Bilateral uterosacral ligament vaginal vault suspension with site-specific endopelvic fascia defect repair for treatment of pelvic organ prolapse

OBJECTIVE: The anatomic and functional success of suspension of the vaginal cuff to the proximal uterosacral ligaments is described. STUDY DESIGN: Forty-six women underwent vaginal site-specific repair of endopelvic fascia defects with suspension of the vaginal cuff to the proximal uterosacral ligaments for pelvic organ prolapse. Outcome measures included operative complications, pelvic organ prolapse quantitation, and assessment of pelvic floor symptoms. RESULTS: After a median follow-up of 15.5 months (range, 3.5 months-3.4 years), 90% of patients had both resolution of vaginal bulging or prolapse symptoms and improvement of the stage of prolapse. There were improvements in all pelvic organ prolapse quantitation measurements except for total vaginal length, for which the median decrease was 0.75 cm. Intraoperatively, ureteral occlusion was noted in 11% (5/46) of patients with universal cystoscopy. In 3 patients the uterosacral suspension sutures were removed and replaced with resolution of the occlusion and in 2 patients ureteral reimplantation was required. Symptomatic prolapse (2 apical segment, 1 anterior, and 1 posterior) developed in 4 patients (10%), and 3 of them underwent reoperation. There were significant improvements in symptoms of bulging and pressure, voiding dysfunction, and vaginal and perineal splinting. CONCLUSION: Suspension of the vaginal vault to the proximal uterosacral ligaments combined with site-specific repair of endopelvic fascia defects provides excellent anatomic and functional correction of pelvic organ prolapse in most women. The risk of ureteral injury with this technique makes intraoperative cystoscopy essential.     

Fixation of the vaginal apex to the coccygeous fascia during repair of vaginal vault eversion with enterocele

Objective: This study was undertaken to compare the effectiveness of fixation of the vaginal apex to the coccygeus fascia with fixation to the sacrospinous ligament during surgical repair of vaginal vault eversion with enetrocele.Study design: The records of 121 patients with postheysterectomy vaginal vault eversion with enterocele treated by the author between 1983 and 1994 were reviewed. Preoperative and postoperative symptoms and findings on pelvic examination and postoperative recovery were compared in patients undergoing sacrospinous ligament suspensino and coccygeus fascial suspension. Statistical analysis was performed with χ² analysis and Kaplan-Meier life tables.Results: Eighty-one patients underwent fixation to the coccygeus fascia and 30 underwent sacrospinous ligament suspension. The two groups are similar for clinical history, symptoms, and findings on pelvic examination. Ten patients, underwent an abdominal sacral colpopexy for specific indications and are not comparable. The incidence of postoperative complications and length of hospital stay were similar for the two vaginal procedures. Patients with coccygeus fascial suspension have a projected 96% cure rate at 2 years compared with an 80% cure rate for patients with a sacrospinous ligament suspension.Consclusion: Bilateral vaginal vault suspension to the coccygeus fascia is a safe, simple, and effective technique in the management of vaginal vault eversion with eneterocele.     

Operative injuries during vaginal hysterectomy.

OBJECTIVE: To evaluate incidence, characteristics and consequences of urinary and intestinal tract injuries during vaginal hysterectomy for benign conditions. STUDY DESIGN: From January 1970 to December 1996, 3076 vaginal hysterectomies with or without additional procedures, were performed for benign conditions in our department. We retrospectively analyzed operative injury cases. RESULTS: Incidence of urinary and intestinal tract injuries were 1.7 and 0.5%, respectively. Concerning urinary tract injuries, we observed only one ureteral lesion, all others being bladder lacerations (54 cases). The bladder lacerations occured during the hysterectomy step of the surgery in 61% of cases and during the additional procedures in 39%. All bladder injuries were recognized and treated during the primary operation. We observed four cases of vesico-vaginal fistula as a consequence of these injuries; all fistulas occured after bladder laceration during the hysterectomy step of the surgical procedure. Intestinal tract injuries (16 cases) were rectal lacerations occuring during the hysterectomy step of the surgery (31% of cases) and during the additional procedures (69%). All rectal injuries were recognized and repaired during the primary operation and all healed without sequellae. CONCLUSION: Operative injuries during vaginal hysterectomy are relatively rare. They are easily recognized and treated during the primary operation without important sequellae.     

The distance between the perceived and the actual arcus tendineus fascia pelvis during vaginal paravaginal repair

OBJECTIVE: This study was undertaken to determine whether the arcus tendineus fascia pelvis (ATFP) can be accurately identified from the paravaginal space (PVS) without entering the retropubic space (RPS). STUDY DESIGN: Eight patients undergoing vaginal paravaginal repair were enrolled. The paravaginal dissection was completed to the most cephalad portion of the PVS without entering the RPS. The apex of each PVS was stained with methylene blue. The RPS was entered, the ATFP visualized, and 4 sutures were placed along its length to be used for the repair. The perpendicular distance between each suture and the most cephalad area of stain was measured. RESULTS: The mean distance from the perceived to actual ATFP at each suture point (1-4) was 3.5 cm, 2.75 cm, 2.0 cm, and 0.91 cm, respectively. CONCLUSION: In these 8 cases, the RPS had to be entered to accurately identify the ATFP. The degree of error increases as the ischial spine is approached (P < .001).     

A double-blind trial of single-dose chemoprophylaxis with co-trimoxazole during vaginal hysterectomy and repair.

Twenty-five patients received 10 ml co-trimoxazole (800 mg sulphamethoxazole and 160 mg trimethoprim) and 25 a placebo by intravenous infusion during one hour from the commencement of surgery for vaginal hysterectomy with anterior colporrhaphy and posterior colpo-perineorrhaphy. Single-dose chemoprophylaxis with co-trimoxazole was shown to be effective in reducing the incidence of postoperative febrile morbidity and urinary tract infection, especially that caused by Proteus species.     

Electrosurgical bipolar vessel sealing during vaginal hysterectomy.

OBJECTIVE: To compare electrosurgical bipolar vessel sealing (EBVS) with traditional suturing during vaginal hysterectomy. METHODS: In a randomized controlled trial involving 68 women undergoing vaginal hysterectomy for benign disease, 37 procedures were performed using EBVS and 31 using traditional suturing. The end points were procedure time, blood loss, number of ligatures used, postoperative pain score, and number of days in hospital. RESULTS: The procedure duration was shorter using EBVS (median duration, 32 vs. 40 min; P=.0003), with fewer ligatures (1 vs. 7; P<.0001) and less pain (median score, 4 vs. 6; P<.0001). There were no significant differences regarding blood loss (median, 100 vs. 160 mL; P=.36) and days in hospital (median, 2 vs. 2; P=.03). CONCLUSION: The EBVS system provided advantages over traditional suturing with regard to procedure time, number of ligatures used, and postoperative pain score.     

腹腔镜辅助阴式子宫切除术与阴式子宫切除术适应证的探讨

目的通过比较腹腔镜辅助阴式子宫切除术(LAVH)与阴式子宫切除术(VH)的不同手术适应证及效果,探讨LAVH与VH手术病人的最佳选择。方法回顾性分析上海瑞金医院1999年6月至2002年12月间LAVH与VH手术病例381例,比较两种手术在手术时间、出血量、术后住院日、术中术后并发症及两者的手术适应证,尤其是子宫大小、盆腔粘连等的不同。结果两组手术在术中出血、手术并发症等方面差异无显著性意义,LAVH手术时间较长与患者子宫大、盆腔粘连者多、手术难度大有关。VH组患者均为正常或小于正常大小的子宫、无盆腔粘连、不伴有附件疾病者,手术适应证明显受限制。结论VH与LAVH均为创伤小、恢复快的微创手术,但VH适合于子宫小、无粘连并伴下垂者,而LAVH扩大了VH的适应证,是值得推广的手术。     

Minilaparotomy-assisted vaginal hysterectomy.

OBJECTIVES: To determine the feasibility and acceptability of minilaparotomy-assisted vaginal hysterectomy. METHODS: A prospective pilot study in a general hospital was conducted. Twenty patients who were on the waiting list for abdominal hysterectomy were included in the study. All these patients had one or more relative contraindications to vaginal hysterectomy. The hysterectomy procedure was started vaginally in all cases. A minilaparotomy incision was performed to complete the procedure if vaginal hysterectomy was not feasible. Results were analyzed on the intention to treat basis. RESULTS: The procedure was successfully completed as intended in 19/20 patients (95%). Six patients had the procedure completed vaginally (30%). Thirteen patients had the procedure completed with minilaparotomy assistance (65%). The mean operative time was 63+/-24.8 min (+/-S.D.). The median estimated blood loss was 155 ml (range: 20-800). One bladder injury occurred. The overall post-operative complication rate was 35% (7/20). This included urinary retention necessitating catheterization for 24 h (n=3), urinary infection (n=2), vaginal infection (n=1) and wound hematoma (n=1). The mean post-operative pain score on a scale from 1 to 10 was 3.1. The overall patient satisfaction based on a scale from 1 to 10 was 9.23 (range: 8-10). CONCLUSIONS: Minilaparotomy-assisted vaginal hysterectomy is a feasible and safe procedure. Our results suggest that this approach is potentially useful in increasing the proportion of hysterectomies performed vaginally.     

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.     

Preventing posthysterectomy vaginal vault prolapse and enterocele during vaginal hysterectomy

One hundred twelve vaginal hysterectomies were performed during a period of 2 years, 8 months. During the first year and a half, fourteen procedures were performed on patients referred to our institution because of posthysterectomy vaginal prolapse. We present our results of abdominal and vaginal repairs for vaginal prolapse. Moreover, we present and emphasize a modified surgical technique for the prevention of posthysterectomy vaginal prolapse and enterocele during vaginal hysterectomy. In all 112 patients no posthysterectomy prolapse has occurred. It is concluded that these procedures are acceptable ones to prevent an infrequent, yet tragic consequence of hysterectomy.     

The scope of vaginal hysterectomy

OBJECTIVE: The study was designed to check the feasibility of the vaginal route as the primary route for hysterectomy. STUDY DESIGN: All patients in whom hysterectomy was indicated were first considered for vaginal hysterectomy unless this route was contraindicated. Vaginal hysterectomy (VH) was performed in 5655 patients, and in 90.4% of these no uterine prolapse was present. The operative intervention required, preconditions and any complications were carefully studied. RESULTS: Of the 6945 cases considered, vaginal hysterectomy was possible in 5655 (81%). Successful simultaneous prophylactic oophorectomy or salpingo-oophorectomy was possible, in 1510 of 1572 cases without laparoscopic assistance. The indications are carefully discussed, with a strong emphasis on examination under anaesthesia, preoperative total uterine volume and, if required, laparoscopic evaluation and surgeons' readiness to reduce the frequency of recourse to laparotomy or laparoscopic assistance. CONCLUSION: The vaginal route is the least invasive and most economical route for hysterectomy and should be the gynaecological surgeon's first choice. A uterus with a volume up to 300 cm3 or uterine size up to 12 weeks should be dealt with vaginally, and as surgeons become more experienced larger uteri and also the adnexa can be approached in the same manner, at least as trial vaginal hysterectomy.     

Ureter injury during laparoscopy-assisted vaginal hysterectomy with the endoscopic linear stapler.

Ureter injury is more common with abdominal hysterectomy than vaginal hysterectomy. Complications during laparoscopy-assisted vaginal hysterectomy cases have not been thoroughly studied. Two cases are presented that highlight urologic misadventures, specifically, ureteral injury, with the endoscopic linear stapler during laparoscopy-assisted vaginal hysterectomy.     

A randomized comparison of tension-free vaginal tape and endopelvic fascia plication in women with genital prolapse and occult stress urinary incontinence

OBJECTIVE: The purpose of this study was to compare 2 anti-incontinence procedures in women who had severe genital prolapse and potential stress incontinence. STUDY DESIGN: In addition to vaginal reconstructive surgery, 50 patients with stage II or higher anterior defect and a positive stress test result with prolapse reduction received either tension-free vaginal tape or plication of the endopelvic fascia. Preoperative evaluation included history, physical examination, stress test, and urodynamic assessment. Data were analyzed with the Student t test, the Fisher's exact test, and the Wilcoxon signed-rank test. RESULTS: The median follow-up time was similar for both groups, 26 and 24 months. Subjective (96% vs 64%; P=.01) and objective (92% vs 56%; P<.01) continence rates were higher after the tension-free vaginal tape procedure. Time for the resumption of spontaneous voiding, rates of urinary retention, or de novo urge incontinence were similar in the 2 groups. CONCLUSION: Tension-free vaginal tape can be recommended for patients with prolapse and occult stress incontinence.     

Surgical method of identifying the ureters during total vaginal hysterectomy

A surgical method allowing transvaginal ureteral dissection was performed on 40 consecutive patients undergoing vaginal hysterectomy. The dissection was accomplished in 37 of 40 patients (90%) without complications. There was no mortality and morbidity was quite low. It is concluded that transvaginal ureteral dissection can be a useful step during vaginal hysterectomy.