A Whole-Pelvis Approach to Pelvic Organ Prolapse

INTRODUCTION: Pelvic organ prolapse (POP) occurs in up to 50% of women with 30% of those affected having symptoms. The anterior compartment is affected twice as often as the posterior compartment. Rectal prolapse, diagnosed either on exam or through imaging studies, can impact up to 60% of women who have POP as well as their treatment course. Patient who undergo concurrent management of their POP and rectal prolapse have been noted to have better treatment outcomes. OBJECTIVE: In this video, we will be demonstrating the importance of concurrent tensioning of the anterior and posterior pelvic compartments in the surgical treatment of pelvic organ prolapse through a case-based format. METHODS: A 39-year-old G3P2A1 with symmetric and symptomatic stage 2 anterior and posterior vaginal wall prolapse presented for evaluation. During the course of her evaluation, she was noted to have significant bowel symptoms, and a defecogram was obtained as part of her evaluation. The results are significant for abnormal anorectal junction descent with defecation, intrarectal intussusception, and evidence of rectal prolapse. Following consultation with our colorectal surgery, the patient underwent combination robot-assisted anterior rectopexy with mesh and sacrocolpopexy with total laparoscopic hysterectomy. Total laparoscopic hysterectomy was initially performed followed by rectopexy by colorectal surgery. The ventral rectopexy mesh was prior to completion of the sacrocolpopexy. During the course of vaginal vault tensioning, the previously tensioned rectopexy mesh is noted to have increased laxity likely from elevation of the anterior pelvic compartment with the sacrocolpopexy mesh. Following tensioning of the anterior pelvic compartment, the sacral arm of the rectopexy mesh was adjusted. RESULTS: Following balanced tensioning of the anterior and posterior pelvic compartments, both meshes were fixed to the anterior longitudinal ligament, ensuring appropriate balance between the two compartments. A similar technique can be utilized when performing posterior rectopexies and uterosacral ligament suspensions. We have noted that balanced tensioning between the anterior and posterior compartments especially in patients who have significant bowel symptoms or overt rectal prolapse has led to greater symptom relief and longevity of the repairs. CONCLUSIONS: Concurrent tensioning of the anterior and posterior pelvic compartments during the laparoscopic management of pelvic organ prolapse allows for greater equilibration between the two compartments. This results in fewer instances of recurrence and greater longevity on both subjective and objective treatment outcomes.