Laparoscopic Management of Vaginal Vault Prolapse Recurring After Pelvic Organ Prolapse Surgery

Abstract

Introduction: Pelvic organ prolapse (POP) is a high prevalent disease.1 Based on the prolapsed organ,2 we usually distinguish between rectocele, cystocele, uterovaginal prolapse, and vaginal vault prolapse (VVP), which commonly occurs following a hysterectomy.3 Many surgical approaches for POP have been described and analyzed,4 but there are few reports on the surgical management of recurring VVP after previous sacropexy (SP)5 or previous anti-POP surgery.6 The aim of the current video is to show some tips and tricks for a salvage SP. Materials and Methods: Current study prospectively includes patients with symptomatic recurrent VVP and previous anti-POP surgery who were treated with laparoscopic sacropexy (LS), approved by the audit committee. The same surgeon operated on all patients. The overall surgery time and time for the main surgical steps were analyzed. The video shows all the steps that are required for a proper LS. In general terms, the checklist for proper re-do SP included three steps: (1) creation of surgical space and restoration of pelvic anatomy avoiding injury to hollow organs (vagina, bladder, bowel); (2) careful preparation of sacral promontory and vaginal walls leaving in place previous mesh; (3) definitive anchorage of new meshes from vaginal walls to sacral promontory. Results and Conclusions: Twenty-two women were included (mean time before recurrence 23 months, range 13–32 months; mean postoperative follow-up 43.5 months). After open SP (8 patients), the dissection of diffuse adherences and restoration of normal anatomy was difficult and long because of the variable distribution of adhesions between bowel, sigmoid colon, peritoneal wall, and meshes. In all but one case, the original meshes were secured to the sacral promontory, presenting marked fibrosis between the meshes and meso-sigma. In seven cases, a weak mesh attachment to the vaginal walls was found, thus causing the recurrence of POP. In vaginal route surgery (14 patients: 10 Perigee, 4 levator-myorrhaphy), adhesions were limited to vaginal vault and sigmoid colon; in cases of mesh insertion, there was fibrosis between mesh and bladder, anteriorly, and peritoneal layer and sigma, posteriorly. In all cases, the new meshes were anchored over the previous meshes, without any particular difficulties. Regression analysis revealed differences according to overall operating time (longer in patients who had undergone SP vs vaginal route, p = 0.028), whereas the time for adhesiolysis approached statistical significance (p = 0.059). Time for vaginal wall preparation and mesh anchorage were similar between groups. An inadvertent, small cystotomy occurred in one case and the bladder was double layer sutured with polyglactin sutures, leaving an indwelling catheter for 5 days. No significant peri- or postoperative complications were observed, whereas one patient presented with vaginal erosion 4 months later, which was corrected by the vaginal route. At follow-up, only two patients presented irritative voiding symptoms; one patient suffered from obstructed defecation. No impact on sexual function was detected. In conclusion, in recurrent VVP, after hysterectomy and previous POP surgery, a very careful approach with LS is feasible, safe, and effective in centers with extensive experience and training. No competing financial interests exist. Runtime of video: 8 mins 55 secs