Apical prolapse surgery — structured oral station (12 minutes)

Opening prompt — "What operation would you offer, and why?"

Model response — decide in three moves: ^[2][4]

• "This is Level I apical failure — vault prolapse after hysterectomy, with C at plus 2 cm. The apex is the priority, so the operation is an apical suspension."
• "She is sexually active, continent and wants durability. Laparoscopic sacrocolpopexy is the gold-standard apical repair: in the 2023 Cochrane review, vaginal procedures had more awareness of prolapse than sacrocolpopexy, risk ratio 2.31, more repeat surgery (RR 2.33) and more prolapse on examination (RR 1.87)."^[4]
• "The trade-off is higher apical recurrence than sacrocolpopexy, and the procedure-specific risk at uterosacral suspension is ureteric kinking — about 4.5% require suture removal (Unger 2015) — so I would confirm ureteric patency with intra-operative cystoscopy."^[5][19]

Examiner is listening for: the DeLancey level, the apical priority, the named trial with numbers, and the mesh awareness. ^[4]

Probe 1 — "She would prefer to avoid an abdominal operation. What is the vaginal alternative?"

• "A vaginal apical suspension — uterosacral ligament suspension or sacrospinous ligament fixation. In OPTIMAL these were not significantly different at 2 years (ULS 59.2% vs SSLF 60.5%) or 5 years (surgical failure 61.5% vs 70.3%), and they avoid mesh and recover faster."^[5][6]
• "The trade-off is higher apical recurrence than sacrocolpopexy, and the procedure-specific risk at uterosacral suspension is ureteric injury — so I would confirm ureteric patency with intra-operative cystoscopy."^[5]

Probe 2 — "She is continent. Do you add anything for continence?"

• "I screen for occult stress incontinence by reducing the prolapse and asking her to cough. Reducing the prolapse unkinks the urethra and can unmask occult SUI."
• "OPUS showed a prophylactic midurethral sling reduced 12-month incontinence in continent women having vaginal prolapse surgery (27.3% vs 43.0%, NNT 6.3), but with more bladder perforation 6.7% vs 0%, UTI 31.0% vs 18.3%, major bleeding 3.1% vs 0% and incomplete emptying 3.7% vs 0%. This is a shared decision about which adverse event she accepts."^[17]

Probe 3 — "She has read about mesh and is frightened. What do you say?"

This is a scored domain. Demonstrate it out loud: ^[15]

• "There are two kinds of mesh, and they are very different. Transvaginal mesh — sewn through the vaginal wall to repair prolapse — has an exposure rate around 11.8% and was withdrawn in Australia in 2018 because of those complications."^[15]
• "Sacrocolpopexy mesh is placed abdominally, against the vault and the sacrum, in a different tissue environment; it erodes in around 3.4% in pooled data and remains the gold-standard apical repair. I would not use transvaginal mesh for her; if she has a sacrocolpopexy, I would counsel her on the small but real risk of erosion, exposure, contraction with pain, and the chance of needing revision, and document that consent."^[8][15]

Probe 4 — "How likely is it to come back?"

• "Sacrocolpopexy has the lowest recurrence and reoperation for vault prolapse. But I would be honest that anatomical recurrence is common with prolapse surgery overall — in OPTIMAL, 5-year surgical failure was 61.5% to 70.3% — while symptom scores stayed improved, so feeling better and the anatomy on examination are different outcomes."^[6]
• "I would frame it honestly: the operation is very likely to relieve her bulge, but recurrence is possible and a second operation is sometimes needed, with the interval shortening each time."

Probe 5 — "She is anxious. How do you close?"

• Move to her eye level, use her name, and summarise plainly: "You have vault prolapse, which is common after hysterectomy. The best durable option is a keyhole operation that uses a small piece of mesh to re-suspend the vagina. There is a small risk from the mesh, which I have explained, and there are mesh-free vaginal alternatives if you prefer. You do not have to decide today."^[8]
• Offer written information, a review appointment, and a named contact; respect her preference and pace.