Laparoscopic repair of vaginal vault prolapse

PURPOSE OF REVIEW: Currently, the two laparoscopic techniques available and described in the literature for the treatment of vaginal vault prolapse are uterosacral ligament vault suspension and sacrocolpopexy. These two techniques are opposing each other fundamentally. While the first is reconstructive, the second is essentially palliative. RECENT FINDINGS: In both methods the surgeon starts with the identification and dissection of the pubocervical and rectovaginal fascia. In the first technique however, the new vaginal vault, made by re approximation of the two fasciae, is attached to the uterosacral complex, while in the second one, each fascia is suspended from the sacral promontorium, using a mesh. In review of the existing literature, it seems that the palliative surgical approach is more successful in the long term, giving a cure rate of approximately 92%, probably as it involves using mesh instead of the native tissue. SUMMARY: In this article we discuss the laparoscopic techniques available currently, analyse their results, discuss their differences and compare them with other non-laparoscopic techniques. Finally, we discuss the different options described, and offer some guidelines for the future of laparoscopic treatment of pelvic prolapse.     

Enterocele repair and vaginal vault suspension

A paradigm shift has occurred in the approach to enterocele repair and vaginal vault suspension. This change in our approach is based on anatomic dissections that demonstrate that the loss of the upper suspensory fibers of the paracolpium and parametrium lead to uterine prolapse and vaginal prolapse after hysterectomy. In addition, the separation of the pubocervical from the rectovaginal fascia results in apical enterocele where the peritoneum is in contact with the vaginal mucosa. These fascial defects are hernias, and appropriate herniorraphy techniques will correct these defects and result in successful reconstruction of the vaginal tube and its reattachment to the suspensory cardinal uterosacral complex.     

High uterosacral vaginal vault suspension with fascial reconstruction for vaginal repair of enterocele and vaginal vault prolapse

OBJECTIVE: The purpose of this study was to review retrospectively the functional and anatomic outcomes of women who underwent vaginal repair of enterocele and vault prolapse with the use of an intraperitoneal suspension of the vaginal vault to the uterosacral ligaments in conjunction with fascial reconstruction of the anterior and posterior vaginal wall. STUDY DESIGN: Two hundred two women with advanced symptomatic uterovaginal prolapse or posthysterectomy vault prolapse underwent a standard transvaginal procedure to correct their prolapse between January 1997 and June 2000. Anatomic results were assessed by standardized examination from 6 months to 3 years after the operation. Functional results were assessed subjectively and with standard quality of life questionnaires. The average age of the women was 60.3 years. Follow-up data were available for 168 of the 202 women. Fifty-three percent of the women had their uterus in place and underwent a vaginal hysterectomy. The prolapse repair was a primary procedure in 45.2% of the women and was performed for a recurrence or persistence in 54.8% of the women. Sixty percent and 78.6% of women underwent anterior and posterior repair, respectively. Thirty-five percent of the women underwent an anti-incontinence procedure. RESULTS: Eighty-nine percent of the women expressed satisfaction with the results of the procedure. Ten women (5.5%) underwent a repeat operation (by the authors) for recurrence of prolapse in one or more segments of the pelvic floor. Quality of life assessment revealed a significant reduction in all aspects of daily living, when the short forms of the incontinence impact questionnaire and urogenital distress inventory were evaluated before and after the operation. Major intraoperative complications included 5 cases (2.4%) of ureteral injury, 1 case of a small bowel injury, and 1 case of a pelvic abscess that required abdominal exploratory operation and diversion of the colon. CONCLUSION: High uterosacral ligament vaginal vault suspension with fascial reconstruction would seem to provide a durable anatomic repair with good functional improvement in patients with significant complex uterine or vaginal vault prolapse.     

Magnetic resonance imaging findings following three different vaginal vault prolapse repair procedures: a randomised study

OBJECTIVE: To compare the vaginal configuration on magnetic resonance imaging following transvaginal sacrospinous fixation (SSF), posterior intravaginal slingplasty (PIVS) (infracoccygeal sacropexy) and sacrocolpopexy (SCP). MATERIALS AND METHODS: Twenty-one patients with vault prolapse requiring surgical treatment were randomly assigned in a balanced way to undergo SSF (n = 7), PIVS (n = 7) or SCP (n = 7). The magnetic resonance imaging of the pelvis were performed preoperatively and at 6-12 weeks postoperatively to assess the vaginal configuration using the method described previously. The two main angles measured were: (i) the angle between the lower vagina and pubococcygeal line 'd-angle' (normal: 53 +/- 15 degrees ); and (ii) the angle between the lower and upper vagina planes 'e-angle' (normal: 145 +/- 7 degrees ). RESULTS: The mean preoperative/postoperatively measured d-angles were 69 degrees /62 degrees, 58 degrees /70 degrees, and 49 degrees /52 degrees for SSF, PIVS and SCP, respectively. The corresponding means for the e-angle were 173 degrees /215 degrees, 189 degrees /146 degrees, and 205 degrees /149 degrees. The changes of the e-angles proved to be statistically significant (P < 0.05) in each surgical group, while no significant change in the d-angle could be found in any of the three groups. CONCLUSIONS: Significant improvements in the restoration of vaginal configuration were achieved in patients who underwent PIVS or SCP. Sacrospinous fixation in contrast seems to increase anatomical distortion of the vaginal configuration.     

Laparoscopic repair of vaginal vault dehiscence after postpartum hysterectomy

Post-hysterectomy vaginal vault dehiscence was triggered by intercourse. Laparoscopy allows examination of vaginal vault and permits laparoscopic repair.     

Ultrasound detection of vault haematoma following vaginal hysterectomy

Objective To assess whether ultrasound detection of vault haematoma can be used as a predictor of post-ooperative morbidity following vaginal hysterectomy.
Design Prospective observational study of consecutive cases of vaginal hysterectomy performed between 1991 and 1994.
Sample Two hundred and twenty-three women having undergone vaginal hysterectomy.
Methods All women hadtransvaginal ultrasound examination by an independent observer on the third post-operative day. Routine observations and clinical assessments were made by establishedmanagement protocol, by staff blinded to the ultrasound findings.
Main out come measures Febrile morbidity; haemoglobin drop; need for blood transfusion; length of stay in hospital; re-admission rate and length of stay.
Results Of the 223 scanned women, 55 (25%) had a vault haematoma. This group was compared with the 168 women with no haematoma. Significant increases in febrile morbidity (31% vs 7%), post-operative haemoglobin drop (2–5 g/dL vs 1.6 g/dL), need for blood transfusion (145% vs 1.2%), representation to hospital (25.5% vs 5.4%)and length of hospital stay (8.87 days vs 6.25 days) wereseen in the haematoma group.
Conclusion Ultrasound detection of vault haematoma following vaginal hysterectomy is a commonfinding associated with increased febrile morbidity, need for blood transfusion, longer hospital stayand higher re-admission rate. In view of increasing demand for early discharge, driven by purchasersand patients, post-operative ultrasound identifies a high risk population and is both convenient andnoninvasive. To further reduce morbidity, it also offers the opportunity to perform a controlled trialof prophylactic antibiotics in this identified subset.     

Operative management of vaginal vault prolapse following hysterectomy

Summary. Nine women suffering from vaginal vault prolapse had an abdominal sacropexy between 1972 and 1983. Marlex mesh was used to anchor the vaginal vault to the promontory of the sacrum and was completely buried retroperitoneally. The women had all had previous attempts at surgical correction. There were no intra- or post-operative complications. No recurrences of vault prolapse occurred during a mean follow-up period of 3.9 years. One woman developed a moderate cystocoele 4 years after sacropexy.     

Perineal rupture following vaginal delivery. Long-term consequences

Twenty-five women with complete perineal rupture were compared with a control group of 25 women, with regard to risk factors and possible long-term sequelae as a consequence of perineal damage. Following an average period of 78 months (52-123), all women received a questionnaire and were invited to a clinical follow-up, which included perineal inspection and measurement of the anal pressure profile. Vacuum extraction was more frequent in the rupture group than among controls (p less than 0.002). Eighty percent of the women in the rupture group were primiparae, compared with an overall rate of 40% (p less than 0.02). Forty-two percent of the women in the rupture group reported anal incontinence, compared with none in the control group (p less than 0.01). Most of these women reported stress-provoked incontinence regarding flatus and loose stools. Measurement of the anal pressure profile showed markedly reduced sphincter pressure, with maximum squeeze in the rupture group, but no differences were found regarding maximum anal pressure at rest. Sphincter length was reduced both at rest and with maximal squeeze in the rupture group. It is concluded that complete perineal rupture is a condition with possible long-term consequences such as reduced sphincter strength and partial anal incontinence.     

Strangulated small bowel through vaginal vault rupture: late complication of abdominal sacrocolpopexy

Sacrocolpopexy is currently a favourable procedure for management of apical defect and vaginal vault prolapse. Recently, it has been extensively evaluated in terms of its efficacy, durability and potential short- and long-term complications. These complications have been investigated by many authors, including urinary retention, urge incontinence, urinary tract infections, wound infection, haematomas, bowel symptoms and gastrointestinal complications. However, we report the first case of strangulated small bowel due to herniation through vaginal vault rupture as a late complication of sacrocolpopexy. This report reviews the risk factors and precipitating causes of bowel evisceration particularly after sacrocolpopexy, and peri- and intraoperative preventive measures are discussed, as well as various management modalities.     

Cooper ligament repair of vaginal vault prolapse twenty-eight years later

Sir Astley P. Cooper, a British surgeon, first described Cooper's ligament in 1841; in 1949 this ligament was, to our knowledge, first used to support prolapse of the vaginal vault. The first preliminary report in 1965 was based on anatomical dissection of 60 autopsy cases and stressed mainly the length, thickness, width, and strength of the Cooper ligament strip and the adjacent fascia overlying the symphysis pubis. The preliminary report suggested that this was indeed a strong fascial support and would support the vaginal vault. Since 1965, some 85 cases have been treated and in each case, since 1965, every effort has been made to incorporate all of the available extra fascial planes in the pelvic structure to add further support to the vaginal vault prolapse. No major complications have been encountered. The risk of infection of Mersilene strips and synthetics is avoided by using homologous Cooper ligament strips and adjacent fascia. No postoperative stress incontinence was encountered in any of the 63 cases.     

Laparoscopic repair of vaginal vault prolapse by lateral suspension with mesh

Background

To evaluate the long-term outcomes of laparoscopic lateral suspension using mesh reinforcement for symptomatic posthysterectomy vaginal vault prolapse.

Materials and methods

We analyzed in a prospective cohort study all the women treated by laparoscopic lateral suspension with mesh for symptomatic vaginal vault prolapse between January 2004 and September 2010. In this procedure, the mesh is laterally suspended to the abdominal wall, posterior to the anterior superior iliac spine. We performed systematic follow-up examinations at 4 weeks, 6 months and yearly postoperatively. Clinical evaluation of pelvic organ support was assessed by the pelvic organ prolapse quantification (POP-Q) grading system. Main outcome measures were recurrence rate, reoperation rate for symptomatic recurrence or de novo prolapse, mesh erosion rate, reoperation rate for mesh erosion, total reoperation rate.

Observations and results

Of the 73 patients seen at a mean 17.5 months follow-up, recurrent vaginal vault prolapse was registered in only one woman (success rate of 98.6 %). When considering all vaginal sites, we observed a total of 13 patients with recurrent or de novo prolapse (17.8 %). The non-previously treated posterior compartment was involved in eight cases (new appearance rate of 11 %). Of these 13 women, only 6 were symptomatic, requiring surgical management (reoperation rate for genital prolapse of 8.2 %). Four patients presented with mesh erosion into the vagina (5.5 %). Two required partial vaginal excision of the mesh in the operating room (2.7 %). There were no mesh-related infections. The total reoperation rate was 11 %.

Conclusion

Laparoscopic lateral suspension with mesh interposition is a safe and effective technique for the treatment of vaginal vault prolapse. This approach represents an alternative procedure to the laparoscopic sacrocolpopexy.     

Mullerian agenesis with vaginal vault prolapse following mechanically created neovagina

A 21-year-old with mullerian agenesis, presented with vaginal mass. Previously, she developed a neovagina by the use of vaginal dilators. Examination revealed vaginal vault prolapse. She was surgically treated with vaginal vault suspension using a mesh.     

Trends in operative vaginal delivery rates and associated maternal complication rates in an inner-city hospital

OBJECTIVE: The aims of this study were to determine trends in operative vaginal delivery rates in a large inner-city hospital and to assess associated risks. STUDY DESIGN: We performed a retrospective cohort study (1980-1996) of women with singleton term pregnancies who underwent operative vaginal delivery at Grady Memorial Hospital, Atlanta. Maternal complication rates were compared between forceps-assisted and vacuum-assisted methods. RESULTS: There was a decline in forceps-assisted deliveries during the 1980s and an increase during the 1990s. The vacuum-assisted delivery rate was exceedingly low during the 1980s and increased during the 1990s. Women who underwent forceps-assisted delivery were more likely to be <24 years old, to be nulliparous, and to have had regional anesthesia, midline episiotomies, and infant presentations other than occipitoanterior (P <.001). Women who underwent forceps-assisted deliveries had increased risks of postpartum infection, cervical laceration, prolonged hospital stay, perineal laceration, and postpartum complications. CONCLUSION: There were upward trends in the rates of operative vaginal delivery at this inner-city hospital. Women who underwent forceps-assisted delivery had greater rates of maternal complications than did those who underwent vacuum-assisted delivery.