Sacrospinous Vault Research Articles

Inversion of uterus due to prolapsed submucous fundal fibroid

Inversion of uterus is rarely encountered by gynecologist during practice; inversion in a non- pregnant uterus is further rarer; only case reports are published in literature on non-puerperal uterine inversion. We present a case of a 40-years multipara who had a history of irregular and excessive vaginal bleeding associated with severe lower abdominal pain during vaginal bleeding for two years. She was referred from general hospital with suspicion of cervical cancer. Being a rare clinical condition diagnosis and management of uterine inversion is challenging. High index of clinical suspicion is necessary which can be aided by radiographic imaging. Our case was diagnosed as a case of complete uterine inversion secondary to fundal fibroid clinically. She underwent abdominal hysterectomy with bilateral salpingectomy with bilateral sacrospinous vault suspension after resuscitation with fluids, blood transfusion and broad-spectrum antibiotics.

Complications After Vaginal Vault Suspension Versus Minimally Invasive Sacrocolpopexy in Women With Elevated Body Mass Index: A Retrospective Cohort Study Using Data From the National Surgical Quality Improvement Program Database.

Overweight and obese women represent a growing share of pelvic floor reconstruction surgeons' practices. Determining perioperative risk specific to this population is essential to inform decision making regarding operative approach in this population. The aim of the study was to compare surgical complications among overweight and obese women undergoing apical compartment prolapse surgery by either minimally invasive abdominal or vaginal approach. The American College of Surgeons National Surgical Quality Improvement Database was used to identify overweight and obese patients (body mass index ≥ 25) undergoing either minimally invasive sacrocolpopexy (MISC) or vaginal vault suspension (VVS) in the form of a sacrospinous vault fixation or uterosacral ligament fixation for pelvic organ prolapse from 2012 to 2019. Odds ratios for surgical complications, readmission, and reoperation were estimated using multivariable logistic regression. Of 8,990 eligible patients, 5,851 underwent a VVS and 3,139 patients underwent MISC. There was a greater odds of any complication in the first 30 days following VVS (n = 608 [10.4%]) compared with MISC (n = 247 [7.9%]; odds ratio, 1.27; 95% confidence interval, 1.08-1.48) on multivariable analysis. Urinary tract infections (UTIs) were the most common complication and were more likely following VVS (112 (3.6%) versus 350 (6.0%), P < 0.001). When UTIs were excluded, there was no difference in complications between approaches (1.00; 95% CI, 0.82-1.22). There were no statistically significant odds of readmission, reoperation, or serious complications between approaches. Vaginal vault suspension may be associated with a higher odds of any complication compared with MISC in overweight and obese women, but the rate of serious complications, readmission, and reoperation are low, and approaches were comparable when considering complications other than UTI.

Postoperative urinary retention after pelvic organ prolapse surgery: influence of peri-operative factors and trial of void protocol

PurposeTransient postoperative urinary retention (POUR) is common after pelvic floor surgery. We aimed to determine the association between peri-operative variables and POUR and to determine the number of voids required for post-void residuals (PVRs) to normalize postoperatively.MethodsWe conducted a retrospective cohort study of 992 patients undergoing pelvic floor surgery at a tertiary referral centre from January 2015 to October 2017. Variables assessed included: age, BMI, ASA score, anaesthesia type, type of surgery, length of postoperative stay, surgeon, bladder protocol used, and number of PVRs required to “pass” the protocol.ResultsSignificant risk factors for POUR included: placement of MUS during POP surgery, anterior repair and hysterectomy with concomitant sacrospinous vault suspension. A total of 25.1% were discharged requiring catheterization. Patients receiving a concomitant mid-urethral sling (MUS) were 2.2 (95% CI1.6–2.9) and 2.3 (95% CI 1.8–3.1) times more likely to have elevated PVR after their second TOV and third TOV (p < 0.0001), respectively, compared with those without concomitant MUS. Permitting a third TOV allowed an additional 10% of women to pass the voiding protocol before discharge. The median number of voids to pass protocol was 2. An ASA > 2 and placement of MUS were associated with increasing number of voids needed to pass protocol.ConclusionsWhile many women passed protocol by the second void, using the 3rd void as a cut point to determine success would result in fewer women requiring catheterization after discharge. Prior to pelvic floor surgery, women should be counselled regarding POUR probability to allow for management of postoperative expectations.

Small bowel evisceration: a late complication following vaginal hysterectomy

We present a case of small bowel evisceration occurring as a late complication following vaginal hysterectomy and subsequent vault prolapse.Case history: A 92-year-old female presented with sudden onset severe abdominal pain, followed by the sensation of vaginal fullness and the discovery of a large prolapse per vagina, with no history of trauma or sexual intercourse.Past medical history consisted of vaginal hysterectomy 20 years previously with a subsequent sacrospinous vault fixation.On examination, a vaginal vault prolapse was found with 3 feet of oedematous small bowel prolapsed through it. Peristalsis remained visible.An emergency laparotomy was undertaken as a joint procedure between the gynaecology and general surgery teams. The small bowel was gently manipulated back through a 3 cm defect in the vault. Once in the abdomen, it was found to be viable and no resection was required. The vault defect was closed with 1/0 Vicryl and the vault was then fixed to the left lateral side wall of the peritoneum. Routine closure of the abdomen was performed after saline washout.Recovery was complicated by a postoperative ileus requiring nasogastric tube insertion for two days. She recovered well following this and will be followed up in the gynaecology outpatient clinic.Discussion: Small bowel evisceration is a rare complication following hysterectomy. With relatively few cases reported in the literature, incidence is difficult to determine. The most commonly reported risk factors are postmenopausal atrophy, previous vaginal surgery and enterocele. Cases have been reported following both abdominal and vaginal surgical approaches, and are commonly precipitated by sexual intercourse, introduction of a foreign body into the vagina or increased intra-abdominal pressure (Gandhi and Jha 2011).Vaginal evisceration is a gynaecological emergency. Prompt recognition is vital in order to prevent compromise of intra-abdominal contents (Codd et al. 2010). Management requires a multidisciplinary approach and early transfer to theatre for urgent surgical repair; various different approaches have been described, however, if there is any question about organ viability exploration via a midline laparotomy is indicated (Gandhi and Jha 2011).Educational message/learning point: We have presented this case in order to raise awareness of small bowel evisceration as a late complication following hysterectomy. Clinicians in both general surgery and gynaecology should be aware of its potentially non-specific presenting symptoms, as eviscerated organs may not be particularly evident on admission. This is a life threatening condition that requires immediate recognition and management via a multidisciplinary approach.

Does bilateral sacrospinous fixation with synthetic mesh recreate nulliparous pelvic anatomy? An MRI evaluation.

The aim of this study was to determine whether the bilateral sacrospinous vault fixation (BSSVF) with synthetic, polypropylene mesh arms restores the nulliparous anatomic relationships of the vaginal vault in women with and without uterus using magnetic resonance imaging (MRI). This was a prospective case series of women with symptomatic pelvic organ prolapse (POP) who, after BSSVF, underwent a pelvic MRI (1-13 months postoperatively). Postsurgical pelvic distances were measured from MRI scans and compared with measurements from a group of 11 nulliparous women with adequate pelvic support who underwent MRI in a previous study. Our primary outcome measure was the difference in average distance from the vault to the ischial spine among women after BSSVF when compared with the average nulliparous distances. The secondary outcome measures were the difference in average distance from the posterior fornix to the sacrum and the change in apical POP quantification parameters 6 weeks after surgery. Ten women underwent MRI post-BSSVF-4 women with and 6 women without uterine preservation. In the BSSVF group, similar to the nulliparous group measurements, the average distance between the vaginal apex and the spine was 5.2 cm (SD, 0.8) (95% confidence interval, -0.6 to 0.5; P = 0.92). There was an anterior-inferior displacement of the line between the vaginal apex and the sacrum in women who underwent BSSVF. The posterior fornix was 7.4 cm (SD, 1.2) from the second sacral vertebra versus 5.6 cm (SD, 1.5) in women without POP (P < 0.01). Adequate clinical resolution of apical prolapse was confirmed in all women 6 weeks post-BSSVF. The BSSVF with synthetic mesh restores the anatomy between the vagina and the ischial spines. Clinical studies are underway to compare BSSVF with standard techniques of vaginal vault prolapse repair.

Prolapso de la cúpula vaginal tratado mediante operación de Richter-Amreich asociada a colporrafia anterior

Objective To study prospectively the succes rate of the sacrospinous vault suspension, using the vaginal approach associating an anterior colporrhaphy, in the cases of posthisterectomy vaginal vault prolapse. Material and methods Between January 1999-July 2005, 41 patients without urinary incontinence and vaginal vault prolapse were treated with the Richter-Amreich’s procedure associated with anterior colporrhaphy by the same surgeon. We have used the the Miya hook in all interventions and 2 sutures of Polyglactin 00. Every patient was 393 followed up a month after the operation and anually till now. We considered success as the lack of prolapse a month after the intervention, and relapse when another prolapse happened in a year or more after surgery. Patients were include in a database and Epi-info 3.3 TM was used to perform the statistical analysis. Results There were vaginal vault prolapse at 1- month follow-up in 4 of the 41 (success rate of 91.2%). Another 3 patients presented minor cystocele (grade 1), and one had a grade 2 cystocele without descent of vaginal apex (9.8%). There is no worsening of these cases till now in the annual follow-ups. The most common postoperatory complication was anemia, that was present in 13 patients (31,7%). The length of complete surgery was 102 ± 35 minutes. There is a clear correlation between operating time and surgeon experience. Conclusions This technique is an effective method, economic and safe to treat posthysterectomy prolapse of the apical vaginal compartment.

Vaginal surgical approach to vaginal vault prolapse: considerations of anatomic correction and safety

Pelvic organ prolapse is a common problem in women and often requires surgical management. Vaginal vault prolapse requires significant expertise. The pelvic reconstructive surgeon should be familiar with various methods of repair, including the vaginal approach, in order to provide appropriate individualized patient care. The safety of procedures should be balanced against the need for anatomic correction. Vaginal surgical approaches such as sacrospinous suspension, although shown in the past to have slightly less success than abdominal approaches such as sacral colpopexy, continue to have good safety and efficacy profiles, and may be used in appropriately selected patients. Randomized clinical trials are still required to compare different vaginal procedures such as sacrospinous and uterosacral ligament suspension. A new minimally invasive transperineal approach, posterior intravaginal slingplasty, requires further evaluation before being used in routine clinical practice. Posthysterectomy prolapse of the apical vaginal compartment frequently requires a surgical solution. This may be approached via the abdominal, vaginal or combined route. A vaginal approach, being less invasive, may be the safer option if carefully performed. The gynecologic surgeon must balance the advantages of anatomic correction (e.g. with sacrospinous vault suspension) against the advantages of a potentially safer yet less anatomically correct procedure (e.g. colpocleisis). The surgical approach must be individualized for every patient.

Safety and efficacy of sacrospinous vault suspension.

The objective of the study was to determine the success rate and complications of sacrospinous vault suspension when performed by an experienced surgeon. Retrospective data collection was performed for 293 women who had undergone sacrospinous vault suspension at Mount Sinai Hospital, Toronto, between November 1993 and 19 December 1998. Primary outcome measures were complication rates (acute and long term) and success rate, with failure defined as any degree of vault prolapse requiring repeat operation, any degree of symptomatic isolated vault prolapse, or any vault prolapse at or beyond the introitus. Statistical analysis was performed using simple descriptive techniques. During the study period, 305 sacrospinous vault suspensions were performed; however, 12 cases were excluded because of inaccessible records. This study therefore comprised the remaining 293 cases: 129 at the time of vaginal hysterectomy, 5 with transvaginal cervical stump excision, 155 for post-hysterectomy vault prolapse, and 4 without hysterectomy. Two hundred had follow-up of 1 year or more, with maximum follow-up 5 years. Of these 200, there were 6 failures (3%). There were no acute hemorrhages and no deaths. There was a complaint of postoperative right buttock pain in 18 of the 293 procedures (6.1%), with this persisting on a chronic basis in 3 patients. Eight patients complained of new-onset postoperative dyspareunia. Nine patients had postoperative stress urinary incontinence, and 14 patients had de novo anal incontinence. Postoperatively, there were 17 patients with a cystocele and 7 with a rectocele. There were three other complications: one pelvic hematoma at the sacrospinous suspension site, one right foot drop which spontaneously resolved, and one case of pain in the right sciatic nerve distribution which spontaneously resolved. Forty-three patients complained of anal incontinence preoperatively, and 38 (88.4%) had the symptoms resolved postoperatively. It was concluded that, when performed by a surgeon experienced in the procedure, sacrospinous vault suspension is safe and effective, with a successful result at 1 year in more than 90% of cases, and rare major complications.

Anterior or posterior sacrospinous vaginal vault suspension: long-term anatomic and functional evaluation

OBJECTIVE: To compare vaginal anatomy and sexual function after the conventional posterior and anterior sacrospinous vault suspension. METHODS: A retrospective repeated measures cohort study included all 168 consecutive sacrospinous vault suspension procedures between July 1990 and February 1997. The posterior suspension ( n = 92) used a posterior vaginal incision and pararectal dissection. Anterior suspension ( n = 76) involved an anterior rather than posterior vaginal incision, retropubic perforation, and dissection of a paravaginal-paravesical rather than pararectal space to accommodate the vaginal vault. Two polytetrafluoroethylene (00) sutures anchored the anterior vaginal cuff (for the anterior sacrospinous suspension) or the posterior vaginal cuff (for the posterior sacrospinous suspension) to the ligament. Postoperative evaluation included an examination using the pelvic organ prolapse quantitative system, assessment of vaginal width and axis, and symptom questionnaire. RESULTS: Total vaginal length and apical suspension were slightly greater after the anterior suspension, and recurrent anterior vaginal relaxation was less likely. No differences were found in maximal dilator size or apical narrowing between the two groups. New onset dyspareunia was reported by two subjects in the anterior vault suspension group, and two in the posterior vault suspension group. Three of these four cases of de novo dyspareunia were attributable to either severe atrophy or recurrent prolapse, and none to vaginal narrowing or shortening. CONCLUSION: After anterior sacrospinous vault suspension, vaginal length and apical suspension were slightly increased, and recurrent anterior vaginal prolapse decreased compared with the posterior sacrospinous suspension technique. Upper vaginal caliber and sexual function appear well preserved using either technique.

Anterior or Posterior Sacrospinous Vaginal Vault Suspension

In Brief OBJECTIVE To compare vaginal anatomy and sexual function after the conventional posterior and anterior sacrospinous vault suspension. METHODS A retrospective repeated measures cohort study included all 168 consecutive sacrospinous vault suspension procedures between July 1990 and February 1997. The posterior suspension (n = 92) used a posterior vaginal incision and pararectal dissection. Anterior suspension (n = 76) involved an anterior rather than posterior vaginal incision, retropubic perforation, and dissection of a paravaginal-paravesical rather than pararectal space to accommodate the vaginal vault. Two polytetrafluoroethylene (00) sutures anchored the anterior vaginal cuff (for the anterior sacrospinous suspension) or the posterior vaginal cuff (for the posterior sacrospinous suspension) to the ligament. Postoperative evaluation included an examination using the pelvic organ prolapse quantitative system, assessment of vaginal width and axis, and symptom questionnaire. RESULTS Total vaginal length and apical suspension were slightly greater after the anterior suspension, and recurrent anterior vaginal relaxation was less likely. No differences were found in maximal dilator size or apical narrowing between the two groups. New onset dyspareunia was reported by two subjects in the anterior vault suspension group, and two in the posterior vault suspension group. Three of these four cases of de novo dyspareunia were attributable to either severe atrophy or recurrent prolapse, and none to vaginal narrowing or shortening. CONCLUSION After anterior sacrospinous vault suspension, vaginal length and apical suspension were slightly increased, and recurrent anterior vaginal prolapse decreased compared with the posterior sacrospinous suspension technique. Upper vaginal caliber and sexual function appear well preserved using either technique. Anterior sacrospinous vaginal vault suspension results in anatomic and functional outcomes similar to the conventional posterior approach, and may reduce the risk of recurrent anterior compartment prolapse.

Persistent site-specific defects after reconstructive pelvic surgery.

Our objective was to determine the persistence rates of site-specific defects after reconstructive pelvic surgery. We conducted a retrospective analysis of the post-operative outcome for 77 patients with pelvic support defects. Forty-five patients in the abdominal group underwent a Burch procedure, paravaginal repair and sacral colpopexy when indicated; 32 patients in the vaginal group had a sacrospinous vault fixation with or without colporrhaphy. A chi2 test, Wilcoxon's two-sample test. Wilcoxon's signed-rank test and multivariate logistic regression model were used for data analysis. The two groups were similar in age, weight, parity and menopausal status. There was significant improvement of all defects except in the vaginal group, which showed a higher rate of persistent paravaginal defects (68.7 vs. 13.3%, P = 0.001). After adjusting for potential confounders, there was no difference in the rates of apical and anterior wall defects between the two groups. The odds ratio for persistent paravaginal defects in the vaginal group was 8.9 (95% CI: 2.3-34). The choice of surgical procedure is the most important factor determining the rate of persistent pelvic support defects. Lateral wall defects must be addressed at the time of reconstructive surgery.

Sacrospinous vault suspension and abdominal colposacropexy: success rates and complications: Hardiman P.J.; Drutz H.P. CAN Am. J. Obstet. Gynecol. 1996 175/3 I (612–616)

Sacrospinous vault suspension and abdominal colposacropexy: success rates and complications: Hardiman P.J.; Drutz H.P. CAN Am. J. Obstet. Gynecol. 1996 175/3 I (612–616)

An in-line suturing device to simplify sacrospinous vaginal vault suspension

A disposable suturing instrument is used in our surgical method for sacrospinous vault suspension to facilitate suture placement and retrieval. The pararectal space is dissected and the suturing device is placed just medial to the lateral third of the sacrospinous ligament-coccygeus muscle complex. Depression of the device's firing button advances a standard needle in a controlled circular path through the sacrospinous ligament-coccygeus muscle complex. The needle is retrieved with a straight-needle holder at a consistent location, 3 mm from the shaft of the instrument. A second suture is placed 0.5-1 cm medial to the first suture. If the holding strength for either suture is considered inadequate, the device is reloaded with the same suture and subsequent bites are taken. The procedure is completed using standard methods. In ten women treated for vaginal vault eversion, lateral dissection was completed in less than 10 minutes, and passage of two sutures through the sacrospinous ligament was accomplished in less than 2 minutes. There were no complications. One patient described mild buttock pain that resolved in 1 week. At 4-6 months' follow-up, vaginal examination with maximal straining demonstrated direct apposition of the vaginal wall to the sacrospinous ligament.

Vaginal versus abdominal reconstructive surgery for the treatment of pelvic support defects: A prospective randomized study with long-term outcome evaluation

OBJECTIVES: Our purpose was to determine whether a vaginal or abdominal approach is more effective in correcting uterovaginal prolapse. STUDY DESIGN: Eighty-eight women with cervical prolapse to or beyond the hymen or with vaginal vault inversion >50% of its length and anterior vaginal wall descent to or beyond the hymen were randomized to a vaginal versus abdominal surgical approach. Forty-eight women underwent a vaginal approach with bilateral sacrospinous vault suspension and paravaginal repair, and 40 women underwent an abdominal approach with colposacral suspension and paravaginal repair. Ancillary procedures were performed as indicated. Detailed pelvic examination was performed postoperatively by the nonsurgeon coauthor yearly up to 5 years. The women were examined while standing during maximum strain. Surgery was classified as optimally effective if the woman remained asymptomatic, the vaginal apex was supported above the levator plate, and no protrusion of any vaginal tissue beyond the hymen occurred. Surgical effectiveness was considered unsatisfactory if the woman was symptomatic, the apex descended >50% of its length, or the vaginal wall protruded beyond the hymen. RESULTS: Eighty women (vaginal 42, abdominal 38) were available for evaluation at 1 to 5.5 years (mean 2.5 years). The groups were similar in age, weight, parity, and estrogen status, and 56% had undergone prior pelvic surgery. There was no significant difference between the groups in morbidity, complications, hemoglobin change, dyspareunia, pain, or hospital stay. The vaginal group had longer catheter use, more urinary tract infections, more incontinence, decreased operative time, and lower hospital charge. Surgical effectiveness was optimal in 29% of the vaginal group and 58% of the abdominal group and was unsatisfactory leading to reoperation in 33% of the vaginal group and 16% of the abdominal group. The reoperations included procedures for recurrent incontinence in 12% of the vaginal and 2% of the abdominal groups. The relative risk of optimal effectiveness by the abdominal route is 2.03 (95% confidence interval 1.22 to 9.83), and the relative risk of unsatisfactory outcome using the vaginal route is 2.11 (95% confidence interval 0.90 to 4.94). CONCLUSIONS: Reconstructive pelvic surgery for correction of significant pelvic support defects was more effective with an abdominal approach. (Am J Obstet Gynecol 1996;175:1418-22.)

Sacrospinous vault suspension and abdominal colposacropexy: Success rates and complications

OBJECTIVE: Our purpose was to compare success rates and complications of sacrospinous vault suspension and abdominal colposacropexy. STUDY DESIGN: A case series is presented of 130 attempted sacrospinous vault suspensions with the Miya hook and 80 cases of abdominal colposacropexy, done in conjunction with other procedures. Patients were assessed 6 weeks and 6 and 12 months after surgery and yearly thereafter. RESULTS: Sacrospinous vault suspension was completed in 125 women (5 abandoned because of technical difficulty). Abdominal colposacropexy was completed in all 80 women. There was only one intraoperative complication - hemorrhage from the presacral veins during abdominal colposacroplexy. The incidence of postoperative febrile morbidity was 10% after sacrospinous vault suspension and 6% after abdominal colposacropexy. Follow-up ranged from 6 months to 5 years. The incidence of recurrent vault prolapse was 2.4% with sacrospinous vault suspension and 1.3% with abdominal colposacropexy. Demonstrable stress urinary incontinence occurred in one woman after abdominal colposacropexy and in none after sacrospinous vault suspension. CONCLUSION: Sacrospinous vault suspension and abdominal colposacropexy are associated with a low incidence of intraoperative and postoperative complications and recurrent vault prolapse. Latent stress urinary incontinence may be unmasked, particularly with abdominal colposacropexy, and preoperative urodynamic evaluation is therefore recommended. (Am J Obstet Gynecol 1996;175:612-6.)