary incontinence; reoperation for persistent, recurrent, or de novo stress urinary incontinence; urge urinary incontinence; and voiding dysfunction); perioperatively recognized urinary tract injury (bladder or ureter); other complications (mesh exposure, defined as mesh being visible and exposed in the vagina, and non-sexual pelvic pain); and sexual function (de novo dyspareunia and sexual function score according to a validated questionnaire).

Benefits, harms, and costs

This guideline will benefit patients seeking surgical correction of apical POP by improving counselling on surgical treatment options and possible outcomes. It will also benefit surgical providers by improving their knowledge of various surgical approaches. Data presented could be used to develop frameworks and tools for shared decision-making.

Evidence

We searched Medline, the Cochrane Central Register of Controlled Trials (CENTRAL), and Embase from 2002 to 2019. The search included multiple terms for apical POP surgical procedures, approaches, and complications. We excluded POP repairs using transvaginal mesh and studies that compared procedures without apical suspension. We included randomized controlled trials and prospective or retrospective comparative studies. We limited language of publication to English and French and accessibility to full text. A systematic review and meta-analysis was performed.

Validation methods

The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and weak recommendations).

Intended users

Gynaecologists, urologists, urogynaecologists, and other health care providers who assess, counsel, and care for women with POP.

SUMMARY STATEMENTS

All statements refer to correction of apical vaginal prolapse in the short and medium term (up to 5 years), except when otherwise specified.

• 1Vaginal suture suspension to various pelvic ligaments was inferior to abdominal sacrocolpopexy (any route) with synthetic mesh for the outcomes of
• •overall objective failure (moderate)
• •objective apical failure (moderate)
• 2Vaginal suture suspension to various pelvic ligaments was similar to abdominal sacrocolpopexy (any route) with synthetic mesh for the outcomes of
• •objective anterior failure (moderate)
• •objective posterior failure (moderate)
• •subjective awareness of pelvic organ prolapse recurrence (moderate)
• •reoperation for pelvic organ prolapse recurrence (moderate)
• •intraoperative bladder and ureteric injuries (low)
• •postoperative lower urinary tract symptoms (low)
• 3Vaginal suture suspension to various pelvic ligaments was not associated with a risk of mesh exposure compared with abdominal sacrocolpopexy (any route) with synthetic mesh, which is associated with a 2.7% to 3.4% risk of mesh exposure (moderate).
• 4Open abdominal sacrocolpopexy was inferior to minimally invasive (laparoscopic or robotic) sacrocolpopexy for the outcomes of
• •overall objective failure (low)
• •objective posterior failure (low)
• 5Open abdominal sacrocolpopexy was similar to minimally invasive (laparoscopic or robotic) sacrocolpopexy for the outcomes of
• •objective anterior failure (low)
• •subjective awareness of pelvic organ prolapse recurrence (moderate)
• •reoperation for pelvic organ prolapse recurrence (moderate)
• •intraoperative bladder injuries (moderate)
• •reoperation for stress urinary incontinence (low)
• •mesh exposure (moderate)
• 6Various minimally invasive sacrocolpopexy approaches (laparoscopic or robotic) showed similar risk of
• •subjective awareness of pelvic organ prolapse recurrence (very low)
• •intraoperative bladder injury (moderate)
• •postoperative stress urinary incontinence (very low)
• •mesh exposure (moderate)
• 7There are insufficient data comparing urge urinary incontinence and voiding dysfunction risk after open abdominal and minimally invasive sacrocolpopexy and among various approaches to minimally invasive sacrocolpopexy (very low).
• 8Uterosacral ligament suspension and sacrospinous fixation showed similar risk of
• •objective failure rates (overall and by compartment) (moderate)
• •subjective awareness of pelvic organ prolapse recurrence (moderate)
• •reoperation for pelvic organ prolapse recurrence (moderate)
• •intraoperative bladder injury (moderate)
• •reoperation for stress urinary incontinence (moderate)
• 9Uterosacral ligament suspension compared with sacrospinous fixation showed a higher risk of
• •intraoperative ureteric injury (moderate)
• 10Hysterectomy and suspension versus hysteropexy (by any route) were similar for the outcomes of
• •overall objective failure (low)
• •objective anterior failure (low)
• •objective apical failure (low)
• •subjective awareness of pelvic organ prolapse recurrence (low)
• •reoperation for pelvic organ prolapse recurrence (low)
• •lower urinary tract symptoms (low)
• •intraoperative bladder or ureteric injury (low)
• 11Hysterectomy and suspension compared with hysteropexy (by any route) were inferior for the outcome of
• •objective posterior failure (low)
• 12Hysterectomy and sacrocolpopexy compared with sacrohysteropexy (abdominal, laparoscopic, or robotic) showed a higher risk of
• •mesh exposure (low)
• 13Vaginal hysterectomy with suspension and vaginal hysteropexy showed similar risk of
• •objective failure (overall and by compartment) (low)
• •risk of reoperation for pelvic organ prolapse recurrence (very low)
• •intraoperative ureteric injury (very low)
• 14In the short-term (1-year) correction of advanced apical vaginal prolapse (stage 3 or 4), vaginal suture suspension to various pelvic ligaments is similar to colpocleisis for the outcomes of overall objective failure, intraoperative urinary tract injury, and condition-specific improvement in quality of life (very low).
• 15Uterosacral ligament suspension compared with sacrospinous fixation showed a lower risk of
• •short-term/transient buttock pain (low)
• 16Current data are inconclusive for the outcomes of persistent pelvic pain or postoperative sexual function, including de novo dyspareunia, when comparing vaginal with abdominal apical suspensions, open with minimally invasive apical suspensions, various vaginal apical suspensions, and hysterectomy and suspension with hysteropexy (very low).

RECOMMENDATIONS

• 1Women seeking surgical correction of apical pelvic organ prolapse should be counselled about the higher risk of objective failure but similar rate of (1) subjective failure, (2) reoperation for pelvic organ prolapse recurrence, and (3) complications after vaginal suture suspensions compared with abdominal sacrocolpopexy (any approach). This is balanced against the ongoing risk of mesh exposure after sacrocolpopexy, possibly requiring reintervention (conditional, moderate).
• 2Appropriately trained surgeons should favour minimally invasive laparoscopic or robotic approaches to sacrocolpopexy (if surgical equipment is available) over open sacrocolpopexy, considering the improved overall objective outcomes and similar subjective outcomes in the short and medium term (conditional, low).
• 3Both vaginal uterosacral ligament suspension and sacrospinous fixation can be offered to women with apical pelvic organ prolapse, based on surgeon and patient preference; they appear to have similar objective and subjective outcomes at up to 5 years, apart from an increased risk of intraoperative ureteric injury with uterosacral ligament suspension and a higher risk of short-term/transient buttock pain after sacrospinous fixation (strong, moderate).
• 4Various hysteropexy routes and techniques can be offered as an alternative to hysterectomy and suspension for women with apical pelvic organ prolapse who wish to conserve their uterus; they are associated with similar objective and subjective outcomes in the first 5 years (conditional, low).
• 5Colpocleisis should be discussed as a treatment option for women who do not wish to be sexually active in the future, despite the paucity of comparative evidence; it appears to be a successful procedure with few reported complications (strong, low).
• 6Women undergoing surgery for symptomatic apical pelvic organ prolapse should receive counselling about the lack of comparative data on postoperative pelvic pain and sexual function for various procedures. Overall, the risk of postoperative pelvic pain appears to be low, and sexual function seems to improve among sexually active women with pelvic organ prolapse who undergo reconstructive surgery (conditional, very low).