Mesh use seems to be safer in this situation and shows favorable functional outcomes and improved sexual function when compared to standard vaginal surgery. Hysterectomy should probably be avoided, or if performed, should be subtotal with cervix conservation to limit the risk of vaginal erosion. For isolated anterior or posterior compartment prolapse, native tissue repair with fascia plication is probably the primary method of choice.
The use of mesh in these situations, although resulting in better anatomical outcome for anterior repair, is not indicated. Diabetes and heavy smoking represent risk factors for erosion and mesh use should be avoided whenever possible.
Young age, obesity, constipation, and chronic cough probably increase the risk of recurrence, but these factors should not radically change our therapeutic approach in case of monocompartment POP. When planning POP surgery, one should always discuss the issue of post-operative sexual function. POP obliterative procedures colpocleisis represent a safe and simple alternative in older women who are not sexually active especially in the setting of comorbidities and short life expectancies.
Alternative conservative therapies such as pessary use should also be discussed. For young and sexually active women with apical prolapse, the abdominal route seems the optimal approach as it limits the risk of dyspareunia.
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For posterior compartment prolapse in these patients, levator myorrhaphy should be avoided to limit the risk of dyspareunia. A therapeutic strategy for reconstructive POP surgery is proposed in Table 2. Table 2 Pelvic organ prolapse POP reconstructive surgery strategies according to anatomical defects and patient characteristics Notes: a In case of recurrence involving only the anterior compartment, a second vaginal surgery with native tissue is also possible.
For patients with increased risk factors of POP recurrence, abdominal approach with mesh is probably the method of choice, but vaginal reconstructive surgery with native tissue is always possible for women with short life expectancy and for women where only one compartment is involved. The ideal surgical treatment of POP is yet to be found. Current use of mesh is perfectible, and in order to reduce potential adverse effects and complications, research for the ideal mesh material is ongoing.
Complex Reoperative Abdominal and Pelvic Surgery | Columbia University Department of Surgery
Cell-based stem cell tissue engineering strategies may provide new alternatives to native tissue repair or mesh repair for POP. At present, research in urogynecology, is focused on SUI cell-based injection therapy to regenerate the urethral sphincter. Another recent advance in POP surgery is the use of robot-assisted surgery. Treatment of apical prolapse has evolved with the adoption by some gynecologists of robot assisted laparoscopic surgery.
The combination of improved robotics and stem cell tissue engineering might open new perspectives in the future of POP surgery. POP is a multifaceted condition which may be considered as physiological when the threshold of the hymen is not overcome and patients are asymptomatic. When symptomatic, it can affect quality of life and requires treatment. Women should always be offered conservative treatment pessary use, physiotherapy as first line therapy. If conservative treatment fails or if patients actively seek reconstructive surgery, standard vaginal surgery with native tissue is still a good alternative for isolated POP of the anterior and posterior compartment.
The use of reinforcement material to improve outcome has to focus on function and must be discussed with caution. Patients need to be informed about their potential complications. Further research is ongoing to find the ideal material and the ideal approach for this condition, with the goal to preserve associated urinary, digestive, and sexual functions. This manuscript is derived from a Privat-Docent thesis accepted by the faculty of Medicine of the University of Geneva Switzerland and was presented orally in a public lesson on October 27, Epidemiology of surgically managed pelvic organ prolapse and urinary incontinence.
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Special Role of Plastic Surgery in Approaches to Complex Reoperative Pelvic Operations
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Pelvic organ prolapse: is it time to define it?
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Anterior colporrhaphy versus transvaginal mesh for pelvic-organ prolapse.