A comparison between the vaginal patch plastron associated with the anterior sacrospinous fixation and the Uphold™ LITE vaginal support system for the treatment of advanced anterior vaginal wall prolapse

OBJECTIVE

The aim of the present study was to compare efficacy and safety of the vaginal patch plastron (VPP) associated to the anterior sacrospinous fixation (SSLF-A) with a TVM procedure (Uphold™ LITE support-system) for the treatment of the advanced anterior vaginal wall prolapse.

STUDY DESIGN

Single-center retrospective study. Women with symptomatic anterior prolapse ≥ III stage according to the POP-quantification (POP-Q) system and submitted to the VPP associated with the SSLF-A or to the Uphold™ procedure were included. Primary outcome was to compare objective and subjective cystocele relapse and reoperation rate at 6- and 12-month follow-up. Secondary outcome was to describe peri- and postoperative complications. Pearson chi-square test and exact Fisher test were adopted for categorical variables, while intergroup Mann-Whitney U test and intragroup Wilcoxon Rank Sum Test for continuous variables; the statistical analysis was conducted at 95 % confidence level.

RESULTS

Fifty-five women in VPP-group and 118 women in Uphold-group were included. At 6-month follow-up, objective anterior relapse in VPP-group (3/55, 5.4 %) was like Uphold-group (5/118, 4.2 %; p = 0.71), as well as objective apical relapse (0/55, 0 % vs 3/118, 2.5 %; p = 0.55); no significant difference emerged in bulge symptoms (1/55, 1.8 % vs 5/118, 4.2 %; p = 0.67). At 12-month follow-up women were telephonically investigated; no significant difference emerged in bulge symptoms (1/55, 1.8 % vs 6/118, 5.1 %; p = 0.43). Reoperation rate for the composite outcome POP relapse, stress urinary incontinence (SUI) and remotion of the TVM resulted lower in the VPP group (1/55, 1.8 % vs 13/118, 11 %; p = 0.03). Post-operative buttock pain (32/55, 58.2 % vs 24/118, 20.3 %; p < 0.0001) and post-operative urinary retention (16/55, 29.1 % vs 6/118, 5.1 %; p < 0.0001) were higher in VPP-group, with a complete resolution between 2 and 3 weeks after treatment.

CONCLUSION

VPP associated with SSLF-A was as effective as Uphold™ LITE support-system for both anterior and central compartment prolapse treatment at 6- and 12-month follow-up. VPP-group presented a lower reoperation rate for the composite outcome prolapse relapse repair, SUI, and removal of the mesh.

Anterior sacrospinous ligament fixation by the vaginal route in ten steps

Pelvic organ prolapse (POP) is a common condition affecting women, characterized by the descent of pelvic organs such as the vagina and uterus. While POP may not always cause symptoms, it can significantly impact a woman's quality of life. Diagnosis is typically made through clinical examination, and treatment options range from pelvic-floor physical therapy to surgery. Anterior sacrospinous ligament fixation (ASSLF) has emerged as a viable technique for treating apical prolapse vaginally. This procedure involves attaching the cervix or vaginal vault to the sacrospinous ligament, providing satisfactory results in the short term. Compared to the posterior approach, ASSLF shows similar efficacy, shorter operative time, and potentially fewer complications. Vaginal surgery offers advantages such as lower morbidity and cost, ability to address other pelvic conditions simultaneously, and suitability for managing recurrences. The presented case involves a 72-year-old woman with stage 3 cystocele, stage 3 hysterocele, stage 1 rectocele, and severe voiding dysfunction. After unsuccessful attempts with a pessary, surgical intervention becomes necessary. An instructive video article has been created to standardize the essential steps of ASSLF and facilitate resident education. The video demonstrates ten surgical steps, including installation/exposure, anterior vaginal wall infiltration, median anterior colpotomy, vesico-vaginal dissection, paravesical dissection, sacrospinous ligament suture, cystocele correction, colpotomy and vaginal wall repair, uterine anterior isthmus suture and sacrospinous ligament fixation, and colporrhaphy final closure. In conclusion, POP is a prevalent condition that can be effectively managed through techniques like ASSLF. Vaginal surgery offers several advantages, and proper training and standardization of surgical steps contribute to successful outcomes and resident education.

Old meets new: vNOTES retroperitoneal promontory fixation in conjunction with the uterus preserving Manchester procedure✰,✰✰

INTRODUCTION AND HYPOTHESIS

The Manchester procedure is a classic native tissue prolapse technique with low recurrence and low complication rate. vNOTES (vaginal natural orifice transluminal endoscopic surgery) is a vaginal approach to enter the intra or retroperitoneal space, with the guidance of endoscopic visualization. Different studies have shown women to prefer uterus-preserving correction of prolapse over hysterectomy, as they worry about complications, impact on sexual function and self- sense. At the same time, an increasing caution and awareness of mesh related complications has evolved, giving a need for the development of additional non-mesh uterus preserving surgical techniques for prolapse. The aim with the video is to show a new surgical technique for prolapse, combining the Manchester procedure with vNOTES retroperitoneal non-mesh promontory hysteropexy.

Subjective outcomes 12 years after transvaginal mesh versus native tissue repair in women with recurrent pelvic organ prolapse; a randomized controlled trial

INTRODUCTION AND HYPOTHESIS

The present study describes an extended follow-up study after 12 years and focusses on subjective outcomes of women who underwent surgery for recurrent pelvic organ prolapse in the randomized index study.

METHODS

One hundred and ninety-four (194) women had been randomized in the original study and in the present study, 45 (47%) in the vaginal mesh repair versus 43 (43%) women with conventional vaginal native tissue repair completed the long-term questionnaires. The mesh used was a first-generation non-absorbable mesh kit. All types of conventional vaginal native tissue repairs were allowed, and additional vaginal native tissue repairs were allowed in the mesh group. The questionnaires as applied at baseline were used. The Patient Global Impression of Improvement questionnaire (PGI-I) was the primary outcome.

RESULTS

At 12 years, 30 (71%) women in the mesh group versus 23 (59%) women in the native tissue repair group reported to be PGI-I (very) much improved (p=0.24). There were no differences found in any of the questionnaire domains. There was, however, a higher number of women who had had additional operations for recurrent pelvic organ prolapse, stress urinary incontinence, and/or exposure in the mesh group: 18 women (40%) in the mesh group versus 8 women (19%) in the native tissue repair group (p=0.03).

CONCLUSIONS

There was no difference in subjective outcome between the groups, but there was a statistically significant higher number of women who had needed further operations. This study confirms that vaginal mesh should not be used in all women with recurrent pelvic organ prolapse.

New native tissue repair for pelvic organ prolapse: Medium-term outcomes of laparoscopic vaginal stump–round ligament fixation

BACKGROUND

Laparoscopic sacrocolpopexy for pelvic organ prolapse (POP) is a new and widely used approach; however, ever since the United States Food and Drug Administration warned against the use of surgical mesh, repairs performed using patients’ tissues [i.e. native tissue repair (NTR)] instead of mesh have attracted much attention. At our hospital, laparoscopic sacrocolpopexy (the Shull method) was introduced in 2017. However, patients with more severe POP who have a long vaginal canal and overextended uterosacral ligaments may not be candidates for this procedure.

AIM

To validate a new NTR treatment for POP, we examined patients undergoing laparoscopic vaginal stump–round ligament fixation (the Kakinuma method).

METHODS

The study patients were 30 individuals with POP who underwent surgery using the Kakinuma method between January 2020 and December 2021 and who were followed up for > 12 mo after surgery. We retrospectively examined surgical outcomes for surgery duration, blood loss, intraoperative complications, and incidence of recurrence. The Kakinuma method involves round ligament suturing and fixation on both sides, effectively lifting the vaginal stump after laparoscopic hysterectomy.

RESULTS

The patients’ mean age was 66.5 ± 9.1 (45-82) years, gravidity was 3.1 ± 1.4 (2-7), parity was 2.5 ± 0.6 (2-4) times, and body mass index was 24.5 ± 3.3 (20.9-32.8) kg/m². According to the POP quantification stage classification, there were 8 patients with stage II, 11 with stage III, and 11 with stage IV. The mean surgery duration was 113.4 ± 22.6 (88-148) min, and the mean blood loss was 26.5 ± 39.7 (10-150) mL. There were no perioperative complications. None of the patients exhibited reduced activities of daily living or cognitive impairment after hospital discharge. No cases of POP recurrence were observed 12 mo after the operation.

CONCLUSION

The Kakinuma method, similar to conventional NTR, may be an effective treatment for POP.

Laparoscopic pectopexy with native tissue repair for pelvic organ prolapse

PURPOSE

The use of mesh for vaginal repair is currently problematic; consequently, there is increased interest in native tissue repair. Combining native tissue repair with sufficient mesh-applied apical repair might provide effective treatment. We describe the study focusing on the combination of pectopexy and native tissue repair.

METHODS

Between April 2020 and November 2021, 49 patients with symptomatic stage III or IV were treated with laparoscopic pectopexy combined with native tissue repair. The mesh was solely used for apical repair. All other clinically relevant defects were treated with native tissue repair. The perioperative parameters including surgical time, blood loss, hospital stay, and complications were recorded. The anatomical cure rate was evaluated according to the Pelvic Organ Prolapse Questionnaire (POP-Q) assessment. Validated questionnaires of the Pelvic Floor Distress Inventory (PFDI-20) and the Pelvic Floor Impact Questionnaire (PFIQ-7) were recorded to evaluate the symptom severity and quality of life.

RESULTS

The mean duration of follow-up was 15 months. All domains of POP-Q, PFDI-20, and PFIQ-7 scores improved significantly after surgery. No major complications, mesh exposure, or mesh complication occurred during the follow-up period.

CONCLUSION

The overall repair concept of laparoscopic pectopexy as the core, assisted by vaginal natural tissue repair for severe pelvic organ prolapse can achieve satisfactory clinical results and improve patient satisfaction.

Surgical outcomes in patients aged 70 years and older following uterosacral ligament suspension: a comparative study

PURPOSE

The number of elderly patients bothered by pelvic organ prolapse symptoms is growing rapidly. The aim of this study was to evaluate the relationship between age and surgical outcomes in women undergoing uterosacral ligament suspension for treatment of apical prolapse.

METHODS

We performed a retrospective cohort study including women who underwent uterosacral ligament suspension between 2010 and 2020. The cohort was divided into two groups: (1) Patients 70 years or older; (2) Patients under the age of 70. Outcome measures included clinical, anatomical, and composite outcomes as well as patient satisfaction.

RESULTS

A total of 271 patients were included in the final analysis. Of them 209 patients were under age 70 and 62 patients 70 years or older. Mean age was 59 ± 6 vs. 73 ± 3 for the young and elderly age groups, respectively. Clinical success was high for both groups, reaching 94% vs. 89% for elderly and young patients, respectively (p = 0.34). Anatomical and composite outcome success were higher in the young age group (76% vs. 56%, p < 0.01 and 70% vs. 54%, p = 0.02, respectively); however, following multivariate analysis these differences were no longer statistically significant. Following multivariate logistic regression analysis for the dependent parameter of anatomical success, increased pre-operative genital hiatus and vaginal surgical route were associated with anatomical failure while performing a concomitant posterior colporrhaphy increased likelihood for anatomical success.

CONCLUSION

Women over the age of 70 undergoing uterosacral ligament suspension for treatment of apical prolapse have comparable outcomes to younger patients.

Financial analysis of minimally invasive sacrocolpopexy compared with native tissue vaginal repair with concomitant hysterectomy

INTRODUCTION

Minimally invasive sacrocolpopexy (MISCP) is increasingly used for uterovaginal prolapse, but comparative cost data of MISCP versus native tissue vaginal repair (NTR) are lacking. The objective was to determine the cost difference, from a hospital perspective, between MISCP and NTR performed with hysterectomy for uterovaginal prolapse.

METHODS

This was a retrospective cohort study at a tertiary care center of women who underwent NTR or MISCP with concomitant hysterectomy in 2021. Hospital charges, direct and indirect costs, and operating margin (revenue minus costs) were obtained from Strata Jazz and compared using SPSS.

RESULTS

A total of 82 women were included, 33 MISCP (25 robotic, 8 laparoscopic) versus 49 NTR. Demographic and surgical data were similar, except that MISCP had younger age (50.5 vs 61.1 years, p<0.01). Same-day discharge and estimated blood loss were similar, but operative time was longer for MISCP (204 vs 161 min, p<0.01). MISCP total costs were higher (US$17,422 vs US$13,001, p<0.01). MISCP had higher direct costs (US$12,354 vs US$9,305, p<0.01) and indirect costs (US$5,068 vs US$3,696, p<0.01). Consumable supply costs were higher with MISCP (US$4,429 vs US$2,089, p<0.01), but the cost of operating room time and staff was similar (US$7,926 vs US$7,216, p=0.07). Controlling for same-day discharge, anti-incontinence procedures and smoking, total costs were higher for MISCP (adjusted beta = US$4,262, p<0.01). Mean charges (US$102,060 vs US$97,185, p=0.379), revenue (US$22,214 vs US$22,491, p=0.929), and operating margin (US$8,719 vs US$3,966, p=0.134) were not statistically different.

CONCLUSION

Minimally invasive sacrocolpopexy had higher costs than NTR; however, charges, reimbursement, and operating margins were not statistically significantly different between the groups.

Double-layered anterior colporrhaphy (DAC)-video and mid-term follow-up of 60 patients

INTRODUCTION AND HYPOTHESIS

Anterior colporrhaphy (AC) exhibits high recurrence rates, and this issue is not appropriately addressed by alloplastic material, which often necessitates reoperation. Aiming to improve the anatomical cure rate, we implemented double-layered anterior colporrhaphy (DAC). With a retrospective investigation, precise description and video of the surgical technique, we want to contribute to the development of native tissue anterior repair.

METHODS

Women treated by DAC and vaginal hysterectomy were included. Primary outcome was anatomic cure defined as prolapse < stage 2. Secondary outcomes were complication rate, resolution of postvoid residual urine, reoperation for prolapse and patient satisfaction. Follow-up encompassed a clinical gynecologic examination, the German Pelvic Floor Questionnaire and a response scale for postoperative quality of life (QoL). The key difference between DAC and AC is the continuous suture followed by the traditional interrupted sutures.

RESULTS

One hundred one patients were eligible, and 60 patients attended follow-up. Cure was achieved in 49 cases (81.7%) of cystocele with a median follow-up of 19.3 months. Fifty-five patients (91.7%) indicated an improvement in QoL.

CONCLUSIONS

We observed high anatomic cure rate and satisfaction after DAC. With description and video of the technique, it is reproducible and comparable to other methods. Randomized controlled trials should follow.

Anatomic identification of laparoscopic uterosacral ligament suspension: A step-by-step procedure

INTRODUCTION AND HYPOSTHESIS

The uterosacral ligament (USL) is the main structure of physiological apical support, and USL suspension is one of the most commonly used methods for native tissue apical suspension. Structures surrounding the USL are complex, and the USL itself is difficult to identify, especially the sacral portion of the USL. Laparoscopy improves visualization, but exposure of the USL is still unsatisfactory.

METHODS

In this study, we report a simple method for exposing and suturing the USL laparoscopically, with step-by-step instructions, well-presented figures and videos. The key techniques are shown as follows: keeping tension on the USL with a uterine manipulator, dissecting the space medial to the USL, exposing the portion of the USL near the sacrum through the natural space, and then suturing it medially and connecting it directly to the posterior cervix.

RESULTS

95 consecutive patients have undergone this modified USLS and none had serious perioperative complication.

CONCLUSION

In this way, the USL anatomy is exposed well, which may make placement of sutures in USL suspension safe and effective.

Anterior bilateral sacrospinous ligament fixation with concomitant anterior native tissue repair: a pilot study

INTRODUCTION AND HYPOTHESIS

Anterior bilateral sacrospinous ligament fixation (ABSSLF) was first described in 2000 but only evaluated in a limited number of studies. However, due to the FDA's ban on transvaginal mesh, interest in this technique has re-emerged. The SSLF procedure is known for its inherent high risk for anterior compartment failure; hence, in our center we started performing a preemptive concomitant anterior repair with the intention to reduce such risk. The aim of this study was to review the feasibility and clinical outcomes of this innovative technique.

METHODS

We performed a retrospective cohort study of all the women who had an ABSSLF and a concomitant anterior native tissue repair between May 2019 and July 2020 in a tertiary hospital in France. Our primary endpoint was surgical feasibility, while as secondary endpoints we wanted to explore the perioperative morbidities and clinical outcomes associated with this technique.

RESULTS

A total of 50 women were operated on in the studied period. The median follow-up time was 10 [8.5] months. It was feasible to perform the combined ABSSLF and concomitant anterior native tissue repair in all cases. The most frequent perioperative complications reported were urinary tract infection (14%) and difficulty in resuming voiding (16%). Anatomical and functional results were improved. The rate of anterior compartment recurrence was 37%.

CONCLUSIONS

ABSSLF with a concomitant anterior native tissue repair is feasible and relatively safe for treating anterior and apical pelvic prolapse. However, anterior compartment failure rate is still a limitation. Further larger studies with long-term anatomical and functional results comparing this technique to alternative transvaginal surgical approaches are needed.

Voiding function after sacrocolpopexy versus native tissue transvaginal repair for apical pelvic organ prolapse in an ERAS era: A retrospective cohort study

Objective

The objectives of this study were to compare time to return of voiding function and associated complications in women undergoing minimally invasive sacrocolpopexy (SCP) versus transvaginal native tissue repair in patients with same-day or early discharge.

Methods

This was a retrospective cohort study conducted at a tertiary care center. The electronic medical record system was queried for women who underwent native tissue vaginal repair or SCP for apical prolapse between March and December 2020 using CPT codes for sacrocolpopexy (57425), extraperitoneal (57282), and intraperitoneal colpopexy (57283). Voiding success was our primary outcome and was defined by a postvoid residual < 150 ml. Secondary outcomes included catheter days and urinary tract infections. The total number of participants was based on a power calculation using internal institutional rates. Participants were compared based on the surgical approach. A multivariate regression analysis was performed to assess for confounding factors.

Results

We included 134 women: 63 SCP and 71 native tissue. The failure rate of the first postoperative voiding trial was 34 vs. 11% (odds ratio: 4.91; 95% CI 1.96–12.3, p < 0.01) in the vaginal and SCP groups, respectively. Both groups had a similar success rate of a second voiding trial (100% in SCP group vs. 95.7% in the vaginal repair group, p = 1). The total number of days (3.108 vs. 1.603 days, p < 0.01) to return of bladder function, postoperative urinary tract infections (23.9 vs. 6.35%, p < 0.01) and emergency department visits (15.5 vs. 1.59%, p < 0.01) were all higher in the vaginal repair group.

Conclusions

Vaginal apical native tissue repair had a fivefold greater risk of acute postoperative urinary retention compared to sacrocolpopexy in addition to increased rates of post-operative urinary tract infection and emergency department visits for urinary tract concerns.

Intermediate term outcomes after transvaginal uterine-preserving surgery in women with uterovaginal prolapse

Introduction and hypothesis

There is growing interest in and performance of uterine-preserving prolapse repairs. We hypothesized that there would be no difference in pelvic organ prolapse (POP) recurrence 2 years following transvaginal uterosacral ligament hysteropexy (USLH) and sacrospinous ligament hysteropexy (SSLH).

Methods

This is a retrospective cohort study with a cross-sectional survey of women who underwent transvaginal uterine-preserving POP surgery from May 2016 to December 2017. Patients were included if they underwent either USLH or SSLH. POP recurrence was defined as a composite of subjective symptoms and/or retreatment. A cross-sectional survey was used to assess pelvic floor symptoms and patient satisfaction.

Results

A total of 47 women met the criteria. Mean age was 52.8 ± 12.5 years, and all had a preoperative POP-Q stage of 2 (55.3%) or 3 (44.7%). Thirty (63.8%) underwent SSLH and 17 (36.2%) underwent USLH. There were no differences in patient characteristics or perioperative data. There was no difference in composite recurrence (26.7% [8] vs 23.5% [4]) and retreatment (6.7% [2] vs 0%) retrospectively between SSLH and USLH groups at 22.6 months. Survey response rate was 80.9% (38) with a response time of 30.7 (28.0–36.6) months. The majority of patients (84.2%) reported POP symptom improvement, and both groups reported great satisfaction (89.5%). In respondents, 13.2% (5) reported subjective recurrence and 5.3% (2) underwent retreatment, with no differences between hysteropexy types. There were no differences in other pelvic floor symptoms.

Conclusions

Although 1 in 4 women experienced subjective POP recurrence after transvaginal uterine-preserving prolapse repair and <5% underwent retreatment at 2 years, our results must be interpreted with caution given our small sample size. No differences in outcomes were identified between hysteropexy types; however, additional studies should be performed to confirm these findings. Both hysteropexy approaches were associated with great patient satisfaction.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00192-021-04987-5

Clinical risk factors for recurrence of pelvic organ prolapse after primary native tissue prolapse repair

OBJECTIVE

To define potential risk factors for recurrence of prolapse.

METHODS

This short report included all women who presented with recurrence of prolapse as well as without any recurrence signs after a vaginal approach of native tissue prolapse repair at an urogynecological center in Austria.

RESULTS

A total of 124 recurrence cases and 64 women with no signs of recurrence after their index prolapse surgery were included. Multivariate analysis identified advanced preoperative POP‑Q stage (pelvic organ prolapse-quantification) as an independent risk factor for postoperative recurrence of prolapse (p = 0.045).

CONCLUSION

Initial proper preoperative counseling is of particular importance to modulate patients' expectations after prolapse surgery.

Short-term outcomes of sacrospinous hysteropexy through an anterior approach

INTRODUCTION AND HYPOTHESIS

The posterior approach to sacrospinous hysteropexy has been well studied but little is known about the anterior approach. This study assessed the efficacy and complications of an anterior approach to sacrospinous hysteropexy compared to hysterectomy with apical repair. We hypothesized that anterior sacrospinous hysteropexy has similar efficacy and fewer complications.

METHODS

This retrospective cohort study compared patients who underwent native-tissue anterior sacrospinous hysteropexy (cases) with those who underwent hysterectomy with apical repair (controls). Composite success was defined as (1) leading edge of prolapse not beyond the hymen and apex not descended > 1/3 total vaginal length; (2) no vaginal bulge symptoms; (3) no prolapse retreatment. Descriptive and bivariate statistics were performed as well as a Cox regression analysis for time to failure.

RESULTS

Fifty cases and 97 controls were compared. The median follow-up time was 7.6 months. Operative time was shorter in the hysteropexy group (110.7 vs. 155.9 min, p < 0.001). The composite success was 92% for both cases and controls (p = 1.000) with no difference in time to surgical failure (p = 0.183). There were no serious intraoperative complications in the hysteropexy group and six in the control group (3 transfusions, 1 conversion to laparotomy, 1 ureteral injury, 1 cystotomy; p = 0.101). There was no difference in the number of postoperative complications (22.0% vs. 30.9%, p = 0.203).

CONCLUSIONS

For primary uterine prolapse, anterior sacrospinous hysteropexy has similar short-term efficacy compared to hysterectomy with apical repair with shorter operative time and a trend towards fewer serious complications.

Ten years' follow-up after iliococcygeus fixation for the treatment of apical vaginal prolapse

INTRODUCTION AND HYPOTHESIS

Various surgical techniques have been described for vaginal vault prolapse repair, but the best surgical approach is still to be proven. The aim of this study is to report the long-term objective and subjective outcomes of women who underwent iliococcygeus fixation for the treatment of vaginal vault prolapse with a minimum follow-up of 10 years.

METHODS

Women with symptomatic vaginal vault prolapse (Pelvic Organ Prolapse Quantification [POP-Q] stage ≥ 2) who had previously undergone hysterectomy for any reason were prospectively enrolled and treated with iliococcygeus fixation. Subjective success was defined as Patient Global Impression of Improvement (PGI-I) ≤ 2 and an absence of bulging symptoms. Objective success was defined as stage of prolapse < 2 in all compartments. Overall success rate was defined as women without prolapse symptoms, PGI-I ≤ 2, stage of prolapse < 2, and no need for other surgery. Prolpase Quality of Life (P-QOL) questionnaires were completed at the preoperative visit and at every follow-up visit. Multiple logistic regression was performed to identify factors involved in the risk of recurrent POP.

RESULTS

After a median (range) follow-up of 120 (120-132) months, the subjective, objective, and overall cure rates were 82% (32/39), 74.4% (29/39), and 74.4% (29/39), respectively. Only stage IV vault descensus independently predicted POP recurrence after ICG (OR: 7.66 [95% CI: 1.21-9.02]; p < 0.001).

CONCLUSION

Iliococcygeus fixation seems to be a safe and effective option for the treatment of vaginal vault prolapse at 10 years' follow-up.

Native tissue sacrospinous hysteropexy from an anterior approach

AIM OF THE VIDEO

The goal of urogynecologic surgeons is to pair patients with the most appropriate and effective surgery. Sacrospinous hysteropexy has become an increasingly utilized surgical option for uterovaginal prolapse repair. The primary aim of this video is to highlight the role that sacrospinous hysteropexy can have in prolapse repair and to demonstrate an anterior approach for this procedure.

METHODS

We performed a literature review to provide general information on the efficacy, risks, and comparative benefits of sacrospinous hysteropexy. Our video demonstrates the key steps in performing a sacrospinous hysteropexy procedure from an anterior approach including method of dissection, suture fixation to the sacrospinous ligament, and cervical suspension.

RESULTS

Sacrospinous hysteropexy has generally been found to be an effective option for uterovaginal prolapse repair in properly selected patients. The demonstrated approach integrates sacrospinous ligament fixation with an anterior colporrhaphy.

CONCLUSIONS

Data and experience to date on sacrospinous hysteropexy are largely based on a posterior approach for access to the sacrospinous ligament. This surgical video demonstrates an anterior approach to sacrospinous hysteropexy that is not well characterized in the literature.

Laparoscopic uterosacral ligament suspension versus vaginal colposuspension using the Uphold Lite™ mesh system: clinical outcome and patient satisfaction

INTRODUCTION AND HYPOTHESIS

The objective was to compare clinical and anatomical outcomes between laparoscopic uterosacral ligament suspension (LUSLS) and vaginal colposuspension using the Uphold Lite™ mesh system for the treatment of apical prolapse.

METHODS

We performed a comparative, retrospective cohort study. All women who underwent either vaginal colposuspension with the Uphold Lite™ System or LUSLS for treatment of apical prolapse between 2010 and 2019 were included. The groups were compared with regard to demographic, pre-operative, intra-operative, and post-operative data. Outcome measures included clinical and anatomical cure, as well as a composite outcome. The PGI-I questionnaire was used to determine patient satisfaction.

RESULTS

One-hundred and nineteen women met the inclusion criteria, including 70 women who underwent LUSLS and 49 women who underwent vaginal colposuspension with the Uphold Lite™ mesh system. At a mean follow-up of 31.7 (SD = 18.1) months, the clinical cure rate was high for both groups, reaching 98.6% in the LUSLS group compared with 89.8% in the Uphold group (NS). Anatomical cure rate was 83.6% in the LUSLS group compared with 69.7% for the Uphold group (NS). With regard to the composite outcome, no difference was found, although a trend towards a higher success rate was noted in the LUSLS group (83.6% vs 66.7%, p = 0.055). Patient satisfaction measured using the PGI-I questionnaire was high, at 98.6% in the LUSLS group and 87.8% in the Uphold group (NS).

CONCLUSION

Laparoscopic uterosacral ligament suspension and vaginal colposuspension using the Uphold Lite™ mesh system both have high clinical cure rates.

Total laparoscopic multi-compartment native tissue repair of pelvic organ prolapse and stress urinary incontinence

AIM OF THE VIDEO

In this video we present the surgical management of a 59-year-old woman with stress urinary incontinece (SUI) and pelvic organ prolapse (POP) who had a history of rheumatoid arthritis and endometrial hyperplasia with atypia.

METHODS

A concomitant laparoscopic hysterectomy with bilateral oophorectomy and a multi-compartment laparoscopic native tissue repair of the POP, combined with a Burch urethropexy, was performed to restore pelvic floor defects and treat the underlying endometrial pathology.

CONCLUSION

Total laparoscopic multi-compartment repair of POP and/or SUI using native tissue appears to be a viable alternative to both laparoscopic procedures using synthetic meshes and vaginal native tissue repairs. Although not a routine option for the majority of patients with POP and SUI, this procedure may be offered in selected cases, where native tissue repair of the pelvic floor is preferred.

Traditional McCall culdoplasty compared to a modified McCall technique with double ligament suspension: anatomical and clinical outcomes

INTRODUCTION AND HYPOTHESIS

This study compared anatomical and clinical outcomes of traditional McCall culdoplasty versus a modified McCall technique with double ligament suspension (DLS).

METHODS

This retrospective study presents outcomes of 68 patients who underwent vaginal hysterectomy and vaginal suspension for apical prolapse ≥ stage II according to the POP-Q score system, at, between January 2016 and February 2018. In 34 women vaginal cuff suspension was obtained with traditional McCall culdoplasty (McCall group), while in 34 women we performed a modified McCall, which consists of a double ligament suspension (DLS group), suspending the vaginal cuff to uterosacral ligaments and also to adnexal peduncles. Primary outcome was prolapse recurrence ≥ stage II according to the POP-Q system. Fisher's, Mann-Whitney U and Student's t tests were used for statistical analysis.

RESULTS

There were no statistical differences among patients' preoperative characteristics, operative time, blood loss or postoperative complications. Follow-up mean duration was 23.2 ± 6.7 and 22.4 ± 8.7 months in the McCall and DLS group, respectively. Prolapse recurrence occurred in 11 (32.3%) women in the McCall group versus 2 (5.9%) women in the DLS group (p < 0.05): among them, 2 patients (5.9%) in the McCall group and 1 (2.9%) in the DLS group required further treatment. Total vaginal length was 6.1 ± 0.9 cm in the McCall group versus 6.9 ± 0.7 cm in the DLS group (p < 0.001). No statistical difference in quality of life assessment was observed.

CONCLUSIONS

DLS group patients had better anatomical outcomes and lower recurrence rates than McCall group patients, without increasing operative time or complications. A prospective study with more cases is needed to confirm our data.

Update in native tissue vaginal vault prolapse repair

The lifetime risk of women for undergoing surgery for pelvic organ prolapse (POP) is estimated to be 11-19%, and 30% of these women will require subsequent reoperation over time. Following hysterectomy, 3.6 per 1,000 person-years need surgical correction of prolapse, and in two-thirds of these cases multi-compartment prolapse is present. In the last decades, vaginally synthetic meshes were widely used in pelvic reconstructive surgery. However, after the decision of the Food and Drug Administration in 2019 to stop selling all surgical mesh devices for transvaginal prolapse repair, native tissue (NT) vaginal repair seems to regain an important role in pelvic reconstructive surgery. In the literature, various surgical techniques have been described for apical repair, but the best surgical approach is still to be proven. This paper analyzes the current evidence from recent literature on NT vaginal vault prolapse (VVP) repair, with special focus on the safety and efficacy of the various vaginal techniques.

Long-term follow-up of native tissue anterior vaginal wall repair: does the POP-Q stage really reflect patients' satisfaction rate?

INTRODUCTION

Anterior colporrhaphy (AC) is one of the most commonly performed surgical procedures for pelvic organ prolapse treatment; however, there are only few data in the literature regarding its long-term outcomes. Our aim was to assess the long-term efficacy and satisfaction rate after AC.

METHODS

Patients who underwent AC at our institution from 2011 to 2014 were invited to this follow-up study, which took place in January-February 2019. Medical history and gynaecological examination with POP-Q assessment were performed. Patients filled out validated questionnaires UIQ-7, CRAIQ-7, POPIQ-7, PFIQ-7, POPDI-6, CRADI-8, and UDI-6 and evaluated their satisfaction with the procedure. Objective success was defined as anterior wall prolapse stage 0 or 1 assessed by the POP-Q system. Subjective success was defined as the absence of bulging sensation or a sense of falling out that can be felt or seen in the vaginal area. Data were analysed using descriptive statistics and non-parametric tests.

RESULTS

Seventy out of 137 (51.1%) patients attended the follow-up. Mean follow-up period up was 74.1 ± 12.6 months. Two patients were excluded from the analysis because they had another surgical procedure due to central compartment prolapse. Of the remaining patients, 50 had AC and 18 had AC and posterior colporrhaphy (PC). Objective success rate was 13.2% and subjective success rate was 68.7%. Almost all patients (98.5%) were satisfied with the procedure. In the group of patients with objective recurrence, 66.1% had no prolapse symptoms.

CONCLUSION

Despite having a low objective success rate, patients' satisfaction with AC is very high.

Very long-term follow-up of the anterior vaginal wall suspension procedure for incontinence and/or prolapse repair

OBJECTIVE

To report outcomes of the anterior vaginal wall suspension (AVWS) procedure for stress urinary incontinence (SUI) and/or anterior compartment prolapse (POP), with minimum 10-year follow-up.

METHODS

Following institutional review board approval, a database of patients with > 10-year follow-up after AVWS for bothersome SUI with early stage anterior compartment prolapse (stage ≤ 2) or symptomatic anterior compartment prolapse (stage > 2) was reviewed. Preoperative evaluation included validated questionnaires [Urogenital Distress Inventory-Short Form (UDI-6), Incontinence Impact Questionnaire-Short Form (IIQ-7), quality of life (QoL)], Pelvic Organ Prolapse Quantification (POP-Q), and voiding cystourethrography. Follow-up data was based on clinic visits or telephone interviews for patients not seen in the past 2 years. Telephone interviews used validated questionnaires and were conducted by a third party not involved in patient care. Failure was defined as reoperation for SUI or POP. The influence of lost to follow-up (LTF) was also analyzed.

RESULTS

Between 1996 and 2008, 161 of 328 patients met study criteria, with follow-up from phone interviews (103) or clinic visits (58). The LTF patients were deceased (52), mentally disabled (5), or unreachable by telephone (110). Median follow-up was 13.5 years (IQR 11.5-17). Type of follow-up (clinic vs. phone) and uterine status (concomitant/prior/no hysterectomy) did not impact reoperation rates. Reoperation occurred in 23/161 (14%) and consisted of sacrocolpopexy (8), anterior colporrhaphy (5), injectable agents (8), fascial sling (2).

CONCLUSIONS

The AVWS procedure to restore anterior vaginal support to the bladder neck and bladder base to correct SUI/POP can provide satisfactory and durable results.

Surgical treatment of complete uterovaginal prolapse and concomitant vaginal cancer: a video case report

INTRODUCTION AND HYPOTHESIS

The concurrence of vaginal cancer with irreducible uterine prolapse is rare. Reports about the management of vaginal cancer and concomitant irreducible prolapse are scanty in the literature, and there is no consensus on optimal treatment. In this video case report, we show surgical management of vaginal cancer and concomitant stage IV uterovaginal prolapse.

METHODS

The featured video shows surgical management of vaginal cancer and concomitant stage IV uterovaginal prolapse through anterior colpectomy and retrograde hysterectomy en bloc plus transvaginal levator ani plication as a non-obliterative native-tissue technique for apical support.

RESULTS

Final examination revealed good apical support and vaginal "habitability" preservation. The patient underwent five sessions of intracavity brachytherapy for a total of 20 Gy as adjuvant therapy.

CONCLUSION

Surgical management of vaginal cancer and concomitant stage IV uterovaginal prolapse was successfully achieved without complications. Transvaginal levator ani plication can provide a versatile non-obliterative native-tissue technique for apical support, allowing subsequent adjuvant brachytherapy.

Surgical technique used in the UK for native tissue anterior pelvic organ prolapse repair (VaST)

Introduction

The PROSPECT study found that outcomes for native tissue and mesh prolapse repairs are similar but mesh repairs have a 10% risk of exposure. The current UK surgical mesh pause has led to renewed interest in native tissue surgery. Previous studies of native tissue anterior repair surgical techniques have been limited by the questionnaire study design. The objective of this study was to describe and categorise native tissue anterior repair surgical techniques.

Methods

This prospective qualitative study used a purposive sampling strategy to recruit surgeons. Data were collected through video-recorded observations of surgery, audio-recorded interviews with surgeons and field notes. The study took place in urogynaecology theatres in 21 UK centres. Thematic analysis was performed using computer-based software and themes of surgical technique were developed.

Results

Thirty consultant surgeons were recruited. In all steps of the anterior repair procedure, infiltration, dissection, method of fascial repair, type and method of suturing and suture placement, surgical technique varied between surgeons. The filming of surgery followed by immediate validation with the surgeons gave greater insight. Surgeons’ terminology to describe techniques varied and the investigators' opinions of the techniques performed were not always consistent with the surgeons' descriptions. The concept of fascia in histological terms was not uniform amongst surgeons.

Conclusion

VaST has demonstrated significant variation in native tissue anterior repair surgical techniques and inconsistency in the terminology used to describe them. These inconsistencies may prevent future meaningful research of prolapse surgery. The variation in technique could affect surgical outcomes and this should be explored further.

Questions surrounding the optimal time for surgical treatment of pelvic organ prolapse

OBJECTIVE

The purpose of study is to evaluate the recurrence rate of pelvic organ prolapse after surgical treatment and pre- to postoperative changes in sexual function of patients with different stages of pelvic organ prolapse.

METHODS

The presented study was a single-centre observational nonrandomized analysis of an ongoing prospective cohort study evaluating anatomical and clinical outcomes in reproductive aged women scheduled for nature tissue repair of POP staged I-III. Two hundred and ten women were recruited, of whom 120 (57.1%) had the advanced prolapse form (POP-Q III). Women at preoperative POP stage I-II were compared with women at stage III without apical prolapse.

RESULTS

The best effectively rate with low recurrence depends on preoperative prolapse stage. The overall objective success rate was about 80% in five years in patients with preoperative stage I-II. Study shows a significant improvement in sexual function in all patients with pelvic organ prolapse in five years after surgery.

CONCLUSION

This study showed that women with advanced POP have a higher risk of recurrence after POP native tissue repair compared with early stages and proved the improvement of sexual function especially in women with advanced prolapse forms. Women with early stage of POP should be advised to postpone surgery until progression of complaints because of the high recurrence risk.

Surgical management of recurrent urethrovaginal fistula with a skin island flap

INTRODUCTION AND HYPOTHESIS

A urethrovaginal fistula is a possible rare complication of tension-free vaginal tape procedures. Surgical management of these fistulas is sometimes complicated, and failure can occur. The operation is difficult when the defect between the urethra and the vagina is larger or scarred, so surgical intervention and the preferred technique are controversial.

METHODS

The patient was referred to our department, where the first operation was performed to address the urethrovaginal fistula by the transvaginal and transabdominal approach with interposed omentum. This initial repair failed, resulting in a large urethrovaginal fistula with minimal redundant anterior vaginal wall to provide a tension-free closure. This video presentation describes the second operation-transvaginal repair of a large recurrent urethrovaginal fistula using the skin island flap technique.

RESULTS

The video of the procedure shows how to address a recurrent urethrovaginal fistula by employing a skin flap. An examination during the patient's follow-up visit 3 months later revealed excellent healing and persistent stress urinary incontinence (SUI). Six months after the fistula repair, the patient underwent a bulking agent procedure.

CONCLUSIONS

The skin island flap procedure allowed the larger defect to heal, though it did not address the SUI, which was later treated by application of a bulking agent.

Transvaginal Suture-Based Repair

An estimated 300,000 women undergo pelvic organ prolapse (POP) surgery in the United States every year at a cost of more than 1 billion dollars per year. The prevalence of POP is approximately 2.9% to 8%, and increases with age. Apical support is required to achieve successful prolapse repair. As the search for the safest, most durable, surgical repair continues, transvaginal native tissue repairs have the advantage of providing minimally invasive surgical repairs without the added risk of abdominal, laparoscopic, or robotic surgery while avoiding the risk of mesh augmentation.

Partially absorbable mesh or native tissue repair for pelvic organ prolapse: a randomized controlled trial

Introduction and hypothesis

The objective was to compare medium-term efficacy and safety of a partially absorbable mesh kit and native tissue repair in pelvic organ prolapse (POP).

Materials and methods

Women with primary POP stage ≥ II were randomized to transvaginal trocar-guided partially absorbable mesh (81 women) or native tissue repair (82 women). Primary outcome was overall anatomical success (POP < stage II) at 24 months. Secondary outcomes were composite success, global improvement, and adverse events.

Results

Sixty-nine (85%) of the women allocated to partially absorbable mesh underwent mesh surgery; 8 (10%) crossed over to native tissue repair and 4 women (5%) withdrew from the study. Eighty (98%) of the women allocated to native tissue repair underwent the assigned treatment and 2 (2%) withdrew. Twenty-four months later, 140 surgically treated women (89%) demonstrated an overall anatomical success of 39%; 45% (32 out of 71 women) for mesh, and 32% (22 out of 69) for native tissue repair (RR 1.4, 95% CI 0.92 to 2.2). Composite success was 88 and 73% respectively (RR: 1.1, 95% CI 0.93 to 1.4). There was global improvement in 86% (48 out of 56 women) in the mesh group and in 77% (47 out of 60 women) in the native tissue group (RR: 1.1, 95% CI 0.92 to 1.3). Four women were diagnosed with mesh exposure at 2 years (6%).

Conclusion

At 24 months, no significant anatomical or composite benefit of partially absorbable mesh over native tissue repair could be demonstrated in women who had been surgically treated for primary POP.

Transvaginal native-tissue repair of enterocele

INTRODUCTION AND HYPOTHESIS

Enterocele repair represents a challenge for pelvic surgeons. Surgical management implies enterocele sac removal. Subsequently, hernial port closure and adequate suspension may be achieved with Shull uterosacral ligament suspension (ULS).

METHODS

A 55-year-old woman with symptomatic stage 3 enterocele was admitted for transvaginal uterosacral ligaments suspension according to the described technique.

RESULTS

Surgical procedure was successfully achieved without complications. Final examination revealed excellent pelvic supports and preservation of vaginal length. This step-by-step video tutorial may represent an important tool to improve surgical know-how.

CONCLUSIONS

Transvaginal uterosacral ligaments suspension provides a safe and effective technique for enterocele repair without the use of prosthetic materials. Identifying uterosacral ligaments, proper suture placement, and reapproximation of pubocervical and rectovaginal fascias with closure of the hernial port are the key points to achieve surgical success.

Vaginal hysterectomy with apical fixation and anterior vaginal wall repair for prolapse: surgical technique and medium-term results

INTRODUCTION AND HYPOTHESIS

Stabilization of the vaginal apex (level 1) is an important component of operations to correct pelvic organ prolapse (POP). We report functional and anatomical results and patient-reported outcomes of our technique of vaginal vault fixation at the time of vaginal hysterectomy.

METHODS

One hundred and nine patients-mean 69 years, range 50.4-83.8; body mass index (BMI) 26.3, range 17.7-39.5-with symptomatic stage 2-3 uterine prolapse combined with stage 3-4 cystocele underwent vaginal hysterectomy with anterior vaginal wall repair; the apex was formed with high closure of the peritoneum and incorporation of the uterosacral and round ligaments. Only absorbable sutures were used. Follow-up included clinical examination with Pelvic Organ Prolapse Quantification system (POP-Q) scoring, introital ultrasonography, quality of life (QoL) Likert scale, and the German Pelvic Floor Questionnaire.

RESULTS

Seventy patients (64%) were available for a follow-up after a mean of 2.8 years (range, 1.6-4.2). At follow-up, point C was stage 0 in 55 (78.6%) women and stage 1 in 15 (21.4%). The anterior vaginal wall was stage 0 or 1 in 35 (50%), stage 2 (no cystocele beyond the hymen) in 34 (49%), and stage 3 in 1 (1.4%). Vaginal length (VL) was 9 cm. Four women (4%) were reoperated for prolapse: two for recurrent anterior compartment prolapse and two for de novo rectocele. Postvoid residuals >150 ml were seen in 21(30%) patients preoperatively and resolved postoperatively in 20. Urgency occurred in nine (13%), stress urinary incontinence (SUI) in ten (14%), and nocturia in 19 (27%). No patient had discomfort at the vaginal vault and 62 patients (87%) reported improved QoL, which did not correlate with anatomical results. Cystocele ≥ 2° at follow-up was associated with BMI >25 (p = 0.03).

CONCLUSIONS

Our surgical technique without permanent material offers good apical support and functional and subjective results. Anatomical improvement was achieved in all cases of cystocele repair. Recurrent cystoceles are often asymptomatic.

Laparoscopic high uterosacral ligament suspension: an alternative route for a traditional technique

INTRODUCTION AND HYPOTHESIS

Uterovaginal prolapse treatment is a challenge for the urogynecologist. Surgical management for apical prolapse can be successful with native tissue and uterosacral ligament (USL) fixation. However, some complications have been described, especially with use of the vaginal approach. The aim of this video is to describe an alternative laparoscopic approach to a traditional vaginal procedure to reduce nerve injury and ureteral complications.

METHODS

A 75-year-old woman was referred to our unit for symptomatic stage III apical prolapse and underwent laparoscopic USL fixation, according to the technique described herein.

RESULTS

This surgical technique was successful in correcting apical prolapse.

CONCLUSIONS

This video tutorial may be useful to urogynecologists for improving surgical technique, thus leading to a reduction in the risk of nerve and ureteral complications. The technique offers the possibility of a correct under-vision suture positioning. Laparoscopic USL fixation can be safely performed to treat apical prolapse.

Demonstration of a box-stitch technique for laparoscopic uterosacral ligament suspension

AIM

We demonstrate a novel box stitch technique of laparoscopic post-hysterectomy uterosacral ligament suspension for apical prolapse in restorative pelvic reconstructive surgery.

MATERIAL AND METHODS

We present a case of a 58yo female with symptomatic stage III pelvic organ prolapse with a history of a total abdominal hysterectomy 30 years prior. She strongly desired the usage of no synthetic or biologic mesh for her restorative surgical repair. This video provides a step-by-step guide on how to perform a laparoscopic box stitch as a technique for uterosacral ligament suspension as an apical native tissue option for patients with the need for post hysterectomy apical prolapse.

CONCLUSION

This video demonstrates a novel box-stitch technique of laparoscopic post-hysterectomy uterosacral ligament suspension as a native tissue option for minimally invasive reconstructive surgery. The procedure is a reasonable option to address apical prolapse in patients who do not desire or who are unable to have synthetic or biologic mesh placed for restorative reconstructive prolapse surgery.

Reasons for and Against Use of Non-absorbable, Synthetic Mesh During Pelvic Organ Prolapse Repair, According to the Prolapsed Compartment

Awareness and reporting of mesh-related complications of pelvic organ prolapse repairs have increased in recent years. As a result, deciding whether to use a mesh or not has become a difficult task for urogynecologists. Our aim was to summarize reasons for and against the use of mesh in prolapse repair based on a review of relevant literature. Scopus and PubMed databases were searched for papers reporting on the efficacy and safety of native tissue versus non-absorbable, synthetic mesh prolapse repairs. Randomized controlled trials, systematic reviews, and meta-analyses were included. Evidence is presented for each vaginal compartment separately. In the anterior compartment, mesh repairs seem to offer clearly superior efficacy and durability of results compared to native tissue repairs, but with an equally clear increase in complication rates. In the isolated posterior compartment prolapse, high-quality evidence is sparse. As far as the apical compartment is concerned, sacrocolpopexy is the most efficacious, yet the most invasive procedure. Data on the comparison of transvaginal mesh versus native tissue repairs of the apical compartment are somewhat ambiguous. Given the inevitable coexistence of advantages and disadvantages of mesh use in each of the prolapsed vaginal compartments, an individualized treatment decision, based on weighing risks against benefits for each patient, seems to be the most rational approach.

Laparoscopic fixation of the vaginal cuff to the uterosacral ligaments at the time of hysterectomy

INTRODUCTION AND HYPOTHESIS

Transvaginal ipsilateral uterosacral ligament colpopexy for pelvic organ prolapse (POP), which was reported by Shull et al. (Shull's colpopexy) in 2000, is one of the most frequently performed non-mesh pelvic floor reconstructive surgical procedures. Despite its excellent anatomical outcomes, ureteral injury and difficulty in uterosacral ligament detection (especially in patients with severe POP) are typical issues with this procedure.

METHOD

This video demonstrates the procedure in a 58-year-old woman, gravida 2 para 2, with POP-Q stage II uterine prolapse and stage I cystocele. At the beginning of the operation, the bilateral uterosacral ligaments were confirmed and separated from the ureters after entering the retroperitoneal space. The inferior hypogastric nerve and pelvic nerve plexus were also separated from the uterosacral ligament. After total laparoscopic hysterectomy, three ipsilateral delayed absorbable monofilament sutures were placed between the uterosacral ligament and the vaginal cuff. Retroperitonealization was then performed using a continuous suture with closure of the Douglas pouch.

CONCLUSION

Laparoscopic Shull's colpopexy for POP is a secure procedure with the advantages of laparoscopy (magnification and sharing the operative field). This may become one of the most useful operations for apical support as native tissue repair.

Native tissue repair for central compartment prolapse: a narrative review

Central descent due to a level 1 defect is a main component in pelvic organ prolapse (POP) reconstructive surgery, whether for symptomatic apical prolapse or for the prolapse repair of other compartments. A recent growth in the rate of native tissue repair procedures for POP, following the US Food and Drug Administration (FDA) warnings regarding the safety and efficacy of synthetic meshes, requires a re-evaluation of these procedures. The safety, efficacy, and determination of the optimal surgical approach should be the center of attention. Functional outcome measures and patient-centered results have lately gained importance and received focus. A comprehensive literature review was performed to evaluate objective and subjective outcomes of apical prolapse native tissue repair, with a special focus on studies reporting impact on patients' functional outcomes, quality of life, and satisfaction. We performed a MEDLINE search for articles in the English language by using the following key words: apical prolapse, sacrospinous ligament fixation, uterosacral ligament suspension, sacral colpopexy, McCall culdoplasty, iliococcygeus vaginal fixation, and functional outcomes. We reviewed references as well. Despite a prominent shortage of studies reporting standardized prospective outcomes for native tissue repair interventions, we noted a high rate of safety and efficacy, with a low complication rate for most procedures and low recurrence or re-treatment rates. The objective and subjective results of different procedures are reviewed. Functional outcomes of native tissue repair procedures have not been studied sufficiently, though existing data present those procedures as favorable and not categorically inferior to sacrocolpopexy. Apical compartment prolapse repair using native tissue is not a compromise. Functional outcomes of native tissue repair procedures are favorable, have a high rate of success, improve women's quality of life (QoL), and result in high rates of patient satisfaction. This subject requires further long-term, standardized prospective studies following the International Continence Society/International Urogynecologists Association guidelines for surgical outcomes report, with the focus on patient-centered functional outcomes.