13.11: Route Of Surgery

There are hundreds of operations described for the correction of POP, with either an abdominal or a vaginal approach. Most textbooks suggest that prolapse surgeons be adept at both abdominal and vaginal procedures, but in reality the majority of POP surgery is performed via the vaginal route. However there are no good data on which to base the decision as to route of surgery. Reviewing prolapse literature is difficult because of the heterogeneous nature of the condition, variability in inclusion and exclusion criteria, the variety of procedures, non-standardized definitions of outcomes, lack of independent reviews and short term followup.

In general terms, there is good level 1 evidence that the abdominal approach is more robust, effective and durable for correcting the anatomy and preserving vaginal and lower urinary tract function. The vaginal route has fewer serious perioperative complications. Maher demonstrated that vaginal sacrospinous colpopexy was faster and cheaper with quicker return to normal activities, but has a significantly higher risk of recurrent anterior or apical prolapse than abdominal surgery using a mesh or sacral colpopexy technique. The vaginal approach is commonly preferred for the obese, chronic strainer who smokes and suffers obstructive pulmonary disease.