The role of apical vaginal support in the appearance of anterior and posterior vaginal prolapse

OBJECTIVE: To describe how simulated apical support affects the appearance of prolapse in the anterior and posterior vagina using a modification of the Pelvic Organ Prolapse Quantification (POP-Q) examination. METHODS: Women with prolapse stage II or greater were examined using the POP-Q. To simulate apical support, the posterior blade of a standard Graves speculum was positioned over the posterior vagina to support the vaginal apex while remeasuring points Aa and Ba and over the anterior vagina to support the apex while remeasuring points Ap and Bp. Change in anterior and posterior POP-Q points and prolapse stage with apical support were calculated. RESULTS: One hundred ninety-seven women were enrolled with mean age of 62+/-14 years, median parity of 2 (range 0-8), and mean body mass index of 28+/-5 kg/m(2). By standard POP-Q, 36% had stage II prolapse, 54% had stage III, and 10% had stage IV prolapse. With simulated apical support, point Ba changed to stage 0 or I in 55% of cases and point Bp changed to stage 0 or I in 30% (P<.001 for each point). Mean change for point Ba with apical support was 3.5+/-2.6 cm and point Bp was 1.9+/-2.9 cm (P<.001). CONCLUSION: When the POP-Q examination is performed with simulated apical support, the critical role of level I vaginal support on the position of the anterior and posterior vagina, particularly the anterior vagina, becomes apparent. LEVEL OF EVIDENCE: II.     

Prolapse of the neovagina in Mayer-Rokitansky-Kuster-Hauser syndrome. A case report.

BACKGROUND: Mayer-Rokitansky-Kuster-Hauser syndrome is a rare entity. The creation of a sigmoid vagina was performed in some patients with this syndrome in the past, though it is not widely used now. We report on a patient who developed prolapse of a sigmoid vagina 33 years after the operation. CASE: A 57-year-old woman presented with a "falling-out" sensation in the vagina, pain, leukorrhea and dyspareunia. She had undergone an operation for creation of a sigmoid vagina 33 years earlier in our hospital. She and her husband desired conservation of the ability for sexual intercourse. The transabdominal method of retroperitoneal sacropexy of the sigmoid vagina was performed. The patient has maintained a satisfactory sexual life with her husband since the operation. CONCLUSION: There are a few cases of prolapse of a sigmoid vagina in the literature, while the repair methods are not described in detail. To our knowledge, this is the first report of reconstruction of a sigmoid vaginal prolapse. Although the reasons for the neovaginal prolapse were not understood, the retroperitoneal sacropexy was successful in this case.     

Prolapse of the vagina after hysterectomy

Twenty-two patients were operated upon for posthysterectomy vaginal prolapse. The original operation had been abdominal hysterectomy in 11 patients and vaginal hysterectomy in an additional 11 patients. All of the corrective operations were performed abdominally. Vaginal sacropexy was performed upon eight patients with our own modified method using a fascial strip taken from the rectum sheath. Dexon sutures were used in the attachment of the strip to the apex of the vagina and to the periosteum of the sacrum. The fascial strip was peritonealized. A high resection of the enterocele sac was performed. Excellent permanent vaginal support was achieved in all of these patients. Other methods of operation used included direct fixation of the vaginal apex to the presacral fascia, fixation of the vagina with round ligaments and the method according to Williams and Richardson. More than one-half of the patients had recurrences.     

Surgical treatment of prolapsed uterus and vagina using the RFV (reposition and fixation of the vagina) method R. Napierala

OBJECTIVES: I am presenting a new and personal method of surgical treating a uterovaginal prolapses using vaginal approach. MATERIAL AND METHODS: From 30th July to 30th November 2004, 12 patients between the ages of 40 and 83 years were operated on using the RFV method. The RFV Surgical Method is a new, inexpensive and technically simple procedure with little risk of complications using vaginal approach. It involves repositioning a prolapsing vagina and uterus to their proper positions as well as stabilizing them with the use of circular, parallel, non-absorbent sutures on the vagina and then the formation of scar tissue around the sutures. RESULTS: After the surgical procedures, all 12 patients anatomical relations returned to normal. There was only one incident where absorbent sutures were used and 2 months after surgery the uterus once again began to prolapse. The patient was operated on once again using nonabsorbent sutures and to this day, four months after surgery, there is no evidence of the uterus or vaginal walls descending. CONCLUSIONS: The above named surgical procedure is recommended for older women who also suffer from other illnesses which might disqualify them from undergoing more traditional, extensive procedures. Preliminary results have been introduced at work of 12 patients operated on using this method.     

Treatment of vaginal vault prolapse with abdominal sacral colpopexy using prolene mesh

BACKGROUND: We report our experience on abdominal sacral colpopexy (CSP) with a prolene mesh in women with vaginal vault prolapse. METHODS: From 1994 to 1997 15 patients (average 57 years), underwent CSP. All patients suffered from a serious vaginal vault prolapse. Eight of them also had a uterine prolapse. Seven patients had already been operated for hysterectomy (5 vaginal, 2 abdominal). Four of them had already been operated for urinary incontinence: (3 Raz, 1 Burch). In 6 cases we have a colposuspension according to Burch associated with CSP. Average follow-up was 15 months. RESULTS: All the patients have carried a bladder catheter for 4-12 days (average 5 days). The patients who were sexually active have begun having normal sexual intercourse again. Neither relapses of the treated prolapses, no infections or rejections of the prosthesis have been verified. In 1 patient pollakiuria insensitive to anticholinergics has persisted. Four patients have complained of hypogastric "sense of weight", without any clinical evidence of pathology. CONCLUSION: Our survey confirms the information and the good result of this technique in the treatment of the total vaginal dome prolapse, also in comparison with our operations for sacrospinosous ligament fixation. This kind of treatment through the vagina, is not always possible, above all after hysterectomy with a very short vagina.     

Functional and anatomic follow-up of enterocele repairs

OBJECTIVE: To identify the functional and anatomic outcomes in women who have surgery for pelvic organ prolapse with enterocele repair. METHODS: Fifty-four women had surgery for pelvic organ prolapse which included enterocele repair. Preoperative and postoperative examinations were done by a research nurse, including a pelvic examination using the International Continence Society staging system and standardized questionnaires about bowel function, sexual function, and prolapse symptoms. RESULTS: Fifty-four women had enterocele repairs as part of their surgery. Mean follow-up time was 16 months (range 6-29 months). Postoperatively five women were excluded from the analysis because of fluctuation in stage of prolapse over time. At the apex and posterior wall of the vagina, 33 women had stage 0 or I prolapse, and 16 had stage II prolapse. None had stage III or IV prolapse. Fifty-three percent of women had improvement in bowel function and 91% had improvement in vaginal prolapse symptoms. Functional outcomes were not significantly different in women with and without stage II prolapse at follow-up. CONCLUSION: Most women who had surgery for pelvic organ prolapse with enterocele repair reported improvement in vaginal prolapse symptoms. Functional outcomes did not differ significantly between women with stage 0 and I prolapse and women with stage II prolapse at the vaginal apex and posterior vaginal wall. This was an observational study and the lack of statistically significant findings could result from inadequate sample size; however, the observed differences were judged to be not clinically significant.     

阴股沟皮瓣阴道再造术12例分析

目的　对应用阴股沟皮瓣进行阴道再造的经验进行总结。方法　以阴唇后动脉外侧支为血管蒂 ,在两侧阴股沟区掀起阴股沟皮瓣 ,皮瓣 9cm× 4cm～ 14cm× 5cm ,通过大阴唇皮下隧道转移至阴道前庭 ,相对缝合形成皮管 ,推入尿道、直肠间隙的腔穴中形成阴道。共为 12例患者实施阴道再造。结果　 1例因术中造穴时损伤直肠导致阴道直肠瘘 ,1例因感染致一侧皮瓣坏死 ,二期修复成功。其余 2 3个皮瓣全部成活 ,随诊 3个月至 8年 ,再造阴道光滑、无缩窄 ,横向可容纳两指 ,深度约9～ 10cm。结论　应用阴股沟皮瓣进行阴道再造 ,具有皮瓣血运丰富 ,解剖简便易行 ,再造阴道无继发挛缩并带有会阴部感觉 ,供区较隐蔽 ,术后少有继发瘢痕畸形的优点。     

Transvaginal Saerospinous Colpopexy for Posthysterectomy Vault Prolapse

Summary: This study assesses the results of transvaginal sacrospinous colpopexy in the treatment of posthysterectomy vault prolapse; 114 of 135 women were available for follow-up between 8 months and 5 years after surgery. There was an initial overall satisfaction rate of approximately 90% and this was maintained at 80% even beyond 4 years. Those initially complaining of a lump or a swelling were relieved of the symptom in almost 90% of cases. Those with a drag or ache were cured in approximately 80% of cases. There was greatly improved bowel function in approximately 60% of patients and in approximately 60% there was cure of stress incontinence with additional buttressing sutures. Frequency and/or urgency was relieved in over 50% of the group and there was more comfortable intercourse in approximately 35% of those in whom this was a problem initially. As in previous series, subsequent prolapse is more likely to be in the anterior vaginal wall and there was an approximately 5% risk of this occurring over this period of follow-up. The variation in technique in this series in which nonabsorbable Ethibond sutures were used to secure the vaginal vault to the sacrospinous ligament, appears to provide better long-term vault support than previous reports in the literature, without altering morbidity. Continuing follow-up will be required to confirm that this will prove to be so in the longer term. This series therefore confirms that the operation produces long-term support of the vaginal vault with preservation of a functional vagina, and has a satisfactory success rate in the relief of bladder and bowel symptoms associated with vault prolapse. However, it also demonstrates that in this mostly aged group of patients there will be a significant minority with limited relief of symptoms. It is important therefore that appropriate preoperative counselling is carried out so that patients have realistic expectations regarding the medium and long-term results of this procedure.     

Transvaginal repair of enterocele and vaginal vault prolapse using autologous fascia lata graft

BACKGROUND: The aim was to describe the operative technique of transvaginal repair of enterocele and apical prolapse using autologous fascia lata and report intra- and postoperative complications and long-term outcome. METHODS: A retrospective chart review of 74 consecutive patients who had repair of a symptomatic enterocele and vaginal vault prolapse or uterine prolapse from January 1987 to August 1999. All patients were followed for a minimum of 3 months and 61 were available for long-term evaluation at 18-106 months (median 52 months). RESULTS: Intra- and postoperative complications were few. Pelvic examination at long-term follow-up disclosed a recurrence rate for enterocele of 1.7%, vaginal vault prolapse of 8.3%, and cystocele of 15%. Ninety-one per cent were subjectively satisfied with the relief of mechanical vaginal symptoms. Only 35% (6/17) were cured of constipation. Out of the 22 women who were sexually active after the procedure, 12 (54%) experienced improved quality. CONCLUSION: Repair of the posterior compartment defect and suspension of the vaginal vault using autologous fascia lata graft provides acceptable intra- and postoperative complication and long-term results.     

Small bowel obstruction associated with post-hysterectomy vaginal vault prolapse

BACKGROUND: Patients may present with post-hysterectomy vaginal vault prolapse in conjunction with small bowel obstruction. Prior pelvic surgery, malignancy, and radiation therapy may be associated with this presentation. CASE: An 83-year-old multiparous woman with a history of poorly differentiated endometrial adenocarcinoma was treated with radiation therapy, total abdominal hysterectomy, and salpingo-oophorectomy. Anterior exenteration was performed for a recurrence. Seventeen years after her last pelvic operation, she had small bowel obstruction that coincided with a worsening post-hysterectomy vaginal vault prolapse. Surgical management included a side-to-side ileoileostomy and excision with closure of the vaginal apex. CONCLUSION: Although pelvic organ prolapse primarily affects quality of life, clinicians should be alert for bowel obstruction occurring with post-hysterectomy vaginal vault prolapse.     

Uterosacral ligament fixation for vaginal vault suspension in uterine and vaginal vault prolapse

OBJECTIVE: The purpose of this study was to determine the simplicity, safety, anatomic, and functional success of using the uterosacral ligaments for correction of significant complex uterine and vaginal vault prolapse by the vaginal route. STUDY DESIGN: Fifty women with uterine or vaginal vault prolapse with descent of the cervix or the vaginal vault to the introitus or greater were treated between 1993 and 1996 by the same surgeon with bilateral uterosacral ligament fixation to the vaginal cuff by the vaginal route. Included were patients with significant enterocele, cystourethrocele, rectocele, and stress urinary incontinence who had concomitant repair of coexisting pelvic support defects. An etiology of vaginal vault prolapse is discussed. RESULTS: Uterosacral ligaments were identified and used for successful vaginal vault suspension by the vaginal route in all 50 consecutive patients without subsequent failure or significant complications with a maximum follow-up of 4 years. One patient had recurrent stress urinary incontinence and two had asymptomatic cystoceles. Three patients had erosion of monofilament sutures at the vaginal apex. CONCLUSIONS: In these 50 patients with significant complex uterine or vaginal vault prolapse, uterosacral ligaments could always be identified and safely used for vaginal vault suspension by the vaginal route with no persistence or recurrence of vaginal vault prolapse 6 to 48 months after surgery. Excessive tension by the surgeon on tagged uterosacral ligaments at the time of hysterectomy may be an etiologic factor in vaginal vault prolapse.(Am J Obstet Gynecol 1997;177:44)     

Management of iatrogenic vaginal constriction

OBJECTIVE: To prospectively assess the outcomes of four approaches to the surgical management of iatrogenic vaginal constriction. METHODS: A prospective study was initiated to evaluate all women who presented to our practice with the complaint of apareunia or dyspareunia secondary to postoperative vaginal constriction. All participants were initially offered and failed a trial of manual dilation. Between 1997 and 2002, 20 women underwent one of four surgical procedures: Z-plasty, vaginal incision of constriction ring, vaginal advancement, or placement of free skin graft. All 20 participants have been followed postoperatively, including assessment of dyspareunia and postoperative vaginal length and caliber. RESULTS: Three patients underwent Z-plasty, eight had incision of vaginal ring or ridge, eight had vaginal advancement, and one underwent placement of a free skin graft. Mean follow-up was 17 months (range, 3-32 months). Subjective cure was defined as resumption of pain-free vaginal intercourse. Objective cure was defined by findings on physical examination. The overall subjective and objective cure rates were 75% and 85%, respectively. CONCLUSION: The appropriate surgical procedure depends on the site and extent of the vaginal constriction, the state of the surrounding tissue, and the overall length and caliber of the vagina.     

"Spontaneous perforation" of Douglas' pouch

"Spontaneous" perforations of Douglas's pouch are a rare complication following gynecological surgery. Three patients are reported, in which Wertheim-Meigs-operation, abdominal and vaginal hysterectomy had been performed. Laceration of the vaginal vault with opening of Douglas's pouch occurred "spontaneously" at sexual intercourse. In another patient rupture of the pelvic floor with prolapse of the intestinum was observed 7 months after colpocleisis. Small perforations may be closed through the vagina; prolapse of the intestinum requires laparotomy.     

经阴道行阴道旁修补术在阴道前壁及膀胱膨出治疗中的应用

目的 探讨经阴道途径行阴道旁修补(VPVR)手术治疗中、重度阴道前壁及膀胱膨出的有效性和安全性。方法采用VPVR手术,治疗25例有临床症状、经盆腔器官脱垂定量(POP-Q)分度法和Baden-Walker盆腔器官脱垂的阴道半程系统分度法,确定为阴道前壁及膀胱膨出的患,其中,POP-Q分度法为Ⅲ～Ⅳ度占92％。VPVR手术主要包括经阴道于耻骨降支下进入耻骨后间隙,暴露盆腔筋膜腱弓(ATFP),用不可吸收线将盆腔内筋膜、盆腔筋膜腱弓及膀胱筋膜逐一缝合,关闭阴道旁缺陷等步骤。同时进行其他盆底修复手术共11种。术后定期随访,对手术效果进行主观(患自觉症状或感觉)及客观(临床检查)评价。结果25例行VPVR手术均获得成功。手术时间平均为40min,出血量平均为70ml;有2例术中耻骨后静脉丛出血,分别为100ml及200ml。无其他手术并发症,无术后病率。有2例术后发生排尿困难及尿潴留,1例于短期内痊愈,另1例为术后2个月现仍在治疗中。25例术后随访2～14个月,平均6个月,患无任何自觉症状,主观治愈率为100％。2、6个月随访时,各有1例临床检查发现为复发(POP-Q分度法为Ⅰ度),客观治愈率为92％。结论VPVR手术可以恢复耻骨宫颈筋膜附着在盆腔侧壁的解剖位置,对纠正中、重度阴道前壁及膀胱膨出,是安全、有效的。     

Vaginal vault suspension by abdominal sacral colpopexy for prolapse: a follow up study of 40 patients

OBJECTIVES: Vaginal vault prolapse is a rare event after hysterectomy. Vaginal repair often results in a narrowed and shortened vagina with diminished function. Abdominal sacral colpopexy attaches the vaginal apex to the sacral promontory and restores the physiological position of the vagina. The objective of the study was to evaluate follow up results of the abdominal sacral colpopexy in 40 patients by a questionnaire and a gynaecologic examination. METHODS: We performed a cohort study. Between 1992 and 1998, 45 consecutive patients with a vaginal vault prolapse treated with an abdominal sacral colposcopy were included. RESULTS: Forty patients were included in the study. No serious complications occurred during surgery. Two patients per- or postoperative hemorrhage required blood transfusion. In two patients, one with a concomittant hysterectomy, the Gore-tex graft infected within 3 months after the operation. If vaginal 'protrusion' was the only preoperative complaint, in 93% (13/14) of the cases, surgery resulted in a condition without any complaint, related to the vaginal prolapse. If initially a combination of complaints (vaginal protrusion, urinary incontinence, defecation problems, sexual dysfunction) was the reason for surgery, only ten of 27 (37%) patients were symptom-free at follow up (P=0.002, Yates corrected). In the whole group 34 (85%) patients noticed before the operation a feeling of vaginal protrusion. At follow-up, 23 patients (56%) had no symptoms at all that could be related to the vaginal prolapse. Problems concerning defecation, like constipation were present before surgery in eight patients. In six of them, these complaints were resolved after surgery. However, in five patients de novo constipation developed after surgery. There were no cases of de novo urinary incontinence. At gynaecological examination in three patients, the vaginal vault prolapse recurred within the follow-up period, accounting for a success rate of 93%. In ten more patients a moderate enterorectocele developed or persisted. No reoperations were performed for that reason. CONCLUSIONS: Abdominal sacral colpopexy is a safe and efficacious treatment of the posthysterectomy vaginal vault prolapse. To prevent the persistence or development of an enterorectocele, a culdoplasty according to Halban or McCall might possibly be helpful. Peritonisation of the graft seems not to be necessary. The use of banked collagen tissue as graft material is promising and needs further investigation.     

Transvaginal repair of anterior and posterior compartment prolapse with Atrium polypropylene mesh

OBJECTIVE: To determine the efficacy and safety of a new technique using Atrium polypropylene mesh (Atrium, Hudson, New Hampshire, USA) as an overlay graft for repair of large or recurrent anterior and posterior compartment prolapse. DESIGN: A retrospective review of women who had vaginal prolapse surgery with Atrium mesh reinforcement. SETTING: Tertiary referral urogynaecology unit in Australia. POPULATION: Forty-seven women where mesh was placed under the bladder base with lateral extensions onto the pelvic sidewall, 33 women where a Y-shaped mesh was placed from the sacrospinous ligaments to the perineal body and 17 women who had mesh placement in both compartments. METHODS: Women were assessed by site-specific vaginal examination pre-operatively and post-operatively at six weeks, six months and two years. MAIN OUTCOME MEASURES: All complications. Rate of recurrent prolapse assessed by the Baden-Walker halfway classification system. RESULTS: Mean follow up was 29 months (range 6 to 52). Four of 64 women with anterior mesh placement (6%) developed a grade 2 asymptomatic cystocele. Five women (5%) required further surgery for recurrent prolapse at a non-mesh site. Erosion occurred in nine women (9%). Three healed after intravaginal oestrogen cream, five after excision of exposed mesh and vaginal closure and one woman also had surgical closure of a rectovaginal fistula. The risk of mesh erosion decreased over the study period. Urinary, coital and bowel symptoms were significantly improved following surgery. CONCLUSIONS: This technique shows promise in correcting pelvic organ prolapse. Vaginal mesh erosion is the most common complication and is related to surgical experience.     

Selecting suspension points and excising the vagina during Michigan four-wall sacrospinous suspension

OBJECTIVE: To describe the variations in the location of the vaginal apex and the length of vagina excised in women undergoing the Michigan four-wall sacrospinous suspension for posthysterectomy vaginal vault prolapse. METHODS: A prospective observational study of 76 women who had the Michigan modification sacrospinous suspension performed between 1998 and 2001 for posthysterectomy vaginal vault prolapse was carried out. Demographics and preoperative, operative, and postoperative findings were noted, including the pelvic organ prolapse quantification score. The locations of the suspension points relative to the hysterectomy scar were recorded. The amount of vagina excised at surgery and the pre- and postoperative vaginal lengths are reported. RESULTS: The mean length and standard deviation of vagina excised was 4.6 +/- 2.5 cm. The apex created at sacrospinous fixation was at the hysterectomy scar in only seven women (9%). It was most often situated behind the hysterectomy scar, in 58 cases (76%); it was situated in front of it in 11 (14%). In seven women no vagina was excised, and in the remaining 69 women a mean length of 5.1 +/- 2.2 cm was removed. The mean vaginal lengths were 9.7 +/- 1.7 cm preoperatively and 9.4 cm +/- 0.8 postoperatively, a 0.3-cm difference. CONCLUSION: When one performs the Michigan modification sacrospinous suspension, the chosen suspension points are often not at the hysterectomy scar, and in women with large prolapses excess vagina frequently is excised without compromising postoperative vaginal length.     

Total vaginal reconstruction with combined 'Split Labia Minora Flaps' and full-thickness skin grafts

PURPOSE: Vaginal reconstruction with split-thickness skin grafts is the most common method for total vaginal reconstruction. Although it has disadvantages like contraction of the graft, foreshortening, donor site morbidity and long-lasting periods of vaginal standing; its easy surgical technique makes it popular. A new method using split labia minora (LM) flaps and full-thickness skin graft is discussed in this study. METHOD: A 19-year-old female was presented with amenorrhea. A total absence of vagina was present and the patient underwent a total vaginal reconstruction for possible sexual intercourse. RESULTS: We observed no contraction and no foreshortening with a patent vaginal cavity up to 11 cm and 4.5 cm width. The need for continuous standing period was as short as 4 weeks and for intermittent standing up to 4 months. Sexual intercourse was encouraged after 4 weeks. During sexual intercourse no external lubrication was reported to be needed. There was no need for further reconstructive intervention. CONCLUSION: Vaginal reconstruction in congenital vaginal agenesis with split LM flaps and full-thickness skin grafts is a simple and effective method, which shortens the standing period and decreases the contraction in neovagina. Total vaginal reconstruction with split LM flaps could also be possible; to achieve this goal, expansion of LM flaps could be a further alternative.     

Posthysterectomy Rectal and Vaginal Prolapse, a Commonly Overlooked Problem

Summary: The existence of combined rectal and vaginal prolapse is more common than the literature would suggest. This paper outlines a further development in the operative management which has been applied to 24 patients with this problem. All had had a hysterectomy and most had had in addition one or more vaginal repairs. The common mode of presentation was one of pelvic pain (19 patients), sometimes severe, crippling and intractable and some form of protrusion (14 patients), difficult or unsatisfied defaecation and rectal incontinence (9 patients). The vaginal prolapse which always involved the vault and usually involved the lower vagina was usually found to be incomplete and the rectal prolapse complete (but occult).
The operative procedure essentially consists of a Wells type rectopexy which has a new modification in which the sling is extended to anchor the vaginal vault after correction of the enterocele by the abdominal approach. A vaginal repair is subsequently performed at the same operation where anterior or posterior vaginal prolapse persists. Important points in the procedure are the avoidance of sepsis (the vaginal vault is not opened during the procedure) and protection of the ureters by careful assessment of the lateral margins of the vaginal vault which is illuminated by transvaginal vault endoscopy. At this early stage operative morbidity has been minimal, relief of the pelvic symptoms has been most encouraging, but the length of follow-up is short (range 6–30 months, average 15.6) and long-term evaluation will be necessary as with all surgery for prolapse.