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Official reprint from UpToDate www.uptodate.com ©2015 UpToDate

AuthorKimberly Kenton, MD, MS, FACOG, FACS

Section EditorLinda Brubaker, MD, FACS, FACOG

Deputy EditorKristen Eckler, MD, FACOG

Pelvic organ prolapse in women: Surgical repair of apical prolapse (uterine or vaginal vault prolapse)

All topics are updated as new evidence becomes available and our peer review process is complete.Literature review current through: Apr 2015. | This topic last updated: Jun 16, 2014.

INTRODUCTION — Apical prolapse is the descent of uterus, cervix, or vaginal vault. Pelvic organ prolapse(POP) affects millions of women; approximately 200,000 inpatient surgical procedures for prolapse are performedannually in the United States [1,2]. Eleven to 19 percent of women will undergo surgery for POP or incontinenceby age 80 to 85 years, and 30 percent of these women will require an additional POP or incontinence surgery [3,4].Anterior vaginal wall prolapse without concomitant apical prolapse is uncommon [5], and apical prolapse repairshould be included in the majority of pelvic reconstructive surgery procedures.

Reconstructive procedures for prolapse of the vaginal apex are reviewed here. Evaluation of women with POP,conservative management, and choosing a primary surgical procedure are discussed separately. Obliterativeprocedures for POP (colpocleisis) are also discussed separately. (See "Pelvic organ prolapse in women: Anoverview of the epidemiology, risk factors, clinical manifestations, and management" and "Vaginal pessarytreatment of prolapse and incontinence" and "Pelvic organ prolapse in women: Choosing a primary surgicalprocedure" and "Pelvic organ prolapse in women: Obliterative procedures (colpocleisis)".)

TERMINOLOGY — The International Continence Society defines apical vaginal prolapse as any descent of thevaginal cuff scar or cervix, below a point which is 2 cm less than the total vaginal length about the plane of thehymen [6]. The clinical significance of apical descent that is not beyond the hymen is unclear, as half ofasymptomatic women presenting for routine gynecologic care have prolapse to the hymen [7]. Similarly, studiessuggest that prolapse becomes symptomatic when the leading edge protrudes beyond the vaginal opening [8].However, isolated anterior vaginal wall defects are uncommon. Therefore, if the anterior vaginal wall protrudesbeyond the hymen, the apex likely has inadequate support, as well [5,9].

ANATOMY AND MECHANISMS OF INJURY — Apical prolapse refers to the downward displacement of thevaginal apex (figure 1). The vaginal apex is either the uterus and cervix or, in women who have undergone subtotalor total hysterectomy, the cervix or vaginal cuff.

Support of the vaginal apex is primarily derived from the integrity of the uterosacral and cardinal ligaments, thecontinuity of the endopelvic fascia, and a neuromuscularly intact levator ani muscle (figure 2). The etiology ofapical prolapse is likely related to connective tissue, neural, and/or muscular defects in these normal supports.

It is rare to find isolated apical prolapse or isolated prolapse of the anterior or posterior vaginal walls, since thedefects in the connective tissue, neural pathways, and muscle are not confined to one site [9,10].

The anatomy of the female pelvic floor is discussed in detail separately. (See "Pelvic organ prolapse in women: Anoverview of the epidemiology, risk factors, clinical manifestations, and management", section on 'Anatomy ofpelvic support'.)

RISK FACTORS — The risk factors for developing apical prolapse are generally the same as for developinganterior or posterior vaginal wall prolapse. (See "Pelvic organ prolapse in women: An overview of theepidemiology, risk factors, clinical manifestations, and management", section on 'Risk factors'.)

The most common risk factors associated with apical prolapse are vaginal parity (number of vaginal deliveries) andprevious hysterectomy [11,12]. The risk of prolapse after hysterectomy was illustrated in a case­control study inwhich 160,000 women who underwent hysterectomy were significantly more likely than age­matched controls torequire subsequent pelvic floor repair (3.2 verus 2.0 percent) [13]. Women who have prolapse at the time of

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hysterectomy have an even higher risk of subsequent surgery for pelvic organ prolapse (POP). A case­controlstudy of women who underwent hysterectomy reported that the risk of subsequent POP repair was 5­fold in thosewho had a history of vaginal delivery, 8­fold in those who had prior surgery for POP or urinary incontinence, andalmost 13­fold in those who had grade 2 or higher prolapse at the time of hysterectomy [14]. Surgeons shouldresuspend the vaginal apex when performing hysterectomy for nonprolapse indications to minimize this risk.

CANDIDATES FOR APICAL PROLAPSE REPAIR — Indications for apical prolapse repair are generally thesame as for other pelvic organ prolapse (POP) repair procedures, ie, symptomatic prolapse in women who declineor fail conservative therapy and who can tolerate surgery. Prolapse is not typically symptomatic until the vaginaprotrudes through the hymen. (See "Pelvic organ prolapse in women: Choosing a primary surgical procedure",section on 'Candidates for surgical treatment' and "Pelvic organ prolapse in women: An overview of theepidemiology, risk factors, clinical manifestations, and management", section on 'Clinical manifestations'.)

PREOPERATIVE EVALUATION AND PREPARATION — In women planning surgical repair of apical prolapse,surgeons should assess each vaginal compartment (apical, anterior, and posterior) for the presence of supportdefects or prolapse. In addition, pelvic organ prolapse (POP) often coexists with urinary and/or anal incontinence.During the history and physical examination, the presence and severity of each of these disorders should beassessed, as this information may alter surgical decision­making.

Aspects of preoperative evaluation and preparation that are specific to apical prolapse repair are discussed in thissection. General principles of evaluation of women undergoing POP repair are discussed in detail separately. (See"Pelvic organ prolapse in women: Diagnostic evaluation".)

Informed consent and patient goals — Surgeons should discuss with each woman the pelvic symptoms that arebothersome to her and their effects on her quality of life. This helps to set realistic goals for reconstructive surgeryand assess postoperative improvement. Patient satisfaction after surgery for POP and urinary incontinencecorrelates highly with achievement of self­described preoperative surgical goals, but poorly with objective outcomemeasures [15­17].

Informed consent for repair of apical prolapse should include a discussion of the risk of persistent or recurrentprolapse at the apex, anterior, or posterior vaginal walls. Since some women develop stress urinary incontinence(SUI) following apical prolapse repair, surgeons should also discuss the risk of developing incontinence, as well asthe risks and benefits of performing a prophylactic incontinence procedure versus deferring an incontinenceprocedure until symptoms develop. (See 'Evaluation of urinary dysfunction' below.)

Other important items to discuss with women planning apical POP surgery include potential postoperative changesin sexual function and mesh­related complications if mesh will be used for the repair. (See "Overview oftransvaginal placement of mesh for prolapse and stress urinary incontinence", section on 'Complications'.)

History — The most common clinical manifestation of prolapse of the vaginal apex is a bulge or protrusion fromthe vagina (picture 1). Protrusion of the vagina may result in vaginal discharge and/or bleeding from ulceration.Other symptoms commonly reported by women with apical prolapse are voiding difficulty and constipation; somewomen need to reduce the prolapse using a finger in the vagina (ie, splint) to urinate or defecate.

Women with advanced anterior or posterior vaginal wall prolapse may have similar symptoms and pelvicexamination is needed to ascertain the site(s) and stage of prolapse. Investigators demonstrated that restoration ofthe vaginal apex during prolapse examination fixes anterior vaginal wall defects 50 percent of the time andposterior vaginal wall defects 30 percent of the time [18].

Physical examination — A thorough speculum and bimanual pelvic examination are performed. We performapical prolapse assessment initially with the woman standing and straining. Each vaginal compartment (apical,anterior, and posterior) should then be examined with the women supine. The apical prolapse can be visualizedduring speculum examination with the woman straining as the speculum is slowly withdrawn from the upper thirdof the vagina. In some women with advanced apical prolapse, protrusion of the apex is visible at or beyond the

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vaginal introitus before the speculum is inserted (picture 1).

Since isolated apical prolapse is rare, careful assessment of the anterior and posterior wall is important [9].

The findings of the examination should be recorded using a quantitative and reproducible method for recordingPOP. The system currently recommended by the International Continence Society and the AmericanUrogynecologic Society is the pelvic organ prolapse quantitation (POP­Q) system (figure 3 and figure 4) [19]. (See"Pelvic organ prolapse in women: Diagnostic evaluation", section on 'Speculum and bimanual examination'.)

Evaluation of urinary dysfunction — Apical prolapse frequently coexists with urinary incontinence or urinaryretention, and women planning apical prolapse repair should be evaluated for these conditions.

Urinary incontinence — Women with symptoms of both POP and SUI are treated with a combined prolapserepair and continence procedure.

Many women with stage II or greater apical prolapse remain continent despite loss of anterior vaginal andbladder/urethral support. However, 13 to 65 percent of continent women develop symptoms of stress incontinenceafter surgical correction of the prolapse [7,20­22]. This likely occurs because the prolapse kinks and obstructs theurethra; this obstruction is alleviated when the prolapse is repaired. This is referred to as "occult" or "potential"stress incontinence. Women with stage I POP are unlikely to have urethral obstruction and resultant occult stressincontinence [7,20­22].

All women with apical prolapse should have a preoperative evaluation for occult stress incontinence with clinical orurodynamic urinary stress testing with reduction of prolapse, although preoperative prolapse reduction testing doesnot accurately predict postoperative urinary incontinence. Approximately 40 percent of women with negativetesting will develop postoperative stress incontinence; however, demonstration of stress incontinence duringreduction testing is associated with rates of SUI of up to 60 percent of after prolapse surgery [23]. (See "Pelvicorgan prolapse and stress urinary incontinence in women: Combined surgical treatment", section on 'Detectingoccult incontinence'.)

For continent women with stage II or greater POP who undergo abdominal sacral colpopexy, high quality dataindicate that bothersome stress incontinence is less likely to develop in women who undergo a concomitant Burchcolposuspension rather than sacral colpopexy alone. While there are fewer data regarding prophylactic surgery forstress incontinence in women undergoing transvaginal apical prolapse repair, it appears such preventive surgery issafe and effective in this population. Combined surgery for POP and SUI is discussed in detail separately. (See"Pelvic organ prolapse and stress urinary incontinence in women: Combined surgical treatment", section on 'POPwith no symptoms of SUI'.)

Urinary retention — Urinary retention is evaluated by measuring a postvoid residual urine volume (PVR)within 10 minutes after the patient has voided. In general, a PVR of less than 50 mL is considered adequateemptying, and a PVR greater than 200 mL is considered inadequate. An elevated preoperative PVR normalizesafter surgical correction of prolapse in over 90 percent of women [24,25].

Evaluation of defecatory dysfunction — Women with POP should be asked about symptoms of defecatorydysfunction (eg, constipation, the need to place pressure on, or “splint,” the posterior vaginal wall to defecate, analincontinence). Such symptoms should be evaluated prior to surgery, as appropriate. (See "Pelvic organ prolapse inwomen: An overview of the epidemiology, risk factors, clinical manifestations, and management", section on'Defecatory symptoms' and "Fecal incontinence in adults: Etiology and evaluation".)

SURGICAL PLANNING — Issues specific to planning repair of apical prolapse are discussed in this section.General principles of surgical decision­making regarding pelvic organ prolapse (POP) (eg, obliterative versusreconstructive surgery, concomitant hysterectomy) are discussed separately. (See "Pelvic organ prolapse inwomen: Choosing a primary surgical procedure", section on 'Candidates for surgical treatment'.)

Abdominal versus vaginal approach — The choice of surgical route for repair of apical prolapse is controversial.

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Open abdominal repairs are more effective in restoring vaginal topography, but vaginal repairs incur less seriousmorbidity and have a shorter recovery [26]. Laparoscopic and robotic approaches may offer the improved vaginalsupport associated with open procedures and the shorter recovery of vaginal procedures.

Two common apical prolapse procedures, abdominal sacral colpopexy and vaginal sacrospinous ligamentsuspension (SSLS), were compared in a meta­analysis of three randomized trials including 321 women. At two­year follow­up, abdominal sacral colpopexy had a significantly lower rate of recurrent vaginal vault prolapse thanSSLS (4 versus 15 percent; RR 0.2, 95% CI 0.07­0.8) [26]; however, reoperation rates in the first two years didnot differ significantly (7 versus 16 percent; RR 0.5, 95% CI 0.2­1.1). The meta­analysis is limited by the smallnumber of patients and short period of follow­up.

Contrary to traditional beliefs, the meta­analysis demonstrated that total complication rates were similar for thevaginal and abdominal approaches. Similarly, another meta­analysis addressed the severity of complications inabdominal sacral colpopexy and transvaginal apical suspension procedures. This study included the same threerandomized trials, as well as 103 observational studies [27]. Similar to the meta­analysis of randomized trials, totalcomplication rates appeared similar for abdominal compared with vaginal procedures (17.1 versus 15.3). However,the abdominal approach was associated with a higher frequency of complications involving surgical or radiologicintervention (5.8 versus 2.1 percent); tests of statistical significance were not reported.

Another difference between surgical procedures is that abdominal sacral colpopexy, but not traditional vaginalprocedures, has the potential for mesh­related complications. There were too few mesh­related complications toreport in the meta­analysis of randomized trials [26], but the reported incidence in a systematic review ofabdominal sacral colpopexy was approximately 3 percent using polypropylene mesh [28].

Women who underwent abdominal sacral colpopexy were less likely to develop postoperative dyspareunia thanthose who underwent SSLS (16 versus 36 percent; RR 0.4, 95% CI 0.2­ 0.9) [29­31]. Rates of dyspareunia werehigh for both surgical approaches; however, the data regarding dyspareunia were only available for 106 patients. Aliterature review of observational studies reported general improvement in sexual function following sacralcolpopexy and dyspareunia rates of 3 to 10 percent after SSLS [32]. Similarly, sexual function and pain withintercourse improved one year after sacral colpopexy in the Colpopexy and Urinary Reduction Efforts (CARE) trial[33].

The only disadvantages of sacral colpopexy compared with SSLS in the meta­analysis of randomized trials wereincreased operative duration (an average of 21 minutes longer), recovery time (an average of 8 days longer), andexpense [26].

In summary, abdominal sacral colpopexy is more effective in restoring vaginal topography without a significantincrease in morbidity when compared to SSLS and may be more appropriate for women with risk factors forprolapse recurrence, including young age, obesity, stage III or IV POP, and previous failed POP repair [34­37].Rare risk factors for recurrent prolapse are bladder exstrophy or spina bifida [38,39]. Abdominal procedures alsoappear to result in a lower incidence of dyspareunia. Other reasons to choose an abdominal approach are:insufficient vaginal length for transvaginal repair and other indications for abdominal surgery (eg, ovariancystectomy).

On the other hand, transvaginal repair is performed in 80 to 90 percent of prolapse surgeries in the United States[2,3,40]. Vaginal surgery has a shorter operative duration and recovery than open abdominal sacral colpopexy. Forthese reasons, it is often selected for women with increased surgical risk. In addition, the transvaginal approachcan be easily combined with other vaginal procedures commonly performed in women with POP (eg, vaginalhysterectomy, midurethral sling placement). With the increasing use of laparoscopic and robotic alternatives tolaparotomy when performing sacral colpopexy, the shorter recovery and decreased morbidity associated withvaginal approaches may become less important.

In summary, when planning surgery for quality of life disorders, such as apical prolapse, factors beyond simpleanatomic outcomes should be considered and weighed by each woman with her surgeon. Selecting the optimal

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operation for treatment of apical prolapse is complicated and impacted by numerous factors, including individualwomen’s goals for surgery, as well as her risk of prolapse recurrence, ability to tolerate surgery, and preferencesregarding recovery time and risk of dyspareunia (algorithm 1). Given the current data, abdominal sacral colpopexyoffers better anatomic outcomes than SSLS for most women undergoing apical prolapse repair. A vaginal approachis a reasonable alternative for women with primary prolapse who are having concomitant vaginal surgery, riskfactors for mesh­related complications (eg, smoking, immunosuppression), or who place a high priority on a shortrecovery period or avoiding an abdominal incision. (See "Overview of transvaginal placement of mesh for prolapseand stress urinary incontinence" and "Wound infection following repair of abdominal wall hernia".)

Uterosacral ligament suspension (ULS) and iliococcygeus suspension are other transvaginal approaches for apicalprolapse repair. There are no comparative studies between ULS and abdominal sacral colpopexy. Thus, anyrecommendation regarding using an abdominal versus vaginal approach would have lower confidence due to thelack of direct evidence for all transvaginal procedures. (See 'Uterosacral ligament suspension' below and'Iliococcygeus suspension' below.)

Concomitant repair of other sites of prolapse — Apical prolapse almost always coexists with other sites ofPOP (anterior or posterior). It is controversial whether repair of apical prolapse is sufficient to support the anteriorand posterior vaginal walls or if additional procedures are required to address anterior and/or posterior prolapse. Ifthe vaginal muscularis is well suspended at the apex, many anterior and posterior defects will also resolve;conversely, correction of anterior or posterior prolapse does not repair apical descent. Anterior vaginal wallprolapse, in particular, is highly correlated with apical prolapse. The approach to concomitant repair of multiplesites of prolapse varies by surgical route and by site of prolapse. A detailed discussion of the concomitant repair ofmultiple sites of prolapse can be found separately. (See "Pelvic organ prolapse in women: Choosing a primarysurgical procedure", section on 'Concomitant repair of apical and anterior or posterior prolapse'.)

Concomitant surgery for stress urinary incontinence — Many women with apical prolapse have coexistingurinary incontinence, as noted above. (See 'Evaluation of urinary dysfunction' above.)

Burch colposuspension performed concurrently with abdominal sacral colpopexy is discussed below. (See'Concomitant Burch colposuspension' below.)

Women with symptomatic urinary incontinence — Women with symptoms of both POP and stressincontinence are treated with a combined prolapse repair and continence procedure. (See "Pelvic organ prolapseand stress urinary incontinence in women: Combined surgical treatment", section on 'Symptomatic prolapse andincontinence'.)

Women at risk for occult urinary incontinence — For women with stage II or greater POP who areundergoing abdominal sacral colpopexy, high quality data support a concomitant Burch colposuspension ratherthan sacral colpopexy alone. For continent women undergoing transvaginal prolapse repair, the decision of whetherto perform a concomitant midurethral sling depends upon patient preference regarding the risk of developing stressurinary incontinence (SUI) compared with the risk of perioperative complications.

Combined surgery for POP and stress incontinence is discussed in detail separately. (See "Pelvic organ prolapseand stress urinary incontinence in women: Combined surgical treatment", section on 'POP with no symptoms ofSUI' and "Pelvic organ prolapse and stress urinary incontinence in women: Combined surgical treatment", sectionon 'Summary and recommendations'.)

EVALUATING APICAL PROLAPSE PROCEDURES — Surgical outcomes of pelvic organ prolapse (POP)treatments have ranged over the years from patients’ reports that they are “happy or cured” to strict anatomiccriteria for cure regardless of patient satisfaction. Improvement in objectively measured outcomes after surgery donot always correspond to patient satisfaction [15,16]. More recently, experts agree that outcomes literature shouldinclude both a measure of subjective cure (based upon the patient's report of cure or improvement) and a measureof objective cure using a validated POP measuring system. A study looked at cure rates using a variety ofanatomic and subjective definitions in a cohort of women two years after abdominal sacral colpopexy [41].

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Reported cure rates range widely, from 19 percent to 97 percent, depending on the definition used with patientreports of no bulge beyond the hymen being most associated patients’ own assessment of improvement. Thesedata should not be over­interpreted to mean objective outcomes are not valuable, as the follow­up period in thisstudy was short (only two years) and anatomic outcomes tend to worsen over time.

ABDOMINAL SACRAL COLPOPEXY — Abdominal repair of apical prolapse is performed by securing theanterior and posterior vaginal walls via surgical mesh to the anterior longitudinal sacral ligament overlying thesacral promontory. This reestablishes a nearly horizontal vaginal axis [42]. The ventral abdominal wall and roundligaments should never be used because of the high risk of recurrent prolapse.

Abdominal sacral colpopexy (attachment between the sacral promontory and the vagina vault in women who haveundergone total hysterectomy) is the most commonly performed procedure. Uterine or cervix sparing proceduresinclude: sacral hysteropexy (attachment between the sacral promontory and the lower uterus) and sacralcervicopexy (attachment between the sacral promontory and the cervix).

Typically, a hysterectomy is done at the time of apical pelvic organ prolapse (POP) repair in women withuterovaginal prolapse. While no prospective comparative studies are available to determine if outcomes areimproved with concomitant hysterectomy, several small studies suggest that POP outcomes are not worse andoperating times are shorter with uterine preservation [43,44]. A retrospective cohort study compared three groups(hysterectomy plus sacral colpopexy, sacral hysteropexy, and hysterectomy plus uterosacral suspension) andshowed a six­fold increase in POP recurrence in the uterosacral suspension group [45].

Concomitant hysterectomy at the time of prolapse repair is discussed in detail separately. (See "Pelvic organprolapse in women: Choosing a primary surgical procedure", section on 'Concomitant hysterectomy'.)

Procedure — Open abdominal sacral colpopexy is performed through a lower abdominal incision, typically aPfannenstiel, although there are increasing numbers of sacral colpopexies being done laparoscopically or withrobotic­assisted laparoscopic procedures.

A commonly performed technique is to attach a permanent mesh to the posterior vagina to the level of the rectalreflection and to the anterior vagina for a distance of 4 cm, or just above the bladder trigone. It is acceptable to usea mesh fashioned into a Y configuration or to use two separate strips of mesh. Alternatively, the posterior meshmay extend to the perineal body, adding support to this area (sacral colpoperineopexy). Two rows of sutures arethen used to widely attach the mesh to the vagina to distribute the tension; the sutures should approximate themesh to the vaginal walls for a distance of several centimeters. Permanent sutures are typically used to attach themesh to the vagina and sacrum. Secondary to concern about vaginal erosion of permanent sutures, somesurgeons are starting to use delayed absorbable sutures. In the Colpopexy and Urinary Reduction Efforts (CARE)trial (a randomized trial that compared abdominal sacral colpopexy with and without Burch colposuspension) of 322women undergoing abdominal sacral colpopexy with permanent sutures, only three participants had a vaginalerosion of the permanent suture in the first two years after surgery [46]. The suture was simply removed in allthree patients; two healed without further problem, and the other was lost to follow­up. Given the lack of highquality data supporting comparable anatomic and/or symptomatic outcomes with use of delayed absorbablesutures and the minimal risks associated with permanent suture, patients should be counseled appropriately ifnonpermanent sutures are used.

Failure to attach the mesh anteriorly results in anterior vaginal wall recurrence rates of almost 30 percent [47]. Theoptimal approach for posterior vaginal wall attachment is unclear; however, simply attaching the mesh to therectovaginal septum to maintain continuity with the perineal body results in high success rates [48]. The mesherosion rates reported from abdominovaginal attachment of the mesh to the perineal body have varied widely (7 to40 percent) [49,50].

After exposing the presacral space, the free end of the mesh is attached to the anterior longitudinal ligament at thesacral promontory using two or three permanent sutures.

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Avoiding presacral hemorrhage — Laceration of the presacral venous plexus leads to profuse hemorrhage.Careful dissection must be used near the sacrum. The sutures are placed through the sacral (anterior longitudinal)ligament just below the sacral promontory since placement lower on the sacrum, at the S3 to S4 level, is morelikely to result in presacral hemorrhage and placement on the promontory may deviate the vaginal axis too farforward.

Choosing a surgical mesh — Simple suturing of the apical vaginal skin to the sacrum is also regarded asinsufficient fixation and likely to result in recurrent prolapse. The best type of mesh and suture material remainscontroversial, but most surgeons agree that synthetic nonabsorbable materials should be used. Synthetic meshsacral colpopexy has consistently outperformed the biologic graft materials (autologous, allogeneic, xenograft) inrandomized trials, but at the expense of higher mesh erosion rates [28,42,51]. In a systematic review of 65 studies(three were randomized trials), the average rate of synthetic mesh erosion was 3.4 percent, the lowest rate was forpolypropylene (0.5 percent) compared with other types of synthetic mesh, such as polyethylene orpolytetrafluoroethylene (3.1 to 5.0 percent) [28].

On rare occasions, a surgeon may also face an intraoperative decision on whether to use synthetic or biologicmesh in the face of a bowel injury or concomitant sigmoid resection with reanastomosis for the treatment of rectalprolapse. Since it is often not advisable to place synthetic nonabsorbable materials during procedurescontaminated by bowel contents, these choices should be determined by carefully weighing the risk and benefitsfor an individual patient.

Surgical treatment of prolapse of the vaginal apex with vaginal mesh kits is increasingly common, althoughoutcome data are lacking [52]. Similar to anterior vaginal mesh placement, use of apical vaginal mesh may beassociated with significant complications [27,53].

Outcome — A systematic review of studies from 1966 to 2004 reported that anatomic success rates afterabdominal sacral colpopexy range from 76 to 100 percent with a 4 percent (range 0 to 18 percent) reoperation ratefor prolapse [28].

The need for concomitant anterior or posterior vaginal wall repairs at the time of sacral colpopexy is controversial.This topic is discussed in detail separately. (See "Pelvic organ prolapse in women: Choosing a primary surgicalprocedure", section on 'Abdominal route'.)

One­year outcomes of the CARE trial showed that abdominal sacral colpopexy performed with or without posteriorvaginal wall repair resulted in statistically and clinically significant improvements in bowel symptoms, includingobstructive defecation and posterior vaginal wall topography regardless of concomitant posterior repair [8].Likewise, there was no difference in anterior vaginal wall support in women who had a concomitant paravaginalrepair and those who did not. Another study of 149 women with advanced prolapse who underwent sacralcolpopexy without any concomitant repairs demonstrated excellent anatomic outcomes one year after surgery [54].

Two­year outcomes of the CARE trial showed that 95 percent of women had support of the vaginal apex within 2cm of the total vaginal length and 3 percent had undergone reoperation for prolapse [55]. Women reportedsignificant improvement in pelvic floor symptoms and sexual function using validated questionnaires. In addition,correction of apical prolapse via abdominal sacral colpopexy with or without Burch colposuspension significantlyreduced bladder symptoms other than incontinence, both irritative (eg, urgency, frequency, nocturia) andobstructive (eg, intermittent flow, straining to void, sensation of incomplete emptying, poor stream) [56]. At one­year, participants reported a significant decrease in obstructive defecatory symptoms, fecal incontinence andanorectal pain [8]. New onset fecal incontinence with activity, as well as pain prior to and with defecation, weremore likely to be reported by women who had a concomitant posterior repair procedure than by those who did not.

Seven­year outcomes of the CARE trial showed that the estimated probabilities of treatment failure for theurethropexy group and the no urethropexy group, respectively, were 0.27 and 0.22 for anatomic POP and 0.29 and0.24 for symptomatic POP [57]. Mesh erosion probability at seven years was 10.5 percent. Long­term studiesreport that, at 10 to 14 years after abdominal sacral colpopexy, 2 to 26 percent of women had undergone

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reoperation for prolapse [58].

Complications — The most frequently reported intraoperative and postoperative complications of open abdominalsacral colpopexy include [28]:

Studies consistently report that gastrointestinal complications, such as small bowel obstruction or ileus, occurafter approximately 1 to 5 percent of abdominal sacral colpopexy procedures [28,59]. In the CARE trial, 4 of 322women required reoperation for small bowel obstruction and all were associated with incisional problems. Nointraoperative bowel injuries were reported [59].

Presacral hemorrhage is the most concerning intraoperative complication and can have life­threateningconsequences. Reconstructive surgeons should be prepared to manage presacral hemorrhage and have bone wax,concave thumbtacks, and thrombin immediately available. (See "Management of hemorrhage in gynecologicsurgery" and "Management of hemorrhage in gynecologic surgery", section on 'Presacral bleeding'.)

Mesh erosion rates vary depending on the type of mesh used. Synthetic nonabsorbable mesh is typically usedand, as noted above, a systemic review found that the average rate of erosion for all types of synthetic mesh was3.4 percent, with a rate of 0.5 percent for polypropylene mesh [28]. (See 'Choosing a surgical mesh' above.)

Several studies report higher mesh erosion rates when sacral colpopexy is performed with concomitant totalhysterectomy, but this is not universally reported [46,60]. In a large multicenter study of women undergoingabdominal sacral colpopexy, concomitant total hysterectomy was more common in women who developed a meshor suture erosion (60 percent versus 24 percent), resulting in a nearly five­fold increased risk of mesh erosion inwomen with a concomitant hysterectomy [46]. Some data suggest that smoking and use of ePTFE mesh (Gore­tex) are also risk factors for mesh erosion following sacral colpopexy [46,61].

Laparoscopic or robotic procedures — Sacral colpopexy is traditionally performed through a laparotomy;however, conventional and robot­assisted laparoscopic approaches have gained popularity. In addition, single portlaparoscopic procedures have been reported [62]. (See "Robot­assisted laparoscopy" and "Abdominal accesstechniques used in laparoscopic surgery", section on 'Single­incision surgery (SIS)'.)

Observational data suggest that the conventional laparoscopic and robot­assisted routes result in a shorter hospitalstay (eg, one to two versus three to four days), faster time to recovery, and less postoperative pain thanlaparotomy, with comparable short­term efficacy [27,63­66]. Some retrospective studies have also found asignificant decrease in blood loss (eg, 60 to 150 mL less) with laparoscopic procedures [63,65]. A disadvantage oflaparoscopic procedures is a longer operative duration (eg, one to two hours longer). In addition, robotic proceduresare more costly than laparotomy or conventional laparoscopy [67,68]. A United Kingdom multicenter randomizedequivalence trial compared open to laparoscopic sacral colpopexy. At one year, there were no differences inanatomic or subjective pelvic floor outcomes; however, blood loss, postoperative hemoglobin values, and hospitalstay were better in the laparoscopic arm [69]. Many surgeons have adopted a higher sacral fixation point whenperforming laparoscopic and robotic procedures. Case reports of vertebral discitis [70] and cadaveric and magneticresonance imaging studies suggest that to avoid disc complications, sutures should be placed inferior to thepromontory to avoid the intravertebral disc [71,72].

Performing sacral colpopexy requires suturing, which is more difficult to do with conventional than during robot­

Incisional problems ­ 4.6 percent

Blood transfusion ­ 4.4 percent

Ileus ­ 3.6 percent

Thromboembolic event ­ 3.3 percent

Cystotomy ­ 3.1 percent

Enterotomy ­ 1.6 percent

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assisted laparoscopy. For this reason, some surgeons prefer robotic­assisted laparoscopy. However, tworandomized trials have found that robotic compared with conventional laparoscopic sacral colpopexy has a longeroperative duration (24 to 67 minutes longer) and higher costs, with similar complication rates and short­termoutcomes [73,74].

Although further studies are necessary to ascertain the role for robotic versus laparoscopic sacral colpopexy,current data suggest that the laparoscopic route may be more cost effective and confer some benefits to thepatients.

CONCOMITANT BURCH COLPOSUSPENSION — Burch colposuspension (also referred to as retropubicurethropexy) is an effective procedure for the treatment and prevention of stress urinary incontinence (SUI). Thisprocedure had been widely used, but has now been largely replaced by midurethral sling procedures. This is due tothe increased operative duration and risk of complications for a Burch procedure compared with a midurethral sling.(See "Surgical management of stress urinary incontinence in women: Choosing a primary surgical procedure",section on 'Midurethral slings versus other procedures'.)

In current practice, Burch colposuspension is typically performed mostly in combination with an abdominalsacrocolpopexy in women with symptomatic SUI or as a prophylactic procedure in women with advanced prolapsewho are likely to develop SUI after sacral colpopexy. The two procedures are both performed via an abdominalincision, and thus, traditionally have been done together. However, some surgeons prefer to perform a midurethralsling procedure even for women undergoing abdominal sacral colpopexy.

Combined prolapse and continence surgery and choice of a concomitant procedure are discussed in detailseparately. (See "Pelvic organ prolapse and stress urinary incontinence in women: Combined surgical treatment"and "Surgical management of stress urinary incontinence in women: Choosing a primary surgical procedure",section on 'Coexistent sui and pelvic organ prolapse'.)

Indications and preoperative evaluation — The Burch colposuspension is indicated for women planning surgicaltreatment of SUI, and for women who prefer this procedure to other types of surgery. Burch colposuspension isintended to support the bladder neck and proximal urethra to prevent downward descent of these structures and toallow for urethral compression; therefore, it is not an appropriate operative choice for women without urethralhypermobility.

The preoperative evaluation of women prior to a Burch procedure is the same as for other surgical treatments forSUI. (See "Surgical management of stress urinary incontinence in women: Preoperative evaluation for a primaryprocedure".)

Outcome — Burch colposuspension is an effective procedure for the treatment of SUI. Randomized trial datashow that the long­term success rate is comparable or slightly lower than for midurethral slings (70 versus 63percent in one trial [75]) or fascial slings (24 versus 31 percent in one trial [76,77]). The success rates reported inthese trials represent a rigorous composite measure of several endpoints (subjective and objective outcomes).Patient satisfaction rates after both procedures are much higher, approaching 80 percent.

Many trials evaluating continence procedures exclude women who are undergoing concomitant prolapse repair.The only trial to evaluate Burch procedures that included concurrent prolapse repair procedures was the StressIncontinence Surgical Treatment Efficacy Trial (SISTEr) [76,77]. The SISTEr trial assigned 655 women at 9 UnitedStates sites with SUI to undergo Burch colposuspension or a rectus fascial sling procedure. Forty­eight percent ofwomen in the Burch arm underwent concomitant prolapse repair, including apical suspension and/or anterior andposterior repair. Using a stringent composite outcome, overall success at 24 months was significantly lower afterBurch colposuspension (38 versus 47 percent), although satisfaction was considerably higher at 78 percent (86percent in sling arm). By five years after surgery, overall continence rates decreased and remained significantlylower in the Burch arm than in the sling arm (24 versus 31 percent). No high quality data exist comparing Burchcolposuspension to midurethral sling in women with prolapse. Forty­eight percent of women assigned to Burch and55 percent to sling underwent concomitant prolapse surgery, including anterior repairs, vaginal and abdominal

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apical suspension procedures, and hysterectomy. Continence outcomes did not differ based on concomitantprolapse surgery. There was no clinically or statistically significant interaction between concomitant surgery andincontinence outcomes in either arm [76].

Burch colposuspension is also safe and effective for the prevention of SUI in women undergoing abdominal sacralcolpopexy for apical prolapse. This was demonstrated in the Colpopexy and Urinary Reduction Efforts (CARE)trial, which is described in detail separately. (See "Pelvic organ prolapse and stress urinary incontinence inwomen: Combined surgical treatment", section on 'Abdominal approach'.)

Procedure — Burch colposuspension is most commonly performed through a low transverse abdominal incision; itmay also be performed laparoscopically.

Regardless of route of access, in a Burch colposuspension, the avascular retropubic space is exposed bilaterallyand the bladder mobilized from the pubic symphysis. With the surgeon’s nondominant hand in the vagina elevatingthe anterior vaginal wall, two sutures are placed near full­thickness through the anterior vagina on either side of themidurethra (figure 5 and figure 6 and figure 7). Two additional sutures are placed through the vagina on either sideof the urethrovesical junction. All sutures are then placed through Cooper’s ligament with the midurethral suturesmedial on the ligament to the urethrovesical junction sutures. The suture arms are tied above Cooper’s ligament sothe urethrovesical junction is supported; there should generally be an approximately 2 cm suture bridge betweenthe vagina and Cooper’s ligament to prevent over­correction of the urethrovesical junction and urinary retention.Intraoperative cystoscopy should be performed after procedure to ensure no sutures were placed into the bladderand bilateral brisk efflux of urine.

Laparoscopic route — Burch colposuspension can be performed laparoscopically. There is no difference inefficacy between the open and laparoscopic approaches to the Burch procedure, but laparoscopic procedures havesomewhat lower complication rates [78,79]. We suggest laparoscopic rather than open Burch colposuspension.However, routine use of the laparoscopic Burch procedure is limited by the availability of surgeons with theappropriate skills. Thus, open colposuspension should be performed if the surgeon is not experienced in thelaparoscopic technique for this procedure.

Open and laparoscopic Burch colposuspension were compared in a meta­analysis of 10 randomized trials [80].Short­term subjective cure rates for laparoscopic compared with open Burch colposuspension were similar (at 18­month follow­up: 78 versus 83 percent, RR 1.0, 95% CI 0.9­1.0) [80]. The lower rate of perioperative complications(eg, infection, hemorrhage) for laparoscopic procedures just reached statistical significance (15 versus 18 percent,RR 0.74, 95% CI 0.58­0.96). Laparoscopic procedures were an average of 14 minutes longer. The mainadvantages of the laparoscopic approach were a shorter hospital stay (an average of one day) and a faster returnto normal activity (10 days sooner). The long­term effectiveness of open Burch colposuspension ranges from 70 to90 percent at 5 to 10 years following surgery [81­83].

Data also suggest similar outcomes after laparoscopic Burch compared with midurethral sling procedures. Onerandomized trial reported incontinence rates of 58 and 48 percent four to eight years after laparoscopic Burchcolposuspension or midurethral sling [84].

When using this approach, some surgeons modify the technique to use mesh and tackers rather than suturing,which can result in significant morbidity [85]. Given the paucity of outcome data and morbidity using thesemodifications, we do not modify the procedure this way in our practice.

Complications

Voiding dysfunction and urgency incontinence — Historically, Burch colposuspension was associated withhigh rates of de novo voiding dysfunction and urgency urinary incontinence. However, well designed studies havereported low complication rates. In the SISTEr randomized trial, postoperative urinary function complicationsincluded: prolonged voiding dysfunction (2 percent) and new onset urgency incontinence (3 percent) [76]. Inanother randomized trial, there was no significant difference in the rate of voiding dysfunction in women who

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underwent Burch compared with a midurethral sling procedure [86]. For Burch, the proportion of women whorequired catheterization at six­month follow­up was 8 percent, which was higher than in the SISTEr trial, but thisdecreased with time. Two years after surgery, 2.4 percent of women required intermittent self catheterization.

Urinary tract infection — Postoperative urinary tract infection is the most commonly reported adverse eventfollowing a Burch procedure, 32 to 50 percent in randomized trials [76,86]. The incidence of cystitis or symptomsof urinary tract infection (with or without positive culture) is highest in the first 6 months, but this issue persists in2 to 9 percent of women up to 24 months after surgery [87].

Apical prolapse — Early reports suggested rates of enterocele of up to 17 percent following Burchcolposuspension [88,89]. This is thought to occur as a result of the more anterior angulation of the vagina as aresult of the procedure, allowing the posterior compartment to become more subject to the pressure transmissionof intraabdominal pressure. As an example, in one study, nearly 5 percent of women with stage II prolapserequired reoperation rate for prolapse [86]. On physical examination, the rate of women with apical prolapseincreased from 21 percent preoperatively to 63 percent at 24 months; 18 percent of the women with prolapse weresymptomatic. Of course, this study did not include women who underwent concomitant apical prolapse repair.

Other complications — Additional adverse events reported in women who underwent the Burchcolposuspension include: incidental cystotomy (3 percent), surgical wound complications requiring surgery (2.4percent), recurrent cystitis leading to diagnostic cystoscopy (1.5 percent), bleeding (1 percent), ureteral injury (1percent), incidental vaginotomy (0.5 percent), ureteral vaginal fistula (0.5 percent), erosion of suture into thebladder (0.5 percent), and pyelonephritis (0.5 percent) [76].

Summary

VAGINAL PROCEDURES — When the vaginal route is used, the vaginal apex is suspended to a ligament in thepelvis, either the sacrospinous ligament, iliococcygeus fascia, or the uterosacral ligament. Of these, only thesacrospinous is a true ligament. This is typically performed in women who have undergone total hysterectomy,although cervix and uterine sparing procedures are possible. Vaginal procedures require a sufficient vaginal lengthto reach the supporting ligament.

Sacrospinous ligament suspension (SSLS) was the most commonly used transvaginal procedure for apicalprolapse repair. However, more recently, uterosacral ligament suspension (ULS) has gained popularity. Theuterosacral technique was introduced in the 1920s, but in the half­century that followed, reconstructive surgeonsseemed to shift focus away from the uterosacral ligaments to more sturdy sites of fixation, such as the SSLS [90].High rates of recurrent anterior vaginal wall prolapse are common after SSLS, so surgeons attempted to find amore anatomic site to attach the apex to prevent defects in other compartments. Uterosacral and iliococcygeussuspension are two such attempts.

In general, surgeons in the United States use a ULS when performing concomitant vaginal hysterectomy, whileSSLS is used more commonly for post­hysterectomy prolapse repair. However, both procedures may beperformed in women with a prior hysterectomy or at the time of concomitant hysterectomy.

No high quality evidence is available to guide surgeons regarding uterine preservation at the time of vaginal apical

Burch colposuspension is a safe, effective treatment for SUI in women with and without concomitant pelvicorgan prolapse (POP).

Open and laparoscopic Burch colposuspension result in similar subjective and objective outcomes for thetreatment of SUI in women.

Open and laparoscopic Burch colposuspension result in similar outcomes to retropubic midurethral slingprocedures.

Burch colposuspension should be considered for the prevention of SUI in stress continent women undergoingabdominal sacral colpopexy.

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suspension procedures. A small, nonrandomized prospective trial compared women undergoing sacrospinouscervicopexy with uterine preservation and those undergoing SSLS with vaginal hysterectomy [91]. Uterinepreservation was associated with less blood loss and shorter operating times. Anatomic pelvic organ prolapse(POP) outcomes and reoperation for POP were similar for both groups. Uterine conservation at the time ofprolapse repair is discussed in detail separately. (See "Pelvic organ prolapse in women: Choosing a primarysurgical procedure", section on 'Concomitant hysterectomy'.)

Sacrospinous ligament suspension — SSLS (also referred to as sacrospinous ligament fixation) is the mostcommonly studied transvaginal procedure for treating vaginal vault prolapse.

Although SSLS may also improve anterior vaginal wall prolapse, it is less effective for this indication. Thus,women with large anterior wall defects in addition to apical defects may benefit from another type of prolapserepair, which better supports the anterior vagina or concomitant anterior colporrhaphy. (See "Pelvic organ prolapsein women: Choosing a primary surgical procedure", section on 'Concomitant repair of apical and anterior orposterior prolapse'.)

SSLS is generally performed unilaterally. Most surgeons prefer the right side since the bowel enters the rectum onthe left side [32]. Some surgeons have proposed bilateral SSLS, although the value of this modification has notbeen proven [92,93]. Use of the bilateral technique depends upon adequate vaginal length and width.

Procedure — Before starting the procedure, the patient is examined to ensure that the vagina is long enoughto reach the sacrospinous ligament. Women who do not have sufficient vaginal length for SSLS may becandidates for abdominal sacral colpopexy.

The sacrospinous ligament extends from the ischial spines to the lower portion of the sacrum and coccyx (figure 8and figure 9). The coccygeus muscle follows the same path as the sacrospinous ligament; together they arereferred to as the coccygeus muscle­sacrospinous ligament complex (figure 10). The ligament can be identified onpelvic examination by palpating the ischial spine and tracing posteriorly and medially to the sacrum [94]. Markingsutures are placed on the vaginal epithelium at the site where it will attach to the sacrospinous ligament.

Several techniques are commonly used when performing a SSLS. In one modification, the perirectal space isentered by opening the posterior vagina in the midline from the perineal body to the apex. The vaginal epithelium isthen separated from the underlying muscularis. The dissection is continued to the level of the ischial spine. Therectovaginal space is opened by gently pushing the rectum medially then perforating the rectal pillar (areolar tissuethat extends from the rectum to the arcus tendineus fascia pelvis and overlies the levator muscle) (figure 11) [95].

Once the perirectal space is entered, the ischial spine can be palpated and the ligament found medially. A longright angle retractor (eg, Briesky­Navratril) is placed on the ischial spine to protect the pudendal neurovascularbundle and two others are used to retract the bladder superiorly and the rectum medially.

With the ligament clearly visible, two to three sutures are placed through the ligament approximately one and one­half finger­breadths medial to the ischial spine. Several techniques and devices are available to assist placing thesuture through the ligament (eg, Miya hook, Deschamps ligature carrier, laparoscopic suturing devices) [32].

After securing the sutures to the ligament complex, each of the sutures is placed through the muscularis on theundersurface of the posterior vaginal epithelium and tied by a pulley stitch, while the free end of the suture is held.Traction on the free end of the suture draws the vaginal apex directly onto the sacrospinous ligament and thesuture is tied.

Another common modification of the SSLS is the "Michigan Modification" technique [96,97]. In the MichiganModification, all four vaginal walls are directly approximated to the sacrospinous ligament (instead of just theposterior vaginal wall). The point on each vaginal wall that reaches the ligament is identified and the interveningdiamond of vaginal epithelium is excised. The sutures are placed through the sacrospinous ligament, as describedabove, then sewn through to both the anterior and posterior vagina and tied to the ligament. A long­lastingabsorbable suture is used. The goal of this modification is to decrease the risk of an anterior vaginal wall

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recurrence; although it has not been evaluated in comparative studies with standard SSLS, case series report highlong­term satisfaction rates after the procedure. A single site study reported that 76 percent of women were“completely or very” satisfied at least five years after SSLS [97].

Avoiding nerve entrapment — There are several techniques to decrease the risk of entrapment of thesciatic nerve or its branches when the sutures are placed. One approach is to perforate the sacrospinous ligamentwith the needle in a vertical rather than horizontal orientation, thereby attempting to place the suture parallel to thecourse of these nerves. Also, since these nerves did not travel in the lateral third segment of the sacrospinousligament, placement of the fixation sutures within this region is another approach to decrease the risk of nerveinjury. Regional anesthesia of prolonged duration should not be used postoperatively in women undergoing SSLS,since this may mask the symptoms of nerve entrapment. (See 'Complications' below.)

Outcome — In a literature review of mostly observational studies, cure rates of prolapse­related symptomsranged from 70 to 98 percent (only four studies reported subjective results) and the range of objective cure rateswas 67 to 97 percent [32]. Recurrence of apical prolapse after SSLS has been reported in 2 to 19 percent ofwomen and of anterior vaginal wall prolapse in 6 to 29 percent [29,30,96,98­105]. Therefore, as noted above,women with large anterior wall defects in addition to apical descent may benefit from an additional type of prolapserepair, which more directly addresses support of the anterior vagina. A study that followed women for 2 to 15 yearsreported that 16 percent had prolapse symptoms [106].

Regarding bowel symptoms, relief of constipation was reported in several studies [32]. Data regarding fecalincontinence were inconsistent, with some studies reporting improvement in patients with preoperative symptoms,and others reporting de novo incontinence in some patients.

Complications — Serious complications are uncommon following SSLS. A literature review of mostlyobservational studies that included 1922 SSLS procedures reported the following complication rates [32]:

Infectious complications are the most common type of adverse event, and are generally mild (eg, cystitis).

Lower urinary tract complications involving ureteral impingement or injury may also occur; cystotomy is infrequent[99]. Enterotomy and postoperative bowel complications are rare, as the procedure is meant to be extraperitoneal.A discussion of lower urinary tract injury in gynecologic surgery can be found separately. (See "Urinary tract injuryin gynecologic surgery: Evaluation and management".)

Hemorrhage during SSLS is most commonly due to laceration of the inferior gluteal or pudendal vessels [107].Pudendal hemorrhage is best treated by tightly packing the ischiorectal fossa and waiting for hemostasis. Furtherdiscussion of hemorrhage during gynecologic surgery can be found separately. (See "Management of hemorrhagein gynecologic surgery".)

Postoperative pain or nerve dysfunction is likely due to injury to the branches of the sciatic nerve that cross thesacrospinous ligament, based on anatomic studies in cadavers [108]. If the sciatic nerve is entrapped in thesuture, the classic triad of nerves entrapment will present (paresthesias, pain, temporary relief with injection of

Cystitis – 4.5 percent

Fever, secondary wound healing, abscess, or septicemia – 4.1 percent

Ureteral kinking, problems with urination – 2.9 percent

Pain (unclassified, gluteal, or bladder) – 2.0 percent

Hemorrhage/blood transfusion – 1.9 percent

Nerve damage (eg, sciatic nerve) – 1.8 percent

Injury to pelvic organs – 0.8 percent

Pelvic or vaginal vault hematoma – 0.4 percent

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local anesthetic). The patient typically awakens with severe buttock pain radiating down the posterior leg. Delay indiagnosis and treatment can result in permanent neuropathy; therefore, as noted above, regional anesthesia ofprolonged duration should not be used for this type of surgery. Upon diagnosis of nerve entrapment, the patientshould be taken back to the operating room immediately to have the sutures removed.

The effect of SSLS on sexual function has not been well studied. Many studies have not evaluated this outcomeand some women who undergo apical prolapse repair are not sexually active [32]. The rate of dyspareunia was 36percent in pooled data from three randomized trials in which SSLS was compared with abdominal sacral colpopexy[26]. (See 'Abdominal versus vaginal approach' above.) In contrast, observational studies have reporteddyspareunia in 3 to 10 percent of women who underwent SSLS [32].

Uterosacral ligament suspension — ULS has increased in popularity. The uterosacral ligaments are thought tobe one of the main connective tissue supports for the upper vagina.

Procedure — This procedure is typically performed transvaginally, but it can also be done laparoscopically.(See "Laparoscopic surgery for repair of pelvic floor defects", section on 'Uterosacral ligament vault suspension'.)The uterosacral ligaments are made of smooth muscle, connective tissue, and nerves. They originate from the S1to S4 vertebrae to insert near the cervix (figure 12).

The key to successful ULS is simultaneous correction of all defects in the apical endopelvic fascia. The anteriorand posterior vaginal muscularis [109] near the apex should be directly approximated to ensure the continuity ofthe vaginal muscularis.

In the most commonly performed ULS technique, the anterior and posterior vaginal walls are opened in the midline;the enterocele sac is identified, if present [110]. The peritoneal cavity is entered and the uterosacral ligamentsidentified. An Allis clamp can be used to tent the uterosacral ligament, making it easier to identify. The rectum isretracted medially.

Two or three permanent sutures are passed through the uterosacral ligament on each side. These are placed 1.5centimeters medial and 1.5 centimeters posterior to the ischial spine. The sutures are numbered sequentially withlabeled Kelly clamps, one through six, to facilitate vaginal placement. In serial fashion, one arm of each suture ispassed through the anterior muscularis surrounding the vaginal apex and the other through the posterior endopelvicfascia. The sutures thereby cross the width of the vaginal apex. All sutures are then tied, re­approximating theanterior and posterior vaginal muscularis, closing any potential enterocele defect, and elevating the vaginal apextoward the sacrum.

Retrospective chart review of 248 procedures found that 1 percent with permanent sutures had loss of supportbeyond the hymen versus 6 percent in delayed absorbable group [111].

Avoiding or detecting ureteral injury — The average distance from the lateral aspect of the suspensionsutures to the medial border of the ureters was 14 mm in a cadaver study [112]. Cystoscopy should be performedafter tying the sutures due to a significant rate of ureteral kinking during this procedure.

Avoiding nerve entrapment — Cadaveric studies suggest a higher risk of sacral nerve entrapment whenuterosacral sutures are placed using a deep, dorsal, posterior technique and suggest that sacral nerve injury maybe minimized by tenting the ligament ventrally prior to placing sutures [113].

Outcome — A meta­analysis of 10 observational studies evaluated ULS in 930 women; a successful anatomicoutcome was defined as POP­Q stage 0 or 1 [114]. The rates of a successful outcome for each compartmentwere: apical (98 percent), anterior (81 percent), and posterior (87 percent). Meta­analysis of subjective outcomeswas not possible due to methodologic differences across studies; relief of prolapse symptoms was reported by 82to 100 percent of patients (this outcome was only reported by five studies). Reoperation for symptomatic prolapsewas reported in 9 percent of women (reported by four studies). There were few reports of significant improvementin bowel symptoms.

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Complications — Complications of ULS are uncommon. The meta­analysis described in the precedingsection reported the following complications rates [114]:

Ureteral obstruction is the most common complication. Cystoscopy should be done routinely at the completion ofeach case to prevent delayed recognition of ureteral injury. Ureteral kinking from the uterosacral suture is foundduring routine intraoperative cystoscopy in up to 11 percent of cases [115,116]. If both ureters do not efflux briskly,the most lateral suture (closest to the ureter) on that side should be removed. Typically, removing this suture issufficient to restore brisk ureteral efflux without further sequelae, although ureteral injury requiringureteroneocystostomy has been reported. (See "Diagnostic cystourethroscopy for gynecologic conditions", sectionon 'Indications'.)

The sacral nerves can be ligated if ULS sutures are placed lateral to the ligament fibers or too deep into the pelvicsidewall [112,117,118]. In a retrospective case series, 7 of 182 women who had undergone a ULS developedsensory neuropathy and pain in the S2 to S3 dermatomes immediately postoperatively [118]. Three of thesewomen had reduction of pain when suspension sutures were removed within four days after surgery.

Iliococcygeus suspension — Iliococcygeus suspension is similar to the SSLS, but uses the iliococcygeus fasciaover the levator plate instead of the sacrospinous ligament. Proposed advantages of the iliococcygeus suspensioncompared with SSLS are lower risks of anterior vaginal wall recurrence and injury to the pudendal neurovascularbundle, but these benefits remain unproven. There are few data regarding this procedure. In a case­control study of128 women, one­ to two­year follow­up, subjective success rates were similar for iliococcygeus suspension andSSLS (91 versus 94 percent), but objective success occurred significantly more frequently in women whounderwent SSLS (53 versus 67 percent) [119]. Perioperative complications were similar for the two procedures.Some data suggest that vaginal length may be longer following iliococcygeus suspension compared with SSLS[120].

Vaginal mesh kits — One systematic review of articles reporting outcomes of vaginal mesh procedures for apicalprolapse concluded that vaginal mesh seemed to effectively cure apical POP; however, long­term anatomic andfunctional data were needed, as well as comparative studies to traditional POP repairs [53]. High complicationrates were found with apical mesh procedures (up to 17.6 percent) with mesh erosion and dyspareunia mostcommon. In contrast, authors of another systematic review of vaginal mesh procedures for POP concluded thatthere were insufficient data to determine efficacy of vaginal mesh procedures for apical POP [52]. This systematicreview also found high complication rates associated with vaginal mesh placement, including graft erosion in up to30 percent, urinary tract infections in up to 19 percent, and visceral injury in up to 3 percent. A randomized trialcompared a total vaginal mesh procedure (Prolift; this device has now been removed from the market) withlaparoscopic sacral colpopexy [121]. At two­year follow­up, women in the sacral colpopexy group had asignificantly higher objective success rate (77 versus 43 percent) and a lower reoperation rate (5 versus 22percent). This study was limited by methodologic issues. Safety issues regarding transvaginal placement of meshor biografts are discussed in detail separately. (See "Overview of transvaginal placement of mesh for prolapse andstress urinary incontinence".)

Comparing among vaginal procedures — The principal choice is between SSLS and ULS for surgeonsperforming native tissue transvaginal apical prolapse repair. ULS potentially improves anterior vaginal wall supportcompared to SSLS. On the other hand, the risk of ureteral injury and need for cystoscopy for ULS aredisadvantages for this procedure compared with SSLS.

Randomized trial data suggest that the efficacy of ULS and SSLS are comparable for treating apical prolapse;however, the risks and benefits of the procedures differ slightly. The Operations and Pelvic Muscle Training in the

Ureteral obstruction – 1.8 percent

Blood transfusion – 1.3 percent

Pelvic organ injury – 0.4 percent

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Management of Apical Support Loss (OPTIMAL) randomized trial compared ULS with SSLS in 374 women withPOPQ stage 2 to 4 apical vaginal prolapse; all participants also had stress urinary incontinence and underwent aconcomitant retropubic midurethral sling procedure [122]. The primary surgical outcome was a composite measureof surgical success, defined as the absence of all of the following: (1) vaginal apical descent to more than one­third of the vaginal length; (2) anterior or posterior vaginal wall descent beyond the hymen; (3) bothersome vaginalbulge symptoms; and (4) re­treatment of prolapse by either surgery or pessary. Two years after surgery, 59.2percent of ULS and 60.5 percent SSLS met this definition of success (odds ratio [OR] 0.9, 95% CI 0.6­1.5). Therewere no significant differences between ULS and SSLS in most perioperative outcomes, including blood loss andsevere intraoperative or postoperative adverse events. However, women who underwent ULS had a significantlylower rate of neurologic pain requiring intervention (6.9 versus 12.4 percent; OR 0.5, 95% CI 0.2­1.0). Pain alsopersisted to the four­ to six­week postoperative visit in fewer women following ULS (0.5 versus 4.3 percent).Ureteral obstruction occurred in six women in the ULS group (3.2 percent) and none in the SSLS group; however,most cases were detected and treated intraoperatively. At two­year follow­up, there was no significant differencein the primary outcome between the ULS and SSLS groups (surgical success 59.2 versus 60.5 percent; OR 0.9,95% CI 0.6­1.5).

It is important to note that this trial also compared perioperative behavioral therapy with pelvic floor muscle trainingwith usual care. In a subgroup analysis of the usual care group, at two­year follow­up, ULS had a significantlylower rate of apical descent than SSLS (8.6 versus 20.8 percent; OR 0.3, 95% CI 0.1­0.9). Among women whoreceived usual care, bothersome vaginal bulge symptoms were also lower in the ULS group (15.4 versus 21.1percent), although the statistical significance was not reported. Rates of re­treatment were not reported for thissubgroup analysis. This raises the question of whether ULS is the superior procedure for most women, since mostwomen receive usual care. The pelvic floor muscle training aspect of the trial is discussed in detail below. (See'Pelvic floor muscle training' below.)

A meta­analysis of observational studies suggests ULS results in excellent apical outcomes; however, anteriorsuccess (stage 0 or I) rates were only 67 percent in women with preoperative stage III prolapse [114].

Given the available data, outcomes appear similar for ULS and SSLS. However, risks and benefits differ slightly,so patients should be counseled regarding a slightly higher risk of persistent neurologic pain that may requirereintervention after SSLS compared with the increased risk for ureteral obstruction with ULS.

POSTOPERATIVE CARE — Postoperative care is similar for both vaginal and abdominal approaches; however,recovery after abdominal sacral colpopexy may be slower than transvaginal procedures due to the abdominalincision. The postoperative course will also vary according to whether concomitant procedures were performed(eg, hysterectomy, surgery for stress urinary incontinence).

We give patients standard instructions regarding postoperative pain control, bleeding, signs of infection, andgastrointestinal function. We advise no sexual intercourse for six weeks to avoid disruption of the repair.

We see patients at two weeks postoperatively for routine follow­up. We perform a wound check and speculumexamination. Few data are available to guide postoperative care and most recommendations are based on thesurgeon's experience and preferences.

Routine discharge instructions can be found separately. (See "Patient information: Care after gynecologic surgery(Beyond the Basics)".)

Pelvic floor muscle training — Pelvic floor muscle training is often used as an initial treatment for pelvic organprolapse (POP) or stress urinary incontinence (SUI). Many clinicians also advise patients to perform theseexercises following pelvic floor reconstructive surgery. However, there is not high quality evidence to support theefficacy of perioperative use. This was investigated in the Operations and Pelvic Muscle Training in theManagement of Apical Support Loss (OPTIMAL) randomized trial (n = 374) that compared sacrospinous ligamentsuspension (SSLS) with uterosacral ligament suspension (ULS), as well as perioperative behavioral therapy withpelvic floor muscle training (BPMT) with usual care; behavioral therapy included education on behavioral strategies

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to reduce urinary and colorectal symptoms [122]. All participants also had stress urinary incontinence andunderwent a concomitant retropubic midurethral sling procedure. BPMT compared with usual care did not result ina significant difference in urinary symptoms at six months or prolapse outcomes at two years.

The surgical outcomes of the trial are discussed in detail above. (See 'Comparing among vaginal procedures'above.)

SUMMARY AND RECOMMENDATIONS

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REFERENCES

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Apical prolapse is the descent of uterus, cervix, or vaginal vault (figure 1). Common symptoms of apicalprolapse are a vaginal bulge, difficulty voiding, or constipation. (See 'Anatomy and mechanisms of injury'above.)

Surgical candidates for apical prolapse include symptomatic women who have failed or declined conservativemanagement. Prolapse is typically a chronic problem, and women often prefer surgery to conservativetherapy since successful surgery does not require ongoing maintenance to control symptoms. (See'Candidates for apical prolapse repair' above.)

Apical prolapse repair via open abdominal sacral colpopexy is more effective at restoring vaginal topographythan traditional vaginal repairs, although subjective outcomes are similar after the two types of procedures.We suggest abdominal sacral colpopexy rather than transvaginal repair for most women undergoing apicalprolapse repair (Grade 2C). (See 'Abdominal versus vaginal approach' above.)

Laparoscopic sacrocolpopexy is as effective as open sacrocolpopexy, but results in decreased blood lossand shorter hospital stays. (See 'Laparoscopic or robotic procedures' above.)

For women with apical prolapse undergoing abdominal sacral colpopexy, we recommend synthetic meshover biografts (Grade 1B). Synthetic mesh use in sacral colpopexy reduces the risk of recurrent apicalprolapse. (See "Overview of transvaginal placement of mesh for prolapse and stress urinary incontinence".)

A vaginal surgical approach is a reasonable alternative to an abdominal approach for women who cannottolerate abdominal surgery, have no risk factors for prolapse recurrence (eg, young age, obesity, stage III orIV POP, previous failed POP repair), are having concomitant vaginal surgery, have risk factors for mesh­related complications (eg, concomitant hysterectomy, smoking, immunosuppression, obesity), or who placea high priority on a short recovery period or avoiding an abdominal incision. (See 'Abdominal versus vaginalapproach' above and 'Comparing among vaginal procedures' above.)

Tranvaginal apical repair procedures include sacrospinous ligament suspension (SSLS) and uterosacralligament suspension (ULS). The efficacy of these two procedures appears comparable, but each procedureis associated with different risks of complications. (See 'Comparing among vaginal procedures' above.)

For women undergoing repair of apical prolapse, a concomitant continence procedure often performed to treator prevent stress urinary incontinence. Midurethral slings are the preferred concomitant procedure if a vaginalroute is used for prolapse repair; some surgeons also place a midurethral sling at the time of abdominalsacral colpopexy. (See 'Concomitant surgery for stress urinary incontinence' above.)

For women undergoing Burch colposuspension, we suggest a laparoscopic rather than open approach (Grade2A). Open colposuspension should be performed if the surgeon is not experience in the laparoscopictechnique for this procedure. (See 'Concomitant Burch colposuspension' above.)

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107. Barksdale PA, Elkins TE, Sanders CK, et al. An anatomic approach to pelvic hemorrhage duringsacrospinous ligament fixation of the vaginal vault. Obstet Gynecol 1998; 91:715.

108. Roshanravan SM, Wieslander CK, Schaffer JI, Corton MM. Neurovascular anatomy of the sacrospinousligament region in female cadavers: Implications in sacrospinous ligament fixation. Am J Obstet Gynecol2007; 197:660.e1.

109. DeLancey JO. Structural anatomy of the posterior pelvic compartment as it relates to rectocele. Am JObstet Gynecol 1999; 180:815.

110. Shull BL, Bachofen C, Coates KW, Kuehl TJ. A transvaginal approach to repair of apical and otherassociated sites of pelvic organ prolapse with uterosacral ligaments. Am J Obstet Gynecol 2000; 183:1365.

111. Chung CP, Miskimins R, Kuehl TJ, et al. Permanent suture used in uterosacral ligament suspension offersbetter anatomical support than delayed absorbable suture. Int Urogynecol J 2012; 23:223.

112. Wieslander CK, Roshanravan SM, Wai CY, et al. Uterosacral ligament suspension sutures: Anatomicrelationships in unembalmed female cadavers. Am J Obstet Gynecol 2007; 197:672.e1.

113. Siddiqui NY, Mitchell TR, Bentley RC, Weidner AC. Neural entrapment during uterosacral ligamentsuspension: an anatomic study of female cadavers. Obstet Gynecol 2010; 116:708.

114. Margulies RU, Rogers MA, Morgan DM. Outcomes of transvaginal uterosacral ligament suspension:systematic review and metaanalysis. Am J Obstet Gynecol 2010; 202:124.

115. Barber MD, Visco AG, Weidner AC, et al. Bilateral uterosacral ligament vaginal vault suspension with site­specific endopelvic fascia defect repair for treatment of pelvic organ prolapse. Am J Obstet Gynecol 2000;183:1402.

116. Karram M, Goldwasser S, Kleeman S, et al. High uterosacral vaginal vault suspension with fascialreconstruction for vaginal repair of enterocele and vaginal vault prolapse. Am J Obstet Gynecol 2001;185:1339.

117. Siddique SA, Gutman RE, Schön Ybarra MA, et al. Relationship of the uterosacral ligament to the sacralplexus and to the pudendal nerve. Int Urogynecol J Pelvic Floor Dysfunct 2006; 17:642.

118. Flynn MK, Weidner AC, Amundsen CL. Sensory nerve injury after uterosacral ligament suspension. Am JObstet Gynecol 2006; 195:1869.

119. Maher CF, Murray CJ, Carey MP, et al. Iliococcygeus or sacrospinous fixation for vaginal vault prolapse.Obstet Gynecol 2001; 98:40.

120. Medina CA, Croce C, Candiotti K, Takacs P. Comparison of vaginal length after iliococcygeus fixation andsacrospinous ligament fixation. Int J Gynaecol Obstet 2008; 100:267.

121. Maher CF, Feiner B, DeCuyper EM, et al. Laparoscopic sacral colpopexy versus total vaginal mesh forvaginal vault prolapse: a randomized trial. Am J Obstet Gynecol 2011; 204:360.e1.

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122. Barber MD, Brubaker L, Burgio KL, et al. Comparison of 2 transvaginal surgical approaches andperioperative behavioral therapy for apical vaginal prolapse: the OPTIMAL randomized trial. JAMA 2014;311:1023.

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GRAPHICS

Uterine prolapse

Prolapse of the Uterus Prolapse of the uterus results from weakness of thesupporting structures of the pelvic floor, and is often associated with acystocele and rectocele. In progressive stages, the uterus becomesretroverted and descends down the vaginal canal to the outside. In first­degree prolapse, the cervix is still well within the vagina. In second­degreeprolapse, it is at the introitus. In third­degree prolapse (procidentia), thecervix and vagina are outside the introitus.

Reproduced with permission from: Bickley, LS, Szilagyi, P. Bates' Guide to PhysicalExamination and History Taking, Eighth Edition. Philadelphia: Lippincott Williams &Wilkins 2003. Copyright © 2003 Lippincott Williams & Wilkins.

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DeLancey levels of vaginal support

Level I consists of the cardinal and uterosacral ligaments, and suspends thevaginal apex. Level II consists of the endopelvic fascia connections to the arcustendineus fascia pelvis, which attaches the vagina to the aponeurosis of thelevator ani. Level III consists of the perineal body and includes interlacing musclefibers of the bulbospongiosus, transverse perinei, and external anal sphincter.

Reproduced with permission from: Walters, MD, Karram, MM. Urogynecology andreconstructive pelvic surgery, 3rd ed, Mosby­Elsevier, 2007. Copyright © 2007 Elsevier.

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Complete vaginal vault prolapse

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Pelvic organ support quantitation

Six sites (points Aa, Ba, C, D, Bp, Ap), genital hiatus (gh), perinealbody (pb), and total vaginal length (tvl) used for pelvic organ supportquantitation.

Reproduced with permission from Bump, RC, Mattiasson, A, BØ, K, et al, Am JObstet Gynecol 1996; 175:10. Copyright ©1996 Mosby, Inc.

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Three­by­three grid used to express the quantifiedpelvic organ prolapse (POP­Q) system

Aa: point A of the anterior wall; Ba: point B of the anterior wall; C: cervix orcuff; D: posterior fornix; gh: genital hiatus; pb: perineal body; tvl: total vaginallength; Ap: point A of the posterior wall; Bp: point B of the posterior wall.

Reproduced with permission from: Harvey, M­A, Versi, E. Urogynecology andpelvic floor dysfunction. In: Kistner's Gynecology and Women's Health, 7th ed,Ryan, KJ, Berkowitz, RS, Barbieri, RL, Dunaif, A (Eds), St. Louis, Mosby 1999.Copyright © 1999 Elsevier.

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Choosing a primary procedure for pelvic organprolapse: Major decision points

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Medial displacement of the bladder for sutureplacement during Burch procedure (retropubiccolposuspension)

Robinson, D, Norton, PA. Diagnosis and Management of Urinary Incontinence.In: Gynecologic Surgery. Mann, WJ, Stovall, TG (Eds), Churchill Livingstone,New York 1996. p.713.

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Suture placement in endopelvic fascia for Burch procedure(retropubic colposuspension)

Robinson, D, Norton, PA. Diagnosis and Management of Urinary Incontinence. In:Gynecologic Surgery. Mann, WJ, Stovall, TG (Eds), Churchill Livingstone, New York 1996.p.715.

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Suture placement through Cooper's ligament forBurch procedure (retropubic colposuspension)

Robinson, D, Norton, PA. Diagnosis and Management of Urinary Incontinence.In: Gynecologic Surgery. Mann, WJ, Stovall, TG (Eds), Churchill Livingstone,New York 1996. p.714.

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Superior view of female pelvis

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Bones and ligaments of the pelvis

(A) The joints of the adult pelvic girdle include the sacroiliac joints and thepubic symphysis. The lumbosacral and sacrococcygeal are joints of theaxial skeleton directly related to the pelvic girdle. (B and C) The ligamentsof the pelvis are shown.

* Inferior pelvic aperture.

Reproduced with permission from: Moore KL, Dalley AR. Clinically OrientedAnatomy, 5th ed, Lippincott Williams & Wilkins, Philadelphia 2006. Copyright ©

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2006 Lippincott Williams & Wilkins. www.lww.com.

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Muscles of the female pelvic floor

Muscles of the anterior pelvis and pelvic floor.

Reproduced with permission from: Clay, JH, Pounds, DM. Basic Clinical Massage Therapy: IntegratingAnatomy and Treatment. Baltimore: Lippincott Williams & Wilkins, 2003. Copyright © 2003 LippincottWilliams & Wilkins.

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Muscles of the female pelvic floor

Pelvic diaphragm ­ view into the pelvic floor illustrating the muscles of the pelvicdiaphragm and their attachments to the bony pelvis.

Reproduced with permission from: LifeART. Copyright © 2010 Lippincott Williams & Wilkins. Allrights reserved.

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Uterosacral ligaments and endopelvic fascia

The cervix measures approximately 2.5 cm in height. Anteriorly (A) thecervix is separated from the bladder by the endopelvic fascia (arrow).Posteriorly (B) the cervix lies below the uterosacral ligaments and iscovered with peritoneum, which reflects off the posterior vagina (cul­de­sac).

Reproduced with permission from: Baggish, MS, Valle, RF, Guedj, H. Hysteroscopy:Visual Perspectives of Uterine Anatomy, Physiology and Pathology. Philadelphia:Lippincott Williams & Wilkins, 2007. Copyright © 2007 Lippincott Williams &Wilkins.

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Disclosures: Kimberly Kenton, MD, MS, FACOG, FACS Nothing to disclose. Linda Brubaker, MD, FACS, FACOG Nothing todisclose. Kristen Eckler, MD, FACOG Nothing to disclose.Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are addressed by vetting through a multi­level review process, and through requirements for references to be provided to support the content. Appropriately referencedcontent is required of all authors and must conform to UpToDate standards of evidence.Conflict of interest policy

Disclosures