**2. Surgical treatment of pelvic organ prolapse**

POP surgery is an increasingly important therapeutic aspect in clinical practice due to the aging of our population, and is increasingly prevalent as a therapeutic

#### *Surgical Treatment of Pelvic Organ Prolapse DOI: http://dx.doi.org/10.5772/intechopen.100232*

option, despite surgical and hospitalization times that are three times longer compared to other surgeries related to the pelvic floor such as continence surgery. Given the increasing time and resources that will be required for POP surgery in the future, it is paramount that we perform effective, long-lasting and cost-effective interventions with minimal morbidity.

Historically, most studies evaluating the treatment of POP have focused exclusively on anatomic success without considering other important aspects such as symptoms, vaginal accommodation, and quality of life. In fact, for a patient, individually, the most important result of a surgical procedure is the relief of their symptoms and improvement of their quality of life [11]. However, until recently these areas have been ignored. The objectives of pelvic floor reconstruction are to relieve symptoms, restore anatomy, improve or preserve function, prevent actions that alter other compartments, and improve quality of life [12].

Anterior colporrhaphy was the standard procedure in the management of the prolapsed anterior compartment. That said in the early 2000s, there was a movement toward the use of prosthetics to increase the efficacy of native tissue repair in reconstructive gynecology. This was due to the articles published by Olsen et al. [13] where they reported a reoperation rate of 29% after prolapse or continence surgery and Weber et al. [14] who reported a 70% failure rate of native tissue anterior compartment repair. Recent reassessment of the same demographic 10 years later revealed a significantly lower reoperation rate of 17% [15]. More importantly, Weber et al. [14] and Sand et al. [16] reported in randomized controlled clinical trials that anterior colporrhaphy was successful in managing cystocele in only 30%. A recent re-analysis of the latter data, using the hymen as the threshold for objective success, reported considerably better results, with only 10% anatomic recurrence beyond the hymen, 5% symptomatic recurrence, and a lower reoperation rate of 1% at 23 months of follow-up [17]. During the decade between these initial and later publications, surgeons introduced a large number of biologic and mesh grafts to improve the outcomes of prolapse surgery. In later studies such as that of Julian et al. [18] it was shown that patients with several vaginal repairs had better results with a new repair with prosthetic material, in this case a Marlex® mesh (Bard, Covington, GA), compared to previous colporrhaphy, although follow-up reported an erosion rate of up to 25%.

The 2016 Cochrane Review also reported on 16 trials that evaluated nearly 2,000 women with the aim of comparing anterior colporrhaphy versus permanent polypropylene mesh POP repair. The meta-analysis showed that recurrence of anterior wall prolapse (RR 0.34, 95% CI 0.25 to 0.46) and reoperation for prolapse (RR 0.44, 95% CI 0.24 to 0.46) were significantly less common after mesh repair compared to colporrhaphy. There were no differences between the groups in terms of quality of life outcomes or dyspareunia rates. However, the transvaginal polypropylene mesh group had higher rates of reoperation due to mesh exposure, stress urinary incontinence or prolapse (RR 1.62, 95% CI 1.15 to 2.28), and prolapse in the apical or posterior compartment (RR 1.85, 95% CI 1.01 to 3.37) compared to anterior colporrhaphy. Surgical time (MD 17.9 min, 95% CI 10.0 to 25.8), transfusion rate (RR 2.37, 95% CI 1.32 to 4.24), cystotomy (RR 4.65, 95% CI 1.22 to 17.77) and de novo stress urinary incontinence (RR 1.55, 95% CI 1.02 to 2.35) were higher after use of transvaginal polypropylene mesh compared to colporrhaphy. The mesh erosion rate was 11.5% and 7% underwent surgical correction for repair [19].

One fact that we must take into account is that recently, most of the products made with polypropylene meshes evaluated in this meta-analysis have been withdrawn by the manufacturers due to the ongoing litigation regarding the use of this type of material vaginally. Because of this, new transvaginal polypropylene prosthetic products have emerged that have been introduced to decrease the rate

of complications, specifically mesh erosion. Altman et al. [20] based on a multicenter prospective case series, which evaluated 207 women with apical prolapse undergoing the Uphold® pelvic floor system (Boston Scientific, USA), reported a subjective success rate of 90% per year and a reoperation rate for mesh exposure of 1.3%. Similarly, De Tayrac et al. [21] found at 3 years, in 79 women with grade 3–4 cystocele, an anatomical success rate of 95%, a satisfaction rate of 98% and a mesh exposure rate of 1.3% using a mesh of lightweight (28 g / m2) polypropylene (Surgimesh® Prolapse Xlight, Aspide Medical, France) [21].

Studies where the device used was Restorelle® (Coloplast, Minneapolis, USA), report rates of absence of postoperative complications of 98.2%. The most frequent complications included urinary retention (8.7%), urinary tract infections (5.5%), and hematoma (2.7%). Other complications related to neighboring organs (bladder, rectum, and ureters) were very rare (<1%). A total of 2.8% of the patients had grade III complications according to the Clavien-Dindo classification (mesh extrusion). 80.3% did not present complications during the 3 months of study follow-up. Despite these promising data, the follow-up time of this study is short to ensure the absence of complications within a longer follow-up period [22]. Despite the current negative sentiment around transvaginal mesh, these new lightweight mesh products require further reassessment.

In the 2016 Cochrane meta-analysis of grafts vs. Native tissue repairs for vaginal prolapse, only one case of reoperation for dyspareunia or pain was reported in the nearly 1000 cases of transvaginal mesh evaluated [19]. However, pain and dyspareunia were the main causes of adverse events that triggered the 2011 FDA (Food and Drug Administration) warnings on the safety of transvaginal mesh [23]. These findings raise the possibility that pain and dyspareunia after transvaginal mesh surgery may be underreported, and possibly only identified in trials with longer term evaluation.

Alternatively, autologous material was considered as a possible option to synthetic prosthetic grafts with a lower risk of host rejection or infection. Gandhi et al. reported preliminary results of a randomized control trial comparing anterior colporrhaphy alone vs. fascia lata graft for cystoceles [24]. In 1 year they could not demonstrate that the addition of the fascia lata graft improved the success rate compared to anterior colporrhaphy alone, being 71% compared to 82% (p 0.07), however, the rate of recurrent anterior prolapse in examination was lower after biological graft repair compared to anterior colporrhaphy (RR 0.74, 95% CI 0.55 to 0.99 n = 646, I2 = 29%, low-quality evidence), being the operative time for colporrhaphy shorter than the biological graft procedure (MD -10.35, 95% CI -14.45 to −6.24).

Reoperation after POP surgery for recurrence is an important measure of the effectiveness of the procedure. It is important to note that reoperation rates represent the "tip of the iceberg" in terms of surgical failures, as there are women with recurrent symptomatic prolapse who do not wish to undergo another operation. However, repeat surgery for recurrent POP is always an undesirable result that should, in most cases, be considered as a failed surgical procedure. Reoperation rates after POP surgery vary widely in the literature, largely due to different definitions and timelines. In a meta-analysis of 258 studies evaluating the reoperation rate after apical prolapse repairs, Diwadkar et al. reported a reoperation rate of 3.9% (95% CI: 3.5–4.4%) for traditional vaginal vault suspensions (sacrospinal ligament suspension and uterosacral vault suspensions) after a mean of 32 months, 2.3% (95% CI 1.9–2.7%) for sacrocolpopexy with follow-up mean 26 months and 1.3% (95% CI 1.0–1.7%) after transvaginal mesh procedures with a mean follow-up of 17 months. In particular, the total reoperation rate, including reoperations for recurrent POP and complications, was higher in the transvaginal mesh group (8.5%) [25].

### *Surgical Treatment of Pelvic Organ Prolapse DOI: http://dx.doi.org/10.5772/intechopen.100232*

The reoperation rate after POP surgery was defined in the joint report by the ICS (International Continence Society) and the IUGA (International Urogynecological Association), making a clear distinction between additional surgeries after primary surgical correction of POP, as the character of these can be very heterogeneous. The classification of these surgeries was established as follows:


Recently, Ow et al. retrospectively compared 237 women who underwent 185 native tissue repairs and 161 transvaginal mesh repairs for recurrent prolapse. The transvaginal mesh group had significantly lower follow-up rates of symptomatic prolapse, prolapse upon examination, and reoperation for prolapse, than the native tissue repairs group. However, the mesh exposure rate (anterior 15%, posterior mesh 21%) and associated reoperation (anterior 9%, posterior 15%) were significantly higher [26]. Trials such as this one show that in women with recurrent prolapse, transvaginal mesh has significant advantages and disadvantages compared to native tissue repairs and this profile is similar to that described for primary repairs, except that the exposure rates of the mesh appear to be higher in recurrent POP surgery.

Another surgical alternative on the rise in the last decade is laparoscopic or robotic sacrocolpopexy. This was born with the purpose of maintaining the existing good results of abdominal sacrocolpopexy but with the advantages of minimally invasive surgery. The case series demonstrate adequate acceptance in the short and medium term, with success rates of 91% (range 60–100%), subjective success rates of 79–98% [27, 28] and a mean reoperation rate of 5.6%. In a meta-analysis, it was concluded that, in general, a large group of vaginal surgery with and without mesh is associated with a higher risk of prolapse recurrence upon examination (RR 1.9 95% CI 1.3–2.7), of reoperation for prolapse recurrence (RR 2.3 95% CI 1.2–4.3), postoperative stress urinary incontinence (RR 1.9 95% CI 1.2–2.9) and dyspareunia (RR 2.5 95% 1.2–5.5) compared with sacrocolpopexy [29]. However, sacrocolpopexy was associated with a higher rate of paralytic ileus or small bowel obstruction (2.7% vs. 0.2%, p < 0.01), of complications related to intraperitoneal mesh or suture (4.2% vs. 0.4%, p < 0.01) and thromboembolic disease (0.6% vs. 0.1%, p = .03) [30].

The robotic sacrocolpopexy is the currently latest version of this technique. The robotic approach is associated with objective cure rates of 84% -100%, subjective cure rates of 92–95%, and a mesh erosion rate of 2% (range 0–8%). In general, we can find postoperative complications in this meta-analysis in up to 11% (range 0–43%), with serious complications in 2%, with a conversion rate of <1% to open surgery (range 0–5%) [31].

Traditionally, researchers have defined surgical success using anatomical results (POP-Q stage 0–1 - **Table 1**) and defined surgical failure as POPQ stage 2 or greater. More recently it is suggested that these anatomical definitions are too strict as more


#### **Table 1.** *POP-Q staging criteria.*

than 75% of women presenting for annual gynecological exams with no symptoms of pelvic organ prolapse would not be found in the definition of "optimal anatomical result" and almost 40% would not meet the definition of "satisfactory anatomical result" [32]. The absence of symptoms of vaginal protrusion postoperatively has a significant relationship with the patient's evaluation of general improvement and improvement in quality of life after surgery, while anatomical success alone does not, and thus vaginal protrusion symptoms are of great importance when evaluating the surgical outcome of POP [11]. Another possible factor to take into account in the different studies is the concept of success used together with the POP classification used. Some authors have used the Baden-Walker prolapse classification system instead of the POP-Q, other studies have used a combination of anatomical criteria and the presence or absence of symptoms to define the success of the treatment. Such variability makes it difficult to compare the results between the different studies.
