Accurate Repair of the Prolapsed Vagina by Use of Measured Lateral Flaps

Abstract

Surgical techniques to correct total vaginal prolapse usually rely on an estimated final vaginal caliber made by the operating surgeon. In 1995, a new method that more accurately measures the width of the vaginal flaps used for repair of a prolapsed vagina was developed at University of South Florida College of Medicine. After the patient has been anesthetized, the most appropriate position for the new vaginal apex is determined by gently replacing the prolapsed vagina and positioning the lateral corners in approximation to the sacrospinous ligaments or the hollow of the sacrum. Once the most satisfactory axis is achieved, the new vaginal angles are marked by silk sutures. The proposed vaginal apex is then grasped with Allis clamps, and the vagina is everted. A line is drawn from each side of the vaginal introitus at 3 and 9 o’clock to the everted vaginal apex. At the midpoint of this line, the width of the lateral flap is measured to be approximately 6 cm and the anterior and posterior dimensions are lightly scored on the vaginal mucosa with the Bovie. The vaginal flaps are made slightly wider for postmenopausal women, and a narrow (3-cm) width is used for women who are no longer sexually active. The vaginal mucosal flap is then outlined as shown in Figure 1, starting anteriorly from the midline, approximately 1 cm inside the urethral meatus, gently curving out toward the vaginal apex and back along the posterior lateral vaginal wall to a point at the posterior introitus or on the perineum. Fig. 1: Marked 3- and 6-cm right vaginal flaps and chosen site for providing apical (right) support in patient with uterine procidentia.If the patient has not had a hysterectomy, then the uterus is removed and the excess anterior and posterior vaginal mucosa is excised. A permanent suture is used to accomplish a high peritoneal closure with pursestring sutures. Any indicated incontinence surgery is then performed. The lower two-thirds of the anterior vaginal wall is closed, and bilateral sacrospinous ligament sutures are placed to support the vaginal apex. The posterior wall is closed, and the vagina is packed for 24 hours. The catheter is removed and voiding trials are initiated on day 3. This technique was used in an initial series of 27 patients who underwent surgery from April 1996 to April 1998. The mean age of these women was 67 years. All of these patients had symptoms of vaginal prolapse before surgery. After surgery, 23 had stage 4 prolapse and 4 had stage 3 prolapse. Fourteen had previously undergone hysterectomy (all vaginal procedures). Twelve patients had bilateral sacrospinous colpopexy, 13 had cystocele and rectocele plication, and the remaining 2 had a high modified McCall culdoplasty. Intraoperative hemorrhage of more than 1000 ml was recorded in 4 patients. Another patient, who was taking warfarin sodium, was readmitted on postoperative day 6 with vaginal bleeding. Cardiac ischemia and ileus developed postoperatively in one 75-year-old woman, but there were no other significant complications. Twenty-four of the 27 patients were followed for 21 to 42 months (mean, 29 months). No patient experienced symptoms related to vaginal prolapse, although three had minor midline anterior prolapse noted on examination 6 to 12 months after the procedure. None of these had progressed. Nineteen patients wanted to retain sexual function, but only nine had actually resumed coitus, which was reported as satisfactory in all cases.