Repair Of Vaginal Vault Prolapse Research Articles

Surgical repair of vaginal vault prolapse: comparing of vaginal and abdominal procedures

Objective. To compare the results of abdominal sacrocolpopexy and vaginal high uterosacral vaginal vault suspension with fascial reconstruction for the uterovaginal and vault prolapse repair.

Repair of recurrent vaginal vault prolapse using sacrospinous ligament fixation with mesh interposition and reinforcement

Our goal was to study the efficacy of performing the repeated sacrospinous ligament fixation with mesh interposition and reinforcement in women with recurrent vaginal vault prolapse. Fifteen consecutive patients with symptomatic severe vaginal vault or uterus prolapse after previous sacrospinous ligament fixation were enrolled. The sacrospinous ligament fixation was performed with a mesh interposition between sacrospinous ligament complex and vaginal apex. The mesh was extended to anterior and posterior vaginal wall for the repair of concurrent cystocele and rectocele, if indicated. The surgical results and complications were evaluated. The prolapse evaluation was performed according to International Continence Society (ICS) ordinal stages of pelvic organ prolapse. The mean age was 55 years. The mean follow-up was 2.9 years (range 1.0-5.5 years). Repeated sacrospinous ligament fixation was performed for all patients. Eleven were performed unilaterally to the right and four to the left. The average time for sacrospinous fixation was 20 min. The average blood loss for sacrospinous fixation was 75 ml. No major complication except one accidental rectotomy was observed. It was repaired intraoperatively without sequel. The concurrent pelvic surgeries included vaginal total hysterectomies, anterior colporrhaphies, posterior colporrhaphies, and tension-free vaginal tape procedures. No recurrence of apical prolapse was observed. However, two patients developed stage I prolapse on anterior vaginal wall (cystocele) and required no further repair. Minor postoperative complications were observed. Repeated sacrospinous ligament fixation with mesh interposition and reinforcement is a safe and effective procedure for the correction of recurrent vault prolapse. The extended implanted mesh can be used for the repair of concurrent cystorectocele effectively. A long-term follow-up is necessary to detect any late complication.

Laparoscopic techniques for the repair of vaginal vault prolapse: Determining if less is more

Repair of vaginal vault prolapse remains a surgical challenge. Abdominal, vaginal, and combined procedures have been described. The ideal operation remains elusive with regard to outcomes, morbidity, and economics. As an extension of the abdominal approach, laparoscopy continues to gain favor as an access method and as a surgical advancement. Recent studies highlight a number of laparoscopic techniques for restoration of apical support that demonstrate feasibility and encouraging results. Further study is necessary to determine if the minimally invasive nature of laparoscopy can duplicate or surpass standard abdominal and vaginal approaches to the repair of pelvic organ prolapse.

Bilateral iliococcygeal fixation for vaginal vault prolapse and enterocele repair using a new suturing device—the digital needle driver

The objective of our study was to evaluate the surgical feasibility, efficacy and safety of the digital needle driver (DND 202), a modified, flexible surgical device, during iliococcygeal fixation (ICF) for vaginal vault prolapse and enterocele repair. A prospective longitudinal study was carried out among 21 consecutive patients who underwent bilateral iliococcygeal fixation at St George's Hospital, London. All patients filled a comprehensive questionnaire for pre- and post-operative prolapse, urinary, bowel and sexual symptoms and underwent pre- and post-operative site-specific vaginal examination, following the standardized International Continence Society scoring for prolapse, pre-operative urodynamic studies and analysis of the surgical results. The outcome measures were the feasibility of the procedure, the time needed, intra- and post-operative complications, short-term post-operative prolapse-associated symptoms and pelvic organ prolapse quantification. The mean age of the patients was 65 [5] years and the mean body mass index (kg/m(2)) was 23 [2.7]. In addition to ICF, 8 patients underwent vaginal hysterectomy, 18 had posterior repairs, 7 had anterior repairs and 6 had TVT. The mean time for ICF was 20 [11] minutes, the mean blood loss per surgical procedure was 264 [225] mL and the mean hospitalization time was 4.6 [1.2] days. Postoperatively, one patient had mesh erosion. At short-term post-operative evaluation none of the patient had prolapse symptoms. There was a statistically significant improvement in all stages of the apical and posterior walls prolapse (p < 0.001). The mean total vaginal length was significantly shorter postoperatively (7.8 [1.0] cm vs 6.6 [1.4] cm, p < 0.001). Thus, we can conclude that the use of DND device may facilitate the vaginal approach for vaginal vault prolapse and enterocele repair.

Repair of vaginal vault prolapse and pelvic floor relaxation using polypropylene mesh

The sacrouterine ligament/cardinal (SULC) complex and prerectal fascia attach at the perineal body, forming a single support unit preventing levator descent. Many patients with vault prolapse have levator descent and widening of the hiatus. Existing transvaginal procedures do not address pelvic floor descent. We describe a technique utilizing polypropylene mesh to repair pelvic floor relaxation and prevent levator descent, along with restoration of the SULC complex in vaginal vault repair. We prospectively evaluated 50 patients who had a transvaginal mesh vault/posterior wall reconstruction. A T-shaped soft prolene mesh is prepared fixing the two arms of the mesh and recreating the SULC complex in support of the cuff. The vertical segment of the mesh is transferred over the prerectal fascia and secured to the pelvic floor musculature. The rectocele is repaired incorporating the mesh distally preventing pelvic floor descent. Surgical outcome was determined by patient self-assessment including quality of life (QoL) measure as well as pelvic examination using POP-Q staging. Mean age was 67 years. Mean follow-up was 6 months (range 3-12). There were no intraoperative complications. There have been two apical (4%) recurrences. Mean QoL score postoperatively on a 0-6 scale was 0.74 (0 = delighted, 1 = pleased). Pelvic floor descent has been repaired on all patients. Postoperative POP-Q reveals restoration of normal anatomy. We report a new technique that recreates the SULC complex in support of the vaginal vault with the aid of prolene mesh. It is the first transvaginal procedure described to reconstruct the pelvic floor in attempt to prevent pelvic floor descent.

Repair of recurrent vaginal vault prolapse using sacrospinous ligament fixation with mesh interposition and reinforcement

Objective. Our goal was to study the efficacy of performing the repeated sacrospinous ligament fixation with mesh interposition and reinforcement in women with recurrent vaginal vault prolapse. Materials and methods. Fifteen consecutive patients with symptomatic severe vaginal vault or uterus prolapse after previous sacrospinous ligament fixation were enrolled. The sacrospinous ligament fixation was performed with a mesh interposition between sacrospinous ligament complex and vaginal apex. The mesh was extended to anterior and posterior vaginal wall for the repair of concurrent cystocele and rectocele, if indicated. The surgical results and complications were evaluated. The prolapse evaluation was performed according to International Continence Society (ICS) ordinal stages of pelvic organ prolapse. Results. The mean age was 55 years. The mean follow-up was 2.9 years (range 1.0–5.5 years). Repeated sacrospinous ligament fixation was performed for all patients. Eleven were performed unilaterally to the right and four to the left. The average time for sacrospinous fixation was 20 min. The average blood loss for sacrospinous fixation was 75 ml. No major complication except one accidental rectotomy was observed. It was repaired intraoperatively without sequel. The concurrent pelvic surgeries included vaginal total hysterectomies, anterior colporrhaphies, posterior colporrhaphies, and tension-free vaginal tape procedures. No recurrence of apical prolapse was observed. However, two patients developed stage I prolapse on anterior vaginal wall (cystocele) and required no further repair. Minor postoperative complications were observed. Conclusion. Repeated sacrospinous ligament fixation with mesh interposition and reinforcement is a safe and effective procedure for the correction of recurrent vault prolapse. The extended implanted mesh can be used for the repair of concurrent cystorectocele effectively. A long-term follow-up is necessary to detect any late complication.

Gynecologic use of robotically assisted laparoscopy: Sacrocolpopexy for the treatment of high-grade vaginal vault prolapse

Transabdominal sacrocolpopexy is an excellent treatment option for patients with high-grade vaginal vault prolapse, with long-term success rates ranging from 93% to 99%. However, it is associated with increased morbidity compared with vaginal repairs. In this article, we describe a novel minimally invasive technique of vaginal vault prolapse repair and present our initial experience. The surgical technique involves placement of 4 laparoscopic ports, 3 for the surgical robot and 1 for the assistant. A prolene mesh is then attached to the sacral promontory and to the vaginal apex using nonabsorbable expanded polytetrafluoroethylene sutures. At the end of the case, the mesh material is covered by the peritoneum. A total of 20 patients underwent a robot-assisted laparoscopic sacrocolpopexy at our institution in the past 18 months for severe symptomatic vaginal vault prolapse; 8 of the 20 (40%) underwent a concomitant anti-incontinence procedure. Mean follow-up was 5.1 (range, 1–12) months and mean age was 66 (range, 47–82) years. The mean total operative time was 3.2 (range, 2.25–4.75) hours. Of these patients, 1 was converted to an open procedure secondary to unfavorable anatomy. All but 1 patient, who left on postoperative day 2, were discharged from the hospital after an overnight stay. Complications were limited to mild port-site infections in 2 patients, which resolved with oral antibiotic therapy. Recurrent grade 3 rectocele developed in 1 patient, but there was no evidence of cystocele or enterocele. Significant incontinence (>1 pad/day) was present in 2 patients. All 18 patients reported being satisfied with the outcome of their surgery and all 10 would recommend it to a friend. This novel technique for vaginal vault prolapse repair combines the advantages of open sacrocolpopexy with the decreased morbidity and improved cosmesis of laparoscopic surgery. It is associated with decreased hospital stay, low complication and conversion rates, and high rates of patient satisfaction. Although our early experience is encouraging, long-term data are needed to confirm these findings and establish longevity of the repair.

Erste Erfahrungen mit der infrakokzygealen Sakropexie nach Petros bei Vaginalprolaps und Harndranginkontinenz

Objective: The infracoccygeal sacropexy (ICS) according to Petros is a surgical procedure with a tension free tape for repair of vaginal vault prolapse. Corresponding to Petros even functional disorders like urinary urgency and nocturia are improved. The aim of this study was to report our experience with ICS. Methods: The infracoccygeal sacropexy was performed on 13 patients with vaginal vault prolapse and 8 with uterine prolapse and enterocele. Urodynamics preoperatively revealed urge incontinence (detrusor instability). The incontinence score was checked pre- and postoperatively with the Gaudenz questionnaire. Results: Preliminary results after 6 months revealed an improvement of urge incontinence in 16 out of 21 patients (76%). The non-responders (24%) to the ICS procedure - concerning relief of urge symptoms - had a history of hysterectomy and previous surgery in the anterior compartment. No recurrence of prolapse was observed. There were no severe intra- or postoperative complications. Conclusions: Infracoccygeal sacropexy is a new surgical procedure for restoration of vaginal vault and uterine prolapse. Additionally urinary urge incontinence is improving. Patients with scar tissue at the bladder neck as a consequence of previous surgery have no benefit according to this study from ICS procedure in concern to relief of urge symptoms.

Longterm followup of posthysterectomy vaginal vault prolapse abdominal repair: a report of 85 cases.

There are many surgical procedures to treat posthysterectomy vaginal vault prolapse. Abdominal sacral colpopexy is one of these procedures. The aim of this study was to review the cases of 85 consecutive patients treated by this technique since 1978 by the same surgical team using the same procedure. Our surgical procedure will be explained. Eighty-five patients were treated in our department between 1978 and 1998 for posthysterectomy vaginal vault prolapse. The mean age was 55.42 years. The mean weight was 63.37 kg. Their parity ranged from 0 to 5 (mean, 2.54). The interval of time between hysterectomy and vaginal vault prolapse repair ranged from 1 to 37 years (mean, 17.92 years). The main indication for hysterectomy was uterine leiomyomas. Of these patients, 67.05% had stress urinary incontinence, and mean urethral closure pressure was 48.7 cm H2O. All patients had abdominal sacral colpopexy associated with a Burch procedure and a posterior perineal repair. Seventeen patients had postoperative fever. Twenty-two had urinary tract infections. Two patients had to undergo blood transfusion. Three patients had postoperative urinary retention. The median longterm followup was 10.5 years; 27.05% of patients had relapsing stress urinary incontinence. Two patients had a relapse of the vaginal vault prolapse. The abdominal sacral colpopexy is a safe operation with low morbidity and long-standing good results. It can be recommended for sexually active women. Nevertheless, the Burch procedure performed with this operation failed to prevent recurrence of urinary incontinence.

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. (Am J Obstet Gynecol 2001;185:1339-43.)

RESOLUTION OF MOTOR URGE INCONTINENCE AFTER SURGICAL REPAIR OF PELVIC ORGAN PROLAPSE

We determined the resolution rate of urge incontinence in women with uterine and/or vaginal vault prolapse plus coexistent motor urge incontinence after the surgical repair of prolapse as well as predictors of postoperative urge incontinence status. We retrospectively reviewed the medical records of 38 women with grade 2 or greater uterine and/or vaginal vault prolapse plus coexistent motor urge incontinence who were evaluated and treated at our institution between July 1, 1996 and December 31, 1999. Urge incontinence resolved in 24 of the 38 women (63%) and persisted in 14 (37%) after the surgical repair of uterine and/or vaginal vault prolapse. Patient age, vaginal parity, body mass index, menopausal status, bladder compliance and the number who underwent previous pelvic surgery were similar in the 2 groups. Uninhibited detrusor contractions less than 25 cm. water during cystometry (p = 0.01) and bladder trabeculation (p = 0.03) were each an independent predictor of urge incontinence resolution after repair. In most women with grade 2 or greater uterovaginal and coexistent motor urge incontinence urge incontinence resolved after the surgical repair of prolapse.

Rectal prolapse in women with other defects of pelvic floor support

Objectives: We describe a series of patients with rectal prolapse who had other pelvic floor defects. Study Design: Patients with rectal prolapse that we examined between 1990 and 2000 were reviewed. Results: During this time frame 55 patients with rectal prolapse were seen by one of us. Fifty-two of these patients had other defects of pelvic floor support and are the subject of this report. The diagnosis was established in all patients with video defecography. Thirty-nine of the patients had internal (occult) prolapse that simulated either a rectocele or an enterocele. The mean number of surgical procedures for pelvic floor support before the diagnosis of rectal prolapse was 1.5. Thirty-one patients underwent a sigmoid resection with rectopexy, 12 underwent a rectopexy alone, 3 underwent a Ripstein procedure, 2 elderly patients had physical therapy alone, and the other 4 patients had surgical correction of the rectal prolapse before being referred for repair of vaginal vault prolapse. Other procedures performed simultaneously included sacral colpopexy, sacrospinous suspension, rectopubic urethropexy, and abdominal fixation of the vagina to the uterosacral ligaments. Conclusions: Rectal prolapse frequently coexists with other pelvic floor defects. Internal rectal prolapse may simulate a rectocele or enterocele and requires defecography to establish the diagnosis. Rectopexy (with or without sigmoid resection) is a satisfactory technique for correction and may be combined with other reconstructive procedures on the pelvic floor. (Am J Obstet Gynecol 2001;184:1488-95.)

Functional cine magnetic resonance imaging in women after abdominal sacrocolpopexy

Objective: To evaluate whether functional cine magnetic resonance imaging (MRI) is a reliable method for verifying postoperative anatomy and function in women after abdominal sacrocolpopexy. Methods: We did postoperative functional cine MRI in 25 women who had sacrocolpopexies. Visibility of grafts and vaginal and sacral fixation points were assessed and correlated with intraoperative results. Ranges of vaginal movement were calculated and compared with results of postoperative gynecologic examinations. Results: Functional cine MRI achieved full view of vaginas in all cases. The mean vaginal axis was 142°. Grafts were entirely visible in 13 women, partly visible in nine, and not visible in three. Functional cine MRI defined exactly the sacral fixation points in 22 women. Compared with intraoperative results, functional cine MRI showed a higher level of fixation in nine of 11 women. Functional cine MRI defined exact vaginal fixations point in 15 of 25 women. According to the pubococcygeal reference line, the postoperative range of movement of the vaginal apex was 1.8 cm. Recurrent vaginal vault prolapses in three women were detected equally by functional cine MRIs and gynecologic examinations. In those cases, no parts of patches were seen on the images. Conclusion: Functional cine MRI provided reliable abdominal sacrocolpopexy follow-up data. It might help with individual surgical planning and augment understanding of benefits and flaws of various surgical approaches to repair of vaginal vault prolapse.

The levator myorraphy repair for vaginal vault prolapse

Various techniques have been described for the repair of vaginal vault prolapse after hysterectomy. Because of inherent difficulties associated with the sacrospinous fixation, a new repair, the levator myorraphy, was devised to simplify reconstruction of the pelvic floor 10 years ago. This repair results in a restored vaginal axis and prevention of posterior enterocele recurrence by recreating the levator shelf high within the peritoneal cavity and fixing the vault in that position. Because this procedure can be performed from a vaginal approach, morbidity is minimized. Over this 10-year time period, we have performed the levator myorraphy in over 120 women. We believe this approach can be easily taught, is highly effective, and results in a repair that most closely restores the normal anatomic position.

Vaginal Vault Prolapse Following Hysterectomy

Abstract: in the last century many different operations were described to correct post hysterectomy vaginal vault prolapse. We analyzed the results of post hysterectomy vaginal vault prolapse repair at our centre, to compare the results of the abdominal colposacropexy to a vaginal approach using the Mayo culdoplasty technique. We also present a literature review of other surgical techniques to correct prolapse of the vagina.Methods: the charts of 78 patients with posthysterectomy vaginal vault prolapse presenting for surgical correction between February 1993 to November 1998 were reviewed. Follow-up phone interview and/or clinical examinations were performed to evaluate patient satisfaction and long-term outcome.Results: the mean age at operation was 67 years. Abdominal hysterectomy had been performed on 69 percent of the patients. The mean time elapsed from hysterectomy to vault prolapse repair was 19.93 years. Abdominal colposacropexy was performed on 24 percent of the patients. The Mayo culdoplasty technique was used in 76 percent of patients. There were few perioperative and postoperative complications. Follow-up ranged from one to 58 months.Conclusion: vaginal vault prolapse repair by the abdominal colposacropexy and the Mayo culdoplasty are safe and effective procedures. Anatomical restoration and patient satisfaction were achieved in the majority of patients.

Follow-up after repair of vaginal vault prolapse with abdominal colposacropexy

Follow-up after repair of vaginal vault prolapse with abdominal colposacropexy

Follow‐up after repair of vaginal vault prolapse with abdominal colposacropexy

Vaginal vault prolapse after hysterectomy is a rare complication, with a prevalence of less than 1/2%. The vaginal depth an axis can be restored by colposacropexy with preservation of coital function. The aim of this follow-up study was to assess the results of colposacropexy with special attention to recurrence of prolapse and urogenital symptoms. During a 4-year period 35 patients with vault prolapse were operated by colposacropexy. At follow-up the patients were interviewed about bladder, bowel and sexual symptoms. A pelvic examination and measurement of residual urine was done. Perioperative complications and any interim surgery was recorded. The patients were multioperated, because of prolapse or incontinence prior to colposacropexy. No serious perioperative complications were seen, except one case of severe bleeding from the presacral veins. Subjectively, 82% were cured of prolapse symptoms, one had recurrent vault prolapse and was reoperated, four had rectocele. Five patients developed urge incontinence, while urge incontinence, frequency, nocturia and voiding problems were cured in 75%, 80%, 50% and 100%, respectively. One patient developed fecal incontinence. No patients had coital problems due to the colposacropexy. Three patients were reoperated because of intestinal obstruction. Colposacropexy has a cure rate of vault prolapse of 97% (85 100%) and a positive effect on irritative bladder symptoms.

Laparoscopic repair of severe vaginal vault prolapse

Laparoscopic repair of severe vaginal vault prolapse

Posthysterectomy vaginal vault prolapse: primary repair in 693 patients

Objective: To examine the results of primary repair of posthysterectomy vaginal vault prolapse in a current, large series of patients with long-term follow-up. Methods: From January 1976 to December 1987, 693 patients underwent primary repair of vault prolapse at the Mayo Clinic. The Mayo culdoplasty technique was used in 95% of these patients. Patients were followed up by reference to their Mayo Clinic medical records, a specifically designed questionnaire, and pelvic examination in a subgroup of patients. Results: The median age at operation was 66 years. Abdominal hysterectomy had been performed on 49.5% of patients and vaginal hysterectomy on 43.4% (hysterectomy type was not documented on 7.1%). The median number of years to vault prolapse repair after hysterectomy was 15.8 (range 0.4–48.4). Information about prolapse after primary repair was available for 504 patients (72.7%) and 80 had evidence or complaint (bulge, protrusion) of recurrent prolapse. Thirty-six of 693 patients (5.2%) had subsequent prolapse repair. Eighty-two percent of patients indicated satisfaction with the result. Complications of operation included entry into the bladder or rectum (2.3% of patients), vault hematoma (1.3%), cuff infection (0.6%), and ureteral complications (0.6%). The number of patients presenting for vault prolapse repair increased during the study interval. Conclusion: The Mayo culdoplasty can be performed with minimal morbidity. It achieved an anatomic restoration of upper vaginal support in a high percentage of patients with long-term follow-up.

A NEW LAPAROSCOPIC PROCEDURE FOR THE CORRECTION OF VAGINAL VAULT PROLAPSE

Purpose We verified the feasibility and results of a new laparoscopic technique for repairing vaginal vault prolapse. Materials and Methods Laparoscopic repair of vaginal vault prolapse was done in 12 women 46 to 82 years old. Stage 1 consisted of culdoplasty similar to that of Moschowitz. Stage 2 included a transverse incision of the peritoneum covering the vaginal vault to expose the vaginal fascia. Two sutures were then fixed to the vaginal corners, passed through the subperitoneal connective tissue and attached to the fascia of the abdominal muscles with multiple stitches. Results No intraoperative or postoperative complications occurred and anatomical repair was complete in all women. Followup ranged from 9 to 28 months. Sexual function was recovered in all cases. Conclusions If these results are confirmed in larger series with a longer followup, our laparoscopic approach would be considered a valid alternative to current surgical techniques.