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Surgical pathway for the treatment of pelvic organ prolapse
REVIEW
Surgical pathway for the treatment of pelvic organ prolapse
While not reproducing the entire body of evidence underlying the pathway we will discuss important aspects. Apical prolapse The central pivot of the reconstructive pathway is the volume of evidence that demonstrates the importance of including adequate apical support at the time of prolapse repairs. Eilber et al. demonstrated a 50 % reduction in the rate of subsequent reoperation for prolapse when an apical suspending procedure was performed at the time of anterior colporrhaphy as compared to an anterior colporrhaphy alone. Importantly, this is the same degree of reduction in reoperation of prolapse achieved with the use of transvaginal mesh as compared to anterior colporrhaphy however there was no associated morbidity reported with the apical suspending procedures. The apical suspending procedures evaluated in Eilbers review of prolapse interventions performed in 1999 would have included sacrospinous and uterosacral colpopexy however a wider variety of contemporary apical suspending procedures are currently available.
Susana M Mikhail Christopher Maher
Abstract During the last decade we have witnessed an unheralded time of change in pelvic organ prolapse surgery with the introduction and subsequent widespread restriction in the utilization of transvaginal mesh. To date no surgical pathway for the treatment of pelvic organ prolapse is available and this is reflected in a significant lack of clarity and variation in management of pelvic organ prolapse. We will present and discuss the evidence based 2017 International Consultation on Incontinence (ICI) surgical pathway for the treatment of pelvic organ prolapse.
Vault prolapse: For the surgical treatment of post-hysterectomy vault prolapse the 2016 Cochrane review compared outcomes from six RCTs that compared sacral colpopexy with a variety of transvaginal apical suspensions including sacrospinous and uterosacral colpopexy and transvaginal mesh. The sacral colpopexy had lower rates of awareness of prolapse, prolapse on examination, reoperation for prolapse, post-operative stress urinary incontinence and dyspareunia as compared to the vaginal based interventions and points to the sacral colpopexy being the gold standard apical suspending procedure for vault prolapse. The pathway recognizes that not all women are suitable for sacral colpopexy (i.e. obese, hostile abdomen, prior radiation) and that the sacrospinous and uterosacral colpopexy remain viable treatment options in this group.
Keywords hysterectomy; hysteropexy; uterine/apical/vault prolapse
Introduction Following the unexpected complications associated with the utilization of transvaginal mesh for prolapse and the associated litigation and Government enquiries in multiple countries, there has been increased scrutiny of all prolapse surgery. The scrutiny demonstrates that there is lack of consistency in the rate at which prolapse interventions are performed in different countries and the type of interventions performed. Haya et al. reported that women in France and United States of America are at least ten times more likely to undergo sacral colpopexy as compared to women in Denmark, Sweden or New Zealand. There was also wide variation in the rates of transvaginal mesh utilization. Most of the recent enquiries and reviews have recommended that transvaginal mesh not be performed as a primary intervention for anterior or posterior compartment prolapse. In the face of increased media attention, the general community, referring medical officers and treating gynaecologist are seeking clarification and leadership as to the appropriate treatment pathways for the surgical management of prolapse. The International Consultation on Incontinence (ICI) produces evidence based treatment pathway for female pelvic floor dysfunction and for the first time delivered a surgical treatment of prolapse pathway (Figure 1) in 2017. A web based application of the pathway is available and simplifies the data that informs the pathway and is available at http://www.urogynaecology.com.au/content.php?id¼58a28e7b ae443&refresh¼954925.
Uterine prolapse: While the preferred apical suspending treatment options for vault prolapse are well defined a myriad of surgical options for uterine prolapse are available and the pathway divides into uterine preserving options as compared to hysterectomy. Relative contraindications to uterine preservation are listed in Table 1. Further to this discussion regarding uterine preservation and hysterectomy is the conversation regarding subsequent risk of gynaecological malignancy. Post-menopausal women who want to preserve the uterus should be informed during the consent process of the lifetime risk of cervical (0.6%), uterine (2.7%), and ovarian cancer (1.4%). Furthermore, pre-and perimenopausal women should be informed that bilateral salpingectomy at hysterectomy may decrease the risk of ovarian cancer (OR 0.51, 95% CI 0.35e0.75). In the reconstructive pathway the surgical options for uterine preservation include the vaginal based sacrospinous colpopexy as seen in Figure 2, as compared to the abdominal sacral hysteropexy which is an abdominal procedure were mesh suspends the uterus to the sacrum as seen in Figure 3. The pathway preferences the vaginal sacrospinous hysteropexy as a result of relatively high reoperation rate associated with sacral hysteropexy and the fact that the vaginal intervention avoids the utilization of mesh for a primary intervention.
Susana M Mikhail MD is Urogynecology Fellow at the Royal Brisbane and Women’s Hospital, Brisbane, Australia. Conflicts of interest: none. Christopher Maher MD PhD is Associate Professor at the Royal Brisbane and Women’s Hospital, Wesley Urogynaecology and University of Queensland, Brisbane, Australia. Conflicts of interest: none.
OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE --:-
1
Ó 2018 Published by Elsevier Ltd.
Please cite this article in press as: Mikhail SM, Maher C, Surgical pathway for the treatment of pelvic organ prolapse, Obstetrics, Gynaecology and Reproductive Medicine (2018), https://doi.org/10.1016/j.ogrm.2018.03.002
REVIEW
Modified pathway for female pelvic floor dysfunction Bladder function POP surgery
Bowel function Risk of recurrent prolapse
Reconstructive surgery
Obliterative surgery
Apical support
Vault
LSC + repair
Anterior support
Posterior support
Uterine
Graft repair
Suture repair
Hysterectomy ± BSO
Hysteropexy
Vaginal hysterectomy
Sub-total hysterectomy ASC
Sacrospinous colpopexy
Uterosacral colpopexy
ASC + hysterectomy
Vaginal SS hysteropexy
Sacral hysteropexy
Preferred option Possible pathway Further data required
From the International Consultation on Incontinence (ICI) 2017
Figure 1
The options for women electing to have hysterectomy at time of prolapse surgery include vaginal hysterectomy with apical suspension as compared to sacral colpopexy with hysterectomy or sub-total hysterectomy and sacral colpopexy. Sacral colpopexy with hysterectomy is associated with significantly higher rates of mesh complications as compared to sacral colpopexy without hysterectomy and is not preferred in the pathway for this reason. The data informing efficacy and safety of subtotal hysterectomy and sacral colpopexy is currently inadequate. However, in a single retrospective comparison between subtotal hysterectomy and total hysterectomy with sacral colpopexy, Myer et al. reported a higher rate of recurrent prolapse after the sub-total hysterectomy and sacral colpopexy. Until better quality data become available vaginal hysterectomy and apical suspension
OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE --:-
are the preferred pathway options for uterine prolapse if a hysterectomy is to be performed. An interesting dichotomy of outcomes is apparent in the pathway. For vault prolapse abdominal sacral colpopexy is the preferred option however for uterine prolapse including both hysterectomy and hysteropexy the vaginal options are preferred on the basis of relatively poor-quality data. As more research becomes available the treatment pathway may change.
Recurrent cystocele One of the longstanding challenges in reparative Gynaecology remains the surgical management of recurrent cystocele. The ICI 2017 surgical treatment of prolapse pathway points to a variety of surgical options.
2
Ó 2018 Published by Elsevier Ltd.
Please cite this article in press as: Mikhail SM, Maher C, Surgical pathway for the treatment of pelvic organ prolapse, Obstetrics, Gynaecology and Reproductive Medicine (2018), https://doi.org/10.1016/j.ogrm.2018.03.002
REVIEW
Relative contraindications to uterine preserving surgery Uterine abnormalities Fibroids, adenomyosis or endometrial pathology Abnormal menstrual bleeding Post-menopausal bleeding Cervical dysplasia/Cervical elongation Increased risk for endometrial cancer Familial cancer BRAC1&2: [ risk ovarian cancer & theoretical risk fallopian tube and serous endometrial cancer Hereditary Non-Polyposis Colorectal Cancer (Lynch Syndrome): 60% lifetime risk endometrial cancer Tamoxifen therapy Obesity Low compliant patients Modified table from the International Consultation on Incontinence (ICI) 2017
Table 1
Sacrospinous colpopexy – suspending the uterus to the sacrospinous ligament with vaginal repair Level two support with final fascial pilcation bite including anterior Iip of cervix
Left internal iliac artery
Left internal pudendal artery
Levi ani nerve (LAN)
Uterus
Level one support with posterior Iip of cervix attached to sacrospinous ligament
Bladder
Left sacrospinous ligament
Rectum
Pudendal nerve Central pilcation of pubocervical fascia Closure of anterior and posterior vaginal wall Central pilcation of rectovaginal fascia
Figure 2
Colpocleisis remains a viable low risk option in those willing to sacrifice vaginal coitus. In the reconstructive pathway transvaginal mesh was considered as an option for this indication, however the data supporting the efficacy of transvaginal mesh in reducing recurrent prolapse and reoperation for prolapse is framed primarily from those with primary cystocele. Given the lack of data around transvaginal mesh for recurrent cystocele, the removal of transvaginal mesh as a treatment option in some countries and the negative publicity surrounding transvaginal mesh repairs women are generally reluctant to undergo transvaginal mesh for prolapse in many countries. In those who have undergone hysterectomy the pathway also points to sacral
OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE --:-
colpopexy and paravaginal repair as being excellent option for the management of recurrent cystocele. In those with the uterus intact options would include a vaginal hysterectomy with apical support and native tissue repair. An alternative would be sacral colpopexy with sub-total hysterectomy however the data supporting this option is limited and further trials are required.
Update on transvaginal mesh for prolapse Increasingly regulatory authorities are banning the use of transvaginal mesh for prolapse. The Scotch government in 2016 and
3
Ó 2018 Published by Elsevier Ltd.
Please cite this article in press as: Mikhail SM, Maher C, Surgical pathway for the treatment of pelvic organ prolapse, Obstetrics, Gynaecology and Reproductive Medicine (2018), https://doi.org/10.1016/j.ogrm.2018.03.002
REVIEW
Sacral hysteropexy mesh suspending the uterus to the sacrum
Edge of peritoneum Arms of anterior mesh Window created in broad ligament Main part of anterior mesh attached to cervix and vaginal wall
Sacral promontory
Uterus
Posterior mesh Left ureter Uterine artery
Va g
in a
Bladder Rectum
Figure 3
the TGA in Australia in 2017 have both withdrawn transvaginal mesh products for prolapse from their markets. The Scottish report concluded that transvaginal mesh procedures must not be offered routinely as the current evidence did not show any additional benefit of using transvaginal mesh over native tissue repair. It is understood that NICE in England will recommend that transvaginal mesh should only be utilized under the auspices of ethics committee research trial. It is highly likely that the further restriction of these products will follow in other countries.
Internationl Consulatation on Incontinence. 6th edn, vol. 2. ICUD ICS, 2017; 1855e992. Maher C, Feiner B, Baessler K, Christmann-Schmid C, Haya N, Brown J. Surgery for women with apical vaginal prolapse. Cochrane Database Syst Rev 2016; 10: CD012376. Myers EM, Siff L, Osmundsen B, Geller E, Matthews CA. Differences in recurrent prolapse at 1 year after total vs supracervical hysterectomy and robotic sacrocolpopexy. Int Urogynecol J 2015; 26: 585e9. http://www.gov.scot/About/Review/Transvaginal-Mesh-Implants (vol 2017). https://www.tga.gov.au/alert/tga-actions-after-reviewurogynaecological-surgical-mesh-implants (vol 2017). http://www.bbc.com/news/health-42110076 (vol 2017).
Conclusion In the wake of the transvaginal mesh saga the community is more closely scrutinizing the treatments for pelvic organ prolapse. The 2017 ICI surgical treatment of prolapse pathway and its web application are important tools in standardising the surgical options available and ensures the data that informs the pathways is easily accessible and understandable to the wider community. Furthermore, the pathways act to stimulate research especially in areas when the data are immature. Finally, the 2017 ICI prolapse pathway is simply a guide that should be used as an adjunct to consultation and should not be utilized in isolation.A
Practice points C
C
FURTHER READING Eilber KS, Alperin M, Khan A, et al. Outcomes of vaginal prolapse surgery among female Medicare beneficiaries: the role of apical support. Obstet Gynecol 2013; 122: 981e7. Maher C, Baessller K, Cheong C, et al. Surgical management of pelvic organ prolapse. In: Abrahams P, Cardozo L, Wein A, eds.
OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE --:-
C
C
4
Adequate apical support is an essential part of a durable prolapse repair Sacral colpopexy is the gold standard apical suspending procedure for vault prolapse. In women suitable for hysteropexy, vaginal sacrospinous hysteropexy is preferred over sacro-hysteropexy. Sacral colpopexy and paravaginal repair are excellent option for the management of recurrent cystocele however further trials are required on this indication.
Ó 2018 Published by Elsevier Ltd.
Please cite this article in press as: Mikhail SM, Maher C, Surgical pathway for the treatment of pelvic organ prolapse, Obstetrics, Gynaecology and Reproductive Medicine (2018), https://doi.org/10.1016/j.ogrm.2018.03.002
REVIEW
Questions It is recognized that the addition of an apical suspending procedure to anterior colporrhaphy as compared to anterior colporrhaphy alone decreases the rate of reoperation for recurrent prolapse by 1. 2. 3. 4.
10% 20% 40% 50%
The answer is number 4. A 54-year-old sexually active lady presents with symptomatic recurrent cystocele and vault prolapse extending 2 cm beyond the introitus. Five years previously she underwent hysterectomy with anterior and posterior colporrhaphy and sacrospinous fixation. What is the most appropriate surgical intervention. 1. 2. 3. 4.
Anterior colporrhaphy Anterior colporrhaphy with sacrospinous fixation Sacral colpopexy with paravaginal repair Colpocleisis
The answer is number 3.
OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE --:-
5
Ó 2018 Published by Elsevier Ltd.
Please cite this article in press as: Mikhail SM, Maher C, Surgical pathway for the treatment of pelvic organ prolapse, Obstetrics, Gynaecology and Reproductive Medicine (2018), https://doi.org/10.1016/j.ogrm.2018.03.002
Surgical pathway for the treatment of pelvic organ prolapse
While not reproducing the entire body of evidence underlying the pathway we will discuss important aspects. Apical prolapse The central pivot of the reconstructive pathway is the volume of evidence that demonstrates the importance of including adequate apical support at the time of prolapse repairs. Eilber et al. demonstrated a 50 % reduction in the rate of subsequent reoperation for prolapse when an apical suspending procedure was performed at the time of anterior colporrhaphy as compared to an anterior colporrhaphy alone. Importantly, this is the same degree of reduction in reoperation of prolapse achieved with the use of transvaginal mesh as compared to anterior colporrhaphy however there was no associated morbidity reported with the apical suspending procedures. The apical suspending procedures evaluated in Eilbers review of prolapse interventions performed in 1999 would have included sacrospinous and uterosacral colpopexy however a wider variety of contemporary apical suspending procedures are currently available.
Susana M Mikhail Christopher Maher
Abstract During the last decade we have witnessed an unheralded time of change in pelvic organ prolapse surgery with the introduction and subsequent widespread restriction in the utilization of transvaginal mesh. To date no surgical pathway for the treatment of pelvic organ prolapse is available and this is reflected in a significant lack of clarity and variation in management of pelvic organ prolapse. We will present and discuss the evidence based 2017 International Consultation on Incontinence (ICI) surgical pathway for the treatment of pelvic organ prolapse.
Vault prolapse: For the surgical treatment of post-hysterectomy vault prolapse the 2016 Cochrane review compared outcomes from six RCTs that compared sacral colpopexy with a variety of transvaginal apical suspensions including sacrospinous and uterosacral colpopexy and transvaginal mesh. The sacral colpopexy had lower rates of awareness of prolapse, prolapse on examination, reoperation for prolapse, post-operative stress urinary incontinence and dyspareunia as compared to the vaginal based interventions and points to the sacral colpopexy being the gold standard apical suspending procedure for vault prolapse. The pathway recognizes that not all women are suitable for sacral colpopexy (i.e. obese, hostile abdomen, prior radiation) and that the sacrospinous and uterosacral colpopexy remain viable treatment options in this group.
Keywords hysterectomy; hysteropexy; uterine/apical/vault prolapse
Introduction Following the unexpected complications associated with the utilization of transvaginal mesh for prolapse and the associated litigation and Government enquiries in multiple countries, there has been increased scrutiny of all prolapse surgery. The scrutiny demonstrates that there is lack of consistency in the rate at which prolapse interventions are performed in different countries and the type of interventions performed. Haya et al. reported that women in France and United States of America are at least ten times more likely to undergo sacral colpopexy as compared to women in Denmark, Sweden or New Zealand. There was also wide variation in the rates of transvaginal mesh utilization. Most of the recent enquiries and reviews have recommended that transvaginal mesh not be performed as a primary intervention for anterior or posterior compartment prolapse. In the face of increased media attention, the general community, referring medical officers and treating gynaecologist are seeking clarification and leadership as to the appropriate treatment pathways for the surgical management of prolapse. The International Consultation on Incontinence (ICI) produces evidence based treatment pathway for female pelvic floor dysfunction and for the first time delivered a surgical treatment of prolapse pathway (Figure 1) in 2017. A web based application of the pathway is available and simplifies the data that informs the pathway and is available at http://www.urogynaecology.com.au/content.php?id¼58a28e7b ae443&refresh¼954925.
Uterine prolapse: While the preferred apical suspending treatment options for vault prolapse are well defined a myriad of surgical options for uterine prolapse are available and the pathway divides into uterine preserving options as compared to hysterectomy. Relative contraindications to uterine preservation are listed in Table 1. Further to this discussion regarding uterine preservation and hysterectomy is the conversation regarding subsequent risk of gynaecological malignancy. Post-menopausal women who want to preserve the uterus should be informed during the consent process of the lifetime risk of cervical (0.6%), uterine (2.7%), and ovarian cancer (1.4%). Furthermore, pre-and perimenopausal women should be informed that bilateral salpingectomy at hysterectomy may decrease the risk of ovarian cancer (OR 0.51, 95% CI 0.35e0.75). In the reconstructive pathway the surgical options for uterine preservation include the vaginal based sacrospinous colpopexy as seen in Figure 2, as compared to the abdominal sacral hysteropexy which is an abdominal procedure were mesh suspends the uterus to the sacrum as seen in Figure 3. The pathway preferences the vaginal sacrospinous hysteropexy as a result of relatively high reoperation rate associated with sacral hysteropexy and the fact that the vaginal intervention avoids the utilization of mesh for a primary intervention.
Susana M Mikhail MD is Urogynecology Fellow at the Royal Brisbane and Women’s Hospital, Brisbane, Australia. Conflicts of interest: none. Christopher Maher MD PhD is Associate Professor at the Royal Brisbane and Women’s Hospital, Wesley Urogynaecology and University of Queensland, Brisbane, Australia. Conflicts of interest: none.
OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE --:-
1
Ó 2018 Published by Elsevier Ltd.
Please cite this article in press as: Mikhail SM, Maher C, Surgical pathway for the treatment of pelvic organ prolapse, Obstetrics, Gynaecology and Reproductive Medicine (2018), https://doi.org/10.1016/j.ogrm.2018.03.002
REVIEW
Modified pathway for female pelvic floor dysfunction Bladder function POP surgery
Bowel function Risk of recurrent prolapse
Reconstructive surgery
Obliterative surgery
Apical support
Vault
LSC + repair
Anterior support
Posterior support
Uterine
Graft repair
Suture repair
Hysterectomy ± BSO
Hysteropexy
Vaginal hysterectomy
Sub-total hysterectomy ASC
Sacrospinous colpopexy
Uterosacral colpopexy
ASC + hysterectomy
Vaginal SS hysteropexy
Sacral hysteropexy
Preferred option Possible pathway Further data required
From the International Consultation on Incontinence (ICI) 2017
Figure 1
The options for women electing to have hysterectomy at time of prolapse surgery include vaginal hysterectomy with apical suspension as compared to sacral colpopexy with hysterectomy or sub-total hysterectomy and sacral colpopexy. Sacral colpopexy with hysterectomy is associated with significantly higher rates of mesh complications as compared to sacral colpopexy without hysterectomy and is not preferred in the pathway for this reason. The data informing efficacy and safety of subtotal hysterectomy and sacral colpopexy is currently inadequate. However, in a single retrospective comparison between subtotal hysterectomy and total hysterectomy with sacral colpopexy, Myer et al. reported a higher rate of recurrent prolapse after the sub-total hysterectomy and sacral colpopexy. Until better quality data become available vaginal hysterectomy and apical suspension
OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE --:-
are the preferred pathway options for uterine prolapse if a hysterectomy is to be performed. An interesting dichotomy of outcomes is apparent in the pathway. For vault prolapse abdominal sacral colpopexy is the preferred option however for uterine prolapse including both hysterectomy and hysteropexy the vaginal options are preferred on the basis of relatively poor-quality data. As more research becomes available the treatment pathway may change.
Recurrent cystocele One of the longstanding challenges in reparative Gynaecology remains the surgical management of recurrent cystocele. The ICI 2017 surgical treatment of prolapse pathway points to a variety of surgical options.
2
Ó 2018 Published by Elsevier Ltd.
Please cite this article in press as: Mikhail SM, Maher C, Surgical pathway for the treatment of pelvic organ prolapse, Obstetrics, Gynaecology and Reproductive Medicine (2018), https://doi.org/10.1016/j.ogrm.2018.03.002
REVIEW
Relative contraindications to uterine preserving surgery Uterine abnormalities Fibroids, adenomyosis or endometrial pathology Abnormal menstrual bleeding Post-menopausal bleeding Cervical dysplasia/Cervical elongation Increased risk for endometrial cancer Familial cancer BRAC1&2: [ risk ovarian cancer & theoretical risk fallopian tube and serous endometrial cancer Hereditary Non-Polyposis Colorectal Cancer (Lynch Syndrome): 60% lifetime risk endometrial cancer Tamoxifen therapy Obesity Low compliant patients Modified table from the International Consultation on Incontinence (ICI) 2017
Table 1
Sacrospinous colpopexy – suspending the uterus to the sacrospinous ligament with vaginal repair Level two support with final fascial pilcation bite including anterior Iip of cervix
Left internal iliac artery
Left internal pudendal artery
Levi ani nerve (LAN)
Uterus
Level one support with posterior Iip of cervix attached to sacrospinous ligament
Bladder
Left sacrospinous ligament
Rectum
Pudendal nerve Central pilcation of pubocervical fascia Closure of anterior and posterior vaginal wall Central pilcation of rectovaginal fascia
Figure 2
Colpocleisis remains a viable low risk option in those willing to sacrifice vaginal coitus. In the reconstructive pathway transvaginal mesh was considered as an option for this indication, however the data supporting the efficacy of transvaginal mesh in reducing recurrent prolapse and reoperation for prolapse is framed primarily from those with primary cystocele. Given the lack of data around transvaginal mesh for recurrent cystocele, the removal of transvaginal mesh as a treatment option in some countries and the negative publicity surrounding transvaginal mesh repairs women are generally reluctant to undergo transvaginal mesh for prolapse in many countries. In those who have undergone hysterectomy the pathway also points to sacral
OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE --:-
colpopexy and paravaginal repair as being excellent option for the management of recurrent cystocele. In those with the uterus intact options would include a vaginal hysterectomy with apical support and native tissue repair. An alternative would be sacral colpopexy with sub-total hysterectomy however the data supporting this option is limited and further trials are required.
Update on transvaginal mesh for prolapse Increasingly regulatory authorities are banning the use of transvaginal mesh for prolapse. The Scotch government in 2016 and
3
Ó 2018 Published by Elsevier Ltd.
Please cite this article in press as: Mikhail SM, Maher C, Surgical pathway for the treatment of pelvic organ prolapse, Obstetrics, Gynaecology and Reproductive Medicine (2018), https://doi.org/10.1016/j.ogrm.2018.03.002
REVIEW
Sacral hysteropexy mesh suspending the uterus to the sacrum
Edge of peritoneum Arms of anterior mesh Window created in broad ligament Main part of anterior mesh attached to cervix and vaginal wall
Sacral promontory
Uterus
Posterior mesh Left ureter Uterine artery
Va g
in a
Bladder Rectum
Figure 3
the TGA in Australia in 2017 have both withdrawn transvaginal mesh products for prolapse from their markets. The Scottish report concluded that transvaginal mesh procedures must not be offered routinely as the current evidence did not show any additional benefit of using transvaginal mesh over native tissue repair. It is understood that NICE in England will recommend that transvaginal mesh should only be utilized under the auspices of ethics committee research trial. It is highly likely that the further restriction of these products will follow in other countries.
Internationl Consulatation on Incontinence. 6th edn, vol. 2. ICUD ICS, 2017; 1855e992. Maher C, Feiner B, Baessler K, Christmann-Schmid C, Haya N, Brown J. Surgery for women with apical vaginal prolapse. Cochrane Database Syst Rev 2016; 10: CD012376. Myers EM, Siff L, Osmundsen B, Geller E, Matthews CA. Differences in recurrent prolapse at 1 year after total vs supracervical hysterectomy and robotic sacrocolpopexy. Int Urogynecol J 2015; 26: 585e9. http://www.gov.scot/About/Review/Transvaginal-Mesh-Implants (vol 2017). https://www.tga.gov.au/alert/tga-actions-after-reviewurogynaecological-surgical-mesh-implants (vol 2017). http://www.bbc.com/news/health-42110076 (vol 2017).
Conclusion In the wake of the transvaginal mesh saga the community is more closely scrutinizing the treatments for pelvic organ prolapse. The 2017 ICI surgical treatment of prolapse pathway and its web application are important tools in standardising the surgical options available and ensures the data that informs the pathways is easily accessible and understandable to the wider community. Furthermore, the pathways act to stimulate research especially in areas when the data are immature. Finally, the 2017 ICI prolapse pathway is simply a guide that should be used as an adjunct to consultation and should not be utilized in isolation.A
Practice points C
C
FURTHER READING Eilber KS, Alperin M, Khan A, et al. Outcomes of vaginal prolapse surgery among female Medicare beneficiaries: the role of apical support. Obstet Gynecol 2013; 122: 981e7. Maher C, Baessller K, Cheong C, et al. Surgical management of pelvic organ prolapse. In: Abrahams P, Cardozo L, Wein A, eds.
OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE --:-
C
C
4
Adequate apical support is an essential part of a durable prolapse repair Sacral colpopexy is the gold standard apical suspending procedure for vault prolapse. In women suitable for hysteropexy, vaginal sacrospinous hysteropexy is preferred over sacro-hysteropexy. Sacral colpopexy and paravaginal repair are excellent option for the management of recurrent cystocele however further trials are required on this indication.
Ó 2018 Published by Elsevier Ltd.
Please cite this article in press as: Mikhail SM, Maher C, Surgical pathway for the treatment of pelvic organ prolapse, Obstetrics, Gynaecology and Reproductive Medicine (2018), https://doi.org/10.1016/j.ogrm.2018.03.002
REVIEW
Questions It is recognized that the addition of an apical suspending procedure to anterior colporrhaphy as compared to anterior colporrhaphy alone decreases the rate of reoperation for recurrent prolapse by 1. 2. 3. 4.
10% 20% 40% 50%
The answer is number 4. A 54-year-old sexually active lady presents with symptomatic recurrent cystocele and vault prolapse extending 2 cm beyond the introitus. Five years previously she underwent hysterectomy with anterior and posterior colporrhaphy and sacrospinous fixation. What is the most appropriate surgical intervention. 1. 2. 3. 4.
Anterior colporrhaphy Anterior colporrhaphy with sacrospinous fixation Sacral colpopexy with paravaginal repair Colpocleisis
The answer is number 3.
OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE --:-
5
Ó 2018 Published by Elsevier Ltd.
Please cite this article in press as: Mikhail SM, Maher C, Surgical pathway for the treatment of pelvic organ prolapse, Obstetrics, Gynaecology and Reproductive Medicine (2018), https://doi.org/10.1016/j.ogrm.2018.03.002