New techniques for correcting vaginal apical prolapse

Abdominal sacral colpopexy is still the "gold standard" for this complicated problem. But early results with two minimally invasive procedures show promise for safely managing prolapse.

Correcting apical vaginal prolapse can be a challenge for even the most experienced gynecologic surgeon. Many women with the condition have a history of pelvic surgery, co-existing medical conditions, are elderly, or present with a vaginal hernia sac that contains portions of the bladder, rectum, and peritoneum. Traditional surgery for vaginal prolapse involves either fixing the hernia through the abdomen or vagina or obliterating the vagina with a partial or complete colpocleisis. Newer, minimally invasive techniques build on our previous success with the well-described abdominal and vaginal procedures.

The exact incidence of vaginal apical prolapse is difficult to measure. Formal graded pelvic examinations (POP-Q) performed on a population of gynecologic patients revealed that 2.6% of the women had stage 3 prolapse (within 1 cm of introitus) and none had stage 4 prolapse.2 The rate of vaginal vault prolapse after hysterectomy is reported to be from 0.5% to 1.5%, but aging of the population likely will further increase the number of women affected. Estimates indicate that by the time they reach age 80, approximately 11% of women will have had a corrective procedure for pelvic organ prolapse or urinary incontinence.

Nonsurgical management Earlier stages of vaginal prolapse often can be managed without surgery. Pelvic floor muscle trainingis commonly recommended to women with stage 1 or 2 vaginal prolapse. However, a recent Cochrane Database Systemic Review determined that there is no evidence from randomized controlled trials to support the use of pelvic floor muscle training in management of pelvic organ prolapse.3 Nevertheless, multiple observational studies have indicated subjective relief for patients treated with these techniques.

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