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Comparison of different surgical options for pelvic organ prolapse

Last reviewed dd mmm yyyy. Last edited dd mmm yyyy

Surgical Treatment	Advantages	Advantages
Manchester repair Pelvic floor repair using the Manchester technique without the need for hysterectomy an operation to support the body of the uterus by shortening the cervix and conserving the body of the uterus. This can be combined with a repair of the vaginal walls if these are prolapsing significantly often referred to as a Manchester repair treatment for: uterine or cervical prolapse	No abdominal incision(s) Main body of uterus still present so pregnancy is possible. Can be done under general anaesthetic or via a local (spinal)	Rarely stenosis of cervix causes pain Pregnancy can be complicated by premature labour
Vaginal Hysterectomy (removal of uterus via the vagina)	No abdominal incision(s) Uterus removed so no risk of cancer of cervix or uterus in future. Can be done under general anaesthetic or via a local (spinal)	Risk of prolapse of the vault of the vagina in the future (2)
Sacrohysteropexy - laparoscopic (key hole) or abdominal (open operation) an operation to treat uterine prolapse. Plastic mesh is used to attach the the uterus to a bone at the bottom of the spine.	Mesh provides strong and continuing support to the uterus reducing the chance of prolapse recurrence. May also treat a co-existing vaginal prolapse. No cuts or stitches in vagina. Vaginal length maintained. Uterus still present so pregnancy is possible. Minimal blood loss and shorter length of hospital stay (equivalent to other options) with laparoscopic approach	Requires a general anaesthetic for laparoscopic or open surgery As mesh is used there is a small risk that the mesh will work its way into surrounding tissues. Only if open surgery (2): more painful than the other procedures slower return to normal activities longer hospital stay
Vaginal Sacrospinous Hysteropexy (stitches to support womb inserted through vagina) an operation used to treat uterine prolapse. The cervix is stitched to a ligament in the pelvis. It is done through a cut on the inside of the vagina	No abdominal incision(s) Pregnancy still possible although prolapse might recur during or after pregnancy Can be done under general anaesthetic or via a local (spinal)	Can cause temporary buttock pain Variable long-term success with recurrence of uterine prolapse 14-30% (2)
Colpocleisis (closing of vagina) operation to treat pelvic organ prolapse by closing the vagina	High success rates (90-95%) both for prolapse of the uterus and the walls of the vagina. No abdominal incision(s) Can be done under general anaesthetic or via a local (spinal)	Sexual intercourse will never be possible after this operation. Not possible to take a smear Difficult to investigate inside the uterus if abnormal bleeding occurs Urinary incontinence in the future may be more difficult to treat (2)

NICE have stated options for surgical management of pelvic organ prolapse (1)

surgery should be offered for pelvic organ prolapse to women whose symptoms have not improved with or who have declined non-surgical treatment
surgery should not be offered to prevent incontinence in women having surgery for prolapse who do not have incontinence
- if uterine prolapse
  - for women with uterine prolapse who have no preference about preserving their uterus, NICE suggest a choice of:
    - vaginal hysterectomy, with or without vaginal sacrospinous fixation with sutures or
    - vaginal sacrospinous hysteropexy with sutures or
    - Manchester repair
    - option of sacro-hysteropexy with mesh (abdominal or laparoscopic)
  - for women with uterine prolapse who wish to preserve their uterus, NICE suggest a choice of:
    - vaginal sacrospinous hysteropexy with sutures or
    - Manchester repair, unless the woman may wish to have children in the future
    - option of sacro-hysteropexy with mesh (abdominal or laparoscopic)
- surgery for vault prolapse
  - vaginal sacrospinous fixation with sutures or
  - sacrocolpopexy (abdominal or laparoscopic) with mesh
colpocleisis should be considered for women with vault or uterine prolapse who do not intend to have penetrative vaginal sex and who have a physical condition that may put them at increased risk of operative and postoperative complications
- surgery for anterior prolapse
  - anterior repair without mesh to women with anterior vaginal wall prolapse
  - synthetic polypropylene or biological mesh insertion for women with recurrent anterior vaginal wall prolapse may considered after MDT review and discussion with the woman about the risks of mesh insertion
    - and if apical support is adequate or an abdominal approach is contraindicated
- surgery for posterior prolapse
  - vaginal repair without mesh

Reference:

NICE (April 2019). Urinary incontinence and pelvic organ prolapse in women: management
British Association of Urogynaecology. Pelvic floor repair using Manchester technique without the need for hysterectomy - Patient Information Leaflet (Accessed 7/5/2019)

Assessment and referral of complications of mesh surgery for urinary incontinence or pelvic organ prolapse

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Comparison of different surgical options for pelvic organ prolapse

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