Apical Suspension During Prolapse Repair: When Is It indicated?

Abstract

The criteria for choosing to perform an apical suspension at the time of prolapse repair are not always clear. The aim of this article is to review the evidence regarding the role of apical suspension at the time of prolapse repair. Several studies have shown that defects in apical vaginal support contribute significantly to both anterior and posterior prolapse. Furthermore, there is evidence that apical suspension at the time of anterior and, to a lesser extent, posterior prolapse repair may decrease the risk of recurrence requiring treatment in the future. Despite this evidence, concomitant apical suspension at the time of surgery for anterior or posterior prolapse remains low. This is likely due to both a lack of recognition of pre-existing apical prolapse and the absence of standard guidelines for apical suspension. Apical suspensions commonly include sacrocolpopexy, uterosacral ligament suspension, and sacrospinous ligament fixation. Published clinical trials suggest that sacrocolpopexy is superior to transvaginal native tissue repairs in terms of recurrence. However, this may not be true for all populations. Uterine-sparing techniques are being performed more frequently, and research in this area is ongoing. These procedures appear safe, but there is conflicting evidence regarding success rates and recurrent prolapse. The integrity of the vaginal apex is likely a critical component to providing vaginal support at the time of pelvic reconstructive surgery for prolapse. Several safe and effective procedures exist to correct loss of apical support. Additionally, new data are emerging comparing safety and efficacy rates of these procedures.