Compiled by Owen Wang
Source｜Medical World Obstetrics and Gynecology Channel
Pelvic organ prolapse (POP) is the prolapse of pelvic organs into or outside the vagina due to defects, damage, or dysfunction of the pelvic floor support structures.
Pelvic organ prolapse affects millions of women worldwide, with approximately 50% of women suffering from it.1 Studies have reported that the incidence of POP requiring hospitalization is 2/1000 among adult women under the age of 60; the probability of a woman undergoing pelvic floor repair surgery in her lifetime is about 20% by the age of 80.2
Current research and evidence-based medicine suggest that vaginal apex prolapse is the key point in pelvic organ prolapse. If the vaginal apex can be suspended, the entire surgery is half successful.
On November 24, 2018, the European Society for Gynecologic Endoscopy (ESGE) Asia-Pacific Regional Conference was successfully held in Shanghai. Professor Zhu Lan from Peking Union Medical College Hospital delivered an excellent presentation on "Self-cut Transvaginal Mesh Implantation for the Treatment of Severe POP and Clinical Outcomes," and subsequently gave an exclusive interview to *Medical World* magazine. Below is a summary of the key points, shared for your reference.
1
What is the apex of the vagina?
The vaginal apex is the highest point of the vagina, located 1.6 ± 0.5 cm³ above the ischial spines. Why can the vaginal fornix maintain this 1.6 cm level? The cardinal and sacrosacral ligaments play a crucial role, forming a pericervical ring that maintains the position of the vaginal apex and supports the uterus and upper vagina. The cardinal-sacrosacral ligament complex, as proposed by DeLancey in 1994, is termed the "Level 1 Upper Support Structure 4" of the pelvic floor support structure. When this apical support structure is weak, uterine prolapse occurs when a uterus is present, and vaginal fornix prolapse occurs when a uterus is absent.
Connective tissues that can cause pelvic floor dysfunction include: ① External urethral ligament (EUL); ② Pubourethral ligament (PUL); ③ Inferior urethral ligament (hammock); ④ Axillary pelvic fascia tendinous arch (ATFP); ⑤ Pubocervical fascia (PF); ⑥ Elastic critical area (ZCE); ⑦ Uterosacral ligament (USL); ⑧ Rectovaginal fascia (RVF); ⑨ Perineal body (PB).
2
How to perform vaginal apex reconstruction?
Vaginal apex reconstruction includes both closure and reconstruction. When the patient is older, has no sexual desire, has complications, or faces high surgical risks, a vaginal closure or semi-closure procedure can be performed. This involves partially or completely closing the vaginal canal, allowing the prolapsed organ to be repositioned back into the vagina. This method has advantages such as minimal trauma, short operation time, rapid recovery, and high success rate. When vaginal function needs to be preserved, it is necessary to restore the anatomical position of the vagina through reconstruction surgery, including: vaginal/uterine presacral fixation, vaginal/uterine sacrospinous ligament suture fixation, high sacrospinous ligament suspension, and vaginal implantation of a sacrospinous ligament sling.
3
Which patients need prophylactic surgery for level 1 defects?
When the uterus is removed, the top is located at the level of the hymen, and a top suspension must be performed, including two procedures: sacrospinous ligament suspension and sacrospinous ligament suspension.
01
Sacroligament suspension
In 1957, McCall performed a transvaginal procedure by folding and suturing the uterosacral ligaments and the peritoneum along the midline, closing the rectouterine pouch. In 1961, Mayo performed a modified McCall procedure. After hysterectomy, the uterosacral ligaments were clamped high (at the level of the ischial spines), and shortened by 2-3 consecutive non-absorbable sutures tied on one side, suspending the vaginal apex on the uterosacral ligaments; hence, it is also called vaginal-sacral ligament suspension. The uterosacral ligament suspension technique evolved from the McCall procedure, improving the suturing site and method. It no longer involves simultaneous suturing of the peritoneum and closing of the rectouterine pouch, but instead utilizes the anterior and posterior vaginal wall fascia for autologous tissue reconstruction. The anatomical success rate is 98%, and 94% of patients are satisfied with their sexual life 5 years post-surgery. Approximately 16% experience recurrence of prolapse requiring repeat surgery.
02
Sacrospinous ligament fixation (SSLF)
In 1967, Richter proposed fixing the vaginal apex to the more easily accessible sacrospinous ligament, based on the previous "sacrotuberous ligament fixation". He made a longitudinal incision of the posterior vaginal wall mucosa (or a slightly right-sided incision if working on the right side) for 3-4 cm, separated the vaginal wall and rectal space, and bluntly dissected the vaginal-rectal space with his index finger to reach the ischial spine. He then slid the inward and downward movement to reach the sacrospinous ligament.
Insert retractors into the anterior and posterior vaginal walls to expose the sacrospinous ligament. Using a sacrospinous ligament suture device modified by Peking Union Medical College Hospital, suture the right sacrospinous ligament with two stitches 1.5 cm from the ischial spine using non-absorbable sutures. At the same time, suture the right sacrocardial ligament. Generally, suturing one side is sufficient (because the right side is easier to operate on, suturing the right side is often performed). 5. Objective satisfaction rate: 88.1%-89.7%, subjective satisfaction rate: 87%-93%.
Common complications include: pain or numbness in the perineum or buttock on the surgical side (10%-15%); rectal injury (2.5%); bleeding and hematoma (0.4%); secondary cystocele (13%); dyspareunia (9%); and other complications such as nerve damage, fecal or urinary incontinence.
03
Ischial Spinal Fibre Fixation (ISFF)
Using the ischial spinous ligament as the attachment point for vaginal vault suspension and reconstructing it using the patient's own tissue has many advantages, including definite surgical results, ease of operation, less bleeding, fewer complications, lower cost, faster postoperative recovery, and no need to insert non-absorbable mesh into the patient's body. However, the vagina is slightly shorter than SSLF, and there is a 6% chance of right leg pain (mostly transient). It can be used as a supplementary procedure to sacrospinous ligament fixation, or when there are no special sacrospinous ligament sutures or when deep operation is not possible.
4
Autologous tissue repair
To ensure successful autologous tissue repair, it is crucial to adhere to the 3T principle: Tissue (age, postmenopausal status, connective tissue disease, long-term hormone use, diabetes, smoking); Trauma (avoiding postoperative chronic abdominal pressure, obesity, chronic constipation, lifting heavy objects, chronic cough, or lung disease); and Technique (the surgeon's skill is a decisive factor in the success and longevity of autologous tissue repair).
Vaginal apex prolapse is a long-term complication of hysterectomy. After hysterectomy, if the apex remains within the hymen, or if the patient has a tendency for pelvic organ prolapse or a family history of pelvic organ prolapse, sacrospinous ligament fixation and sacrospinous ligament suspension should be performed. When the patient has multiple high-risk factors and concurrent connective tissue diseases, sacrospinous ligament fixation is preferred. If the condition is not severe, sacrospinous ligament suspension can be chosen to reduce postoperative complications.
Sacrospinous ligament fixation is a level 4 surgery because the surgical site is the deepest and surrounded by blood vessels and nerves. It requires a thorough understanding of the anatomical structure and specialized instruments, and it is unrealistic to expect all doctors to reach this level of skill.
Therefore, mild pelvic organ prolapse surgery can generally be performed by obstetricians and gynecologists. However, more specialized procedures such as sacrospinous ligament suspension and sacrospinous ligament fixation are best performed by gynecological urologists or specialists in pelvic floor surgery.
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