Treatment Of Vaginal Vault Prolapse Research Articles

Ten years’ follow-up after iliococcygeus fixation for the treatment of apical vaginal prolapse

Various surgical techniques have been described for vaginal vault prolapse repair, but the best surgical approach is still to be proven. The aim of this study is to report the long-term objective and subjective outcomes of women who underwent iliococcygeus fixation for the treatment of vaginal vault prolapse with a minimum follow-up of 10years. Women with symptomatic vaginal vault prolapse (Pelvic Organ Prolapse Quantification [POP-Q] stage ≥ 2) who had previously undergone hysterectomy for any reason were prospectively enrolled and treated with iliococcygeus fixation. Subjective success was defined as Patient Global Impression of Improvement (PGI-I) ≤ 2 and an absence of bulging symptoms. Objective success was defined as stage of prolapse < 2 in all compartments. Overall success rate was defined as women without prolapse symptoms, PGI-I ≤ 2, stage of prolapse < 2, and no need for other surgery. Prolpase Quality of Life (P-QOL) questionnaires were completed at the preoperative visit and at every follow-up visit. Multiple logistic regression was performed to identify factors involved in the risk of recurrent POP. After a median (range) follow-up of 120 (120-132) months, the subjective, objective, and overall cure rates were 82% (32/39), 74.4% (29/39), and 74.4% (29/39), respectively. Only stage IV vault descensus independently predicted POP recurrence after ICG (OR: 7.66 [95% CI: 1.21-9.02]; p < 0.001). Iliococcygeus fixation seems to be a safe and effective option for the treatment of vaginal vault prolapse at 10years' follow-up.

Transvaginal Sacrospinous Ligament Fixation: Revisited in Modern Gynecology

ABSTRACT Background To evaluate intraoperative and postoperative complications and to evaluate recurrence of vault prolapse in women who have undergone unilateral (left) sacrospinous ligament fixation. Aim To evaluate safety, effectiveness, and ease of sacrospinous ligament fixation for prevention and treatment of vaginal vault prolapse. Materials and methods This study was conducted between January 2016 and October 2017 at Smt. Kashibai Navale Medical College and General Hospital, Pune. This study included 106 patients (out of which18 had vault prolapse and 88 patients had III or IV degree uterine prolapse). Concomitant hysterectomy and sacrospinous ligament fixation were done in 88 patients with uterine prolapse, and patients with vault prolapse underwent sacrospinous ligament fixation. Sacropinous ligament fixation was combined with any other additional procedure if required for that patient. Results All complications including intraoperative and postoperative were noted in all patients. One patient had rectal injury (n = 1; 0.94%), 1 patient had abscess (n = 1; 0.94%), 1 patient had hemorrhage requiring blood transfusion (n = 1;0.94%), 1 patient had cystocele (n = 1; 0.94%), 3 patients had urinary tract infection (n = 3; 2.8%), 16 patients had postoperative fever (n = 16; 15%), 21 patients had postoperative pain (n = 21; 20%), and 2 patients had sciatic neuralgia (n = 2; 2.8%). No recurrence of vault prolapse was noted. Conclusion Sacrospinous ligament fixation is a safe, effective, and simple procedure for prevention and treatment of vaginal vault prolapse. How to cite this article Shastri SS, Darawade SP, Yedage NR. Transvaginal Sacrospinous Ligament Fixation: Revisited in Modern Gynecology. J South Asian Feder Obst Gynae 2020;12(3):155–158.

Laparoscopic sacral colpopexy with polyester fiber suture: Ozerkan modification.

Mesh-related problems are significant complications of laparoscopic sacral colpopexy. The conventional technique precludes performing laparoscopic sacral colpopexy without using a mesh. We describe the Ozerkan modification for laparoscopic sacral colpopexy using a polyester fiber suture instead of a standard mesh and report 1-year objective and subjective outcomes. Women diagnosed with stage ≥ 2 vaginal vault prolapse were prospectively recruited for the Ozerkan modification between 2015 and 2017. The primary outcome was the anatomic success of the repair, defined by objective parameters using the pelvic organ prolapse quantification system (stage 0 or 1). Secondary outcomes were subjective outcomes assessed with the quality of life scores. Twenty-two women underwent the Ozerkan modified laparoscopic sacrocolpopexy. Mean operation time was 85.6min. Mean estimated blood loss was 71ml. One patient was lost during the clinical follow-up in the outpatient clinic up to 1 year. Nineteen of 21 patients had stage 0 or 1 prolapse at the end of 1 year. Two patients were not satisfied with their pelvic floor after 1 year. Both the objective and subjective cure rates were 90.4%. There were no bladder or bowel complications during the peri- or postoperative period. The new modification of laparoscopic sacral colpopexy seems a feasible and safe option to avoid mesh complications in the treatment of vaginal vault prolapse.

Bilateral Sacrospinous Colposuspension (BSC) for the treatment of vaginal vault prolapse – description of a novel method

Vaginal vault prolapse is observed with increasing frequency in the era of large ageing populations. Various surgical techniques have been established, varying in performance, difficulty and outcome, specifically complications. A bilateral sacrospinous colposuspension technique (BSC) with a corresponding mesh prosthesis was developed using a direct I-Stitch fixation of the 38 micro-gram mesh from the vaginal apex or uterine cervix to the sacrospinous ligament or the para-sacral tendinous region for the treatment of an anatomical central pelvic floor defect. As a minimally invasive approach with the potential for conservation of the uterus, this technique should be applicable to all age groups including the increasingly frequent elderly patient with significant comorbidities.

Laparoscopic sacrocolpopexy (LSCP) using an ultra-lightweight polypropylene mesh.

ObjectivesSince 2005 the preferred method for surgical treatment of vaginal vault prolapse within the department has been laparoscopic sacrocolpopexy with an ultra-lightweight polypropylene mesh. The study aimed to explore the functional and anatomical outcomes and mesh adverse events of women following this procedure.Study designAll women who had a Laparoscopic Sacrocolpopexy (LSCP) using an ultra-lightweight (19 g/m2) polypropylene mesh in two units in the North West of England between March 2005 and January 2013 (n = 238) were invited to participate in the study.Functional outcome data was collected using the Patient Global Impression Questionnaire (PGI-I), the Pelvic Floor Distress Inventory (PFDI-20) and the Electronic Personal Assessment Questionnaire (EPAQ) post-operatively. Anatomical outcome was assessed by Pelvic Organ Prolapse Quantification System (POP-Q) measurement. A mesh palpability assessment was performed and any mesh complications were recorded using the International Continence Society/International Urogynecology Association (ICS/IUGA) classification system. The results were compared to those in our previously published series using the same surgical technique but a standard weight mesh (82.5 g/m2).Results89% of participants reported that they felt their post-operative condition had improved. POP-Q results revealed that the median position of C changed from −3 pre-op to −7 post-operatively. Mesh was palpable during vaginal examination in only 3 women (3%). No mesh extrusion was identified during the study.ConclusionsThe study demonstrates that LSCP performed with an ultra-lightweight polypropylene mesh improves women’s functional and anatomical symptoms and appears to have a low risk of mesh extrusion.

Treatment of vaginal vault prolapse in The Netherlands: a clinical practice survey.

A great variety of conservative and surgical procedures to correct vaginal vault prolapse have been reported. The aim of this study was to describe practice pattern variation-the difference in care that cannot be explained by the underlying medical condition-among Dutch gynecologists regarding treatment of vaginal vault prolapse. A clinical practice survey was conducted from March to April 2017. The questionnaire was developed to evaluate treatment of vaginal vault prolapse. All members of the Dutch Society for Urogynaecology were invited to participate in a web-based survey. One hundred four Dutch gynecologists with special interest in urogynecology responded to the survey (response rate, 44%). As first-choice therapy for vaginal vault prolapse, 78% of the respondents chose pessary treatment, whereas sacrospinous fixation was the second most common therapy choice according to 64% of the respondents. Preferences on how to approach vaginal vault prolapse surgically are conflicting. Overall, the most performed surgery for vaginal vault prolapse is sacrospinous fixation, followed by laparoscopic and robotic sacrocolpopexy. Gynecologists in The Netherlands manage vaginal vault prolapse very differently. No standardized method could be determined for the treatment of vaginal vault prolapse in The Netherlands, and we observed practice pattern variations.

Impact of transvaginal modified sacrospinous ligament fixation with mesh for the treatment of pelvic organ prolapse-before and after studies

BackgroundPelvic organ prolapse (POP) is a common disease in women. The aim of this research was to evaluate the safety, efficacy and complication of transvaginal modified sacrospinous ligament fixation with mesh using for the treatment of vaginal vault prolapse. Materials and methodsThis was a prospective study including information from 60 symptomatic women with anterior-apical pelvic floor prolapse. The patients underwent transvaginal modified sacrospinous ligament fixation combined with anterior vaginal wall mesh between May 2014 and Sep 2015. The perioperative data including clinical characteristic, operation time, blood loss, and surgical complications were collected at 1 year and 2 years. During a 2-year follow-up, the primary outcome evaluation included Pelvic organ prolapse Quantification system (POP-Q), Incontinence Quality of Life scale (I-QoL), the Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12) and the Pelvic Floor Distress Inventory, short form 20 (PFDI-20). ResultsThe mean follow-up time was 2 years (range 24–37 months). The patients' mean age was 66.75 ± 6.44. Of 60 patients who were enrolled in this research, 26 patients had severe stress urinary incontinence (SUI). The mean operation time was 99.14 ± 19.60 min and the mean estimated blood loss was 73.83 ± 41.05 ml. The rate of anatomical success was 98.3% and one patient had a recurrence. The POP-Q point measurements were evaluated preoperatively and postoperatively (P < 0.001). Moreover, the quality of life and sexual activity were all improved postoperatively via I-QoL, PISQ-12 and PFDI-20 scores (P < 0.001). There was no injury to the rectum, bladder, major pelvic vessels and pudendal nerves. However, 18 patients had postoperative complications. ConclusionsThis study showed that transvaginal modified sacrospinous ligament fixation with mesh might be performed easily and might be a safe surgery for elderly patients whose requirements for sexual life were relatively low. Further researches were required to investigate its long-term efficacy.

Surgical treatment of vaginal vault prolapse using different prosthetic mesh implants: a finite element analysis

Abstract Particularly multiparous elderly women may suffer from vaginal vault prolapse after hysterectomy due to weak support from lax apical ligaments. A decreased amount of estrogen and progesterone in older age is assumed to remodel the collagen thereby reducing tissue stiffness. Sacrocolpopexy is either performed as open or laparoscopic surgery using prosthetic mesh implants to substitute lax ligaments. Y-shaped mesh models (DynaMesh, Gynemesh, and Ultrapro) are implanted in a 3D female pelvic floor finite element model in the extraperitoneal space from the vaginal cuff to the first sacral (S1) bone below promontory. Numerical simulations are conducted during Valsalva maneuver with weakened tissues modeled by reduced tissue stiffness. Tissues are modeled as incompressible, isotropic hyperelastic materials whereas the meshes are modeled either as orthotropic linear elastic or as isotropic hyperlastic materials. The positions of the vaginal cuff and the bladder base are calculated from the pubococcygeal line for female pelvic floor at rest, for prolapse and after repair using the three meshes. Due to mesh mechanics and mesh pore deformation along the loaded direction, the DynaMesh with regular rectangular mesh pores is found to provide better mechanical support to the organs than the Gynemesh and the Ultrapro with irregular hexagonal mesh pores.

A new laparoscopic technique of inguinal ligament suspension for vaginal vault prolapse

IntroductionThe aim of the study was to evaluate the efficacy and safety of laparoscopic inguinal ligament suspension (LILS) as a new surgical technique for the treatment of vaginal vault prolapse. MethodsFrom Feb 2014 to Mar 2016, 21 symptomatic women with grades III-IV vaginal vault prolapse were enrolled. All patients underwent LILS procedure in which a bifurcated mesh was used to suspend the vaginal vault to inguinal ligament. The perioperative parameters including surgical time, blood loss, and hospitalization time were recorded. At a minimal 12-month follow-up, the primary outcome measures, such as the anatomical cure rate and patients' satisfaction were respectively evaluated according to Pelvic organ prolapse questionnaire (POP-Q) and Patient Global Impression of Improvement (PGI-I) scale. The secondary outcomes including the impact on symptom severity, quality of life and sexual activity were also recorded. ResultsThe mean surgical time was 130.71 ± 16.07 min, the mean estimated blood loss was 53.57 ± 48.43 ml, and the mean hospital stay was 6 days (range: 5–8 days). After a minimal 12-month follow-up (range: 12–36 months), the rate of anatomical success and the subjective satisfaction were 100% and 90.5%. The symptom severity, quality of life and sexual activity also presented significant improvement. In addition, no serious peri- and postoperative complications occurred. ConclusionsLILS was a potential method for the treatment of vaginal vault prolapse. The technique could be performed easily and might be an alternative to other POP surgeries. However, further studies were required to focus on its long-term efficacy.

Are the Effectiveness of Minimally Invasive Sacrocolpopexy Similar with Abdominal Sacrocolpopexy for the Treatment of Vaginal Vault Prolapse?

Objective: The aim of this study was to present the outcomes of open abdominal sacrocolpopexy (ASC) and minimally invasive sacrocolpopexies (MISC). Material and Methods: A total of 41 women with a mean age of 59 (34-76) underwent sacrocolpopexy, with 21 ASC and 20 MISCs. Within the MISC group, 17 were laparoscopic (LSC) and 3 were robotic (RSC). The patients were presented with vaginal mass in 40 and bilateral lombar pain in 1. Statistical analyses were done using Mann-Whitney U test and Fisher's exact test with SPSS version 15.0. Results: The mean follow-up time was 61.3 (11-90) months. Mean estimated blood loss and length of hospitalization were significantly longer for ASC (p<0.001), whereas the operative time was significantly shorter (p<0.001). Recurrence was seen in 1 patient after MISC and repaired with ASC. Grade 2 prolapsus was seen in 4 at follow-up, however vaginal erosion was not. The success rates were; 90.0% for MISC and 90.4% for ASC. Conclusion: MISC led to shorter hospitalization, better hemostasis than ASC. MISC is as effective as ASC for the treatment of vaginal vault prolapse. Further prospective and randomized controlled studies including large series of patients are needed.

Robotic sacrocolpopexy for posthysterectomy vaginal vault prolapse: a case series of 31 patients by a single surgeon with a long term follow-up.

The aim of this paper was to evaluate the feasibility, short-term complications of robotic surgery and clinical outcomes in terms of long-term complications, pain relief and recurrence rate, for the treatment of vaginal vault prolapse (VVP). Prospective analysis of robotic-assisted laparoscopic sacrocolpopexy (RALS) performed between October 2011 and February 2015, in patients with advanced post-hysterectomy VVP and significant apical defects as defined by Baden- Walker Score ≥3. Thirty-one consecutive of RALS were performed, with a mean follow-up of 27 months (range 2-48). Average total operative time was 185 minutes (range: 170-235). Estimated blood loss was 50 ml (range: 30-150). One case of cystotomy was reported, repaired with a 2.0 point. No others intra-operative complications occurred. Successful outcome was reported in 94% (29/31) of VVP repairs. This series demonstrates optimal outcomes at long-term follow-up. RALS may provide the same long-term durability of open sacrocolpopexy with the benefit of a minimally invasive approach.

Sacrocolpopexy in management of vaginal vault prolapse

Aims &amp; Objectives: To review the efficacy of Sacrocolpopexy in the management of vaginal vault prolapse Study Design: Interventional study. Setting &amp; Population: Department of Obstetrics &amp; Gynaecology, Jinnah Hospital, Lahore. Women with vaginal vault prolapse after hysterectomy. Methods and Main-outcome measures: Abdominal Sacrocolpopexy using proline mesh. Follow-up in these patients were carried out at one week, four weeks, six months, and one year. Results: Sacrocolpopexy was carried out in ten patients for vaginal vault prolapse after vaginal (6) and abdominal hysterectomy (4). The mean age was 49.8 years. Parity was between P3 - P6 (Mean parity 4.3). Mean operation time was 79.3 minutes. Estimated blood loss was less than 200m1. No intra-operative or post-operative complications occurred in any case. Conclusion: Abdominal sacrocolpopexy is effective and safe in the treatment of vaginal vault prolapse. This procedure has high success rate in correcting prolapse without a time dependent decrease in efficacy.

The effect of lidocaine on urodynamic parameters in the Bladder Pain Syndrome

Introduction: Sacrocolpopexy remains the gold standard for the treatment of vaginal vault prolapse (VVP). Robotic surgery rates are increasing with few large prospective studies available to assess the benefits. Objective: The primary aim was to assess the efficacy of the procedure. The secondary aims included assessing the safety profile and surgical variables using the robot. Methods: A prospective European multi-centred cohort study was performed from August 2011 to August 2014. There were strict entry criteria: VVP stage 2 (simplified POP-Q point C 2). The primary outcome was anatomical cure at 6 weeks and 1 year using the simplified POP-Q. Secondary outcomes included mesh erosion rates, reoperations rate and intra-peri and post-operative complications. Statistical analysis was performed using student ttest and linear regression where appropriate. Results: 172 women were enrolled, mean age was 64years (range 38–83years), mean parity: 3 (range 0–12), mean BMI: 26.7 (range 20.46–37.1). The prolapse results: Table 1. The conversion rate was 2.9% (5/172). Intraoperative complication rate was 1.1%(2/172). 17% (30/172) had concomitant surgery. The reoperation rate was 9.3% (16/172) none for recurrent VVP. No mesh erosions have been reported. Console time varied from 53 to 141 min with longer console times reported for the more challenging cases.

Robotic sacrocolpopexy – efficacy in treating vaginal vault prolapse

Introduction: Sacrocolpopexy remains the gold standard for the treatment of vaginal vault prolapse (VVP). Robotic surgery rates are increasing with few large prospective studies available to assess the benefits. Objective: The primary aim was to assess the efficacy of the procedure. The secondary aims included assessing the safety profile and surgical variables using the robot. Methods: A prospective European multi-centred cohort study was performed from August 2011 to August 2014. There were strict entry criteria: VVP stage 2 (simplified POP-Q point C 2). The primary outcome was anatomical cure at 6 weeks and 1 year using the simplified POP-Q. Secondary outcomes included mesh erosion rates, reoperations rate and intra-peri and post-operative complications. Statistical analysis was performed using student ttest and linear regression where appropriate. Results: 172 women were enrolled, mean age was 64years (range 38–83years), mean parity: 3 (range 0–12), mean BMI: 26.7 (range 20.46–37.1). The prolapse results: Table 1. The conversion rate was 2.9% (5/172). Intraoperative complication rate was 1.1%(2/172). 17% (30/172) had concomitant surgery. The reoperation rate was 9.3% (16/172) none for recurrent VVP. No mesh erosions have been reported. Console time varied from 53 to 141 min with longer console times reported for the more challenging cases.

Laparoscopic Technique of Vagino-Sacropexy for Treatment of Vaginal Vault Prolapse and Urinary Urge Incontinence

Introduction: Pelvic organ prolapse is a common problem in women, especially in elderly. Many women with pelvic organ prolapse also suffer from urinary incontinence. Based on the studies of de Lancey, three levels of vaginal support are important for maintaining pelvic organ support and continence.1,2 Uterosacral and cardinal ligaments are the main structures in level 1 support that suspends the cervix and upper vagina. Uterosacral ligaments extend between upper vagina and sacrum at the level of S2 through S4 and maintain length and horizontal axis of the vagina. Horizontal axis of the vagina is essential for continence by supporting bladder base. Laxity or defects in the uterosacral ligaments are frequently associated with apical utero-vaginal descensus, urgency, and urge incontinence.3,4 It was proved that urgency or urge incontinence may be caused by anatomical defects of the posterior compartment and could be treated with surgery.5,6 Vagino-sacropexy (VASA) is a new surgical technique that was described for correcting vaginal stump descensus, prolapse, and/or urge incontinence in a hysterectomized patient.7 Cure rates in urge incontinence were reported as 70% to 77%.7 In this operation, vaginal vault is fixed to sacrum at the level of S2 bilaterally by using a one-piece polyvinylidene fluoride (PVDF) mesh. Although promontory is accepted to be the simplest localization for attachment of mesh in unilateral sacrocolpopexy, it is not the safest area for fixation.8,9 However, bilateral fixation of mesh on S2 results in a more anatomic suspension of vaginal vault when compared with unilateral mesh attachment on sacral promontory. In VASA, restoring vaginal horizontal axis improves urge incontinence. In this video, our aim was to demonstrate the laparoscopic surgical technique of VASA in a hysterectomized patient with vaginal vault prolapse and urge incontinence. According to our knowledge, this is the first report in the literature. Video run time is 05 mins 7 secs. Materials and Methods: Laparaoscopic VASA was performed in a 65-year-old woman with POP-Q stage 4 vaginal prolapse and urge incontinence (Video 1). The purpose of VASA is to re-create synthetic uterosacral ligaments to support vaginal vault by placing a one-piece mesh implant between vaginal cuff and second sacral vertebrae (S2) on the left side and right side of the pelvis. Vaginal part of the mesh implant should be fixed to the vaginal cuff with three or four nonabsorbable or late-absorbable multifilament sutures. Results and Conclusions: Vaginal vault prolapse was corrected anatomically by replacement of uterosacral ligaments with a synthetic PVDF surgical mesh by laparoscopic VASA operation. Postoperative term was uneventful and the patient was discharged at the first day following operation. In the first follow-up visit at 15th day postsurgery, the patient had no symptom of urge incontinence. Long-term anatomic and functional outcomes were also satisfactory. Laparoscopic vagino sacropexy is a little bit more difficult procedure than conventional laparoscopic unilateral sacrofixation because the normal anatomic position of the sigmoid colon challenges the placement of mesh implant on the left side. So, sigmoid colon should be deviated to the right side, and then the left arm of the mesh implant is placed under peritoneum in a similar manner to the right side. In addition, pelvic curve challenges formation of peritoneal tunnels from the sacrum to the level of insertion of uterosacral ligaments on the vaginal cuff, bilaterally. To facilitate this step, we prefer to use a flexible dissector for passing the pelvic curve. If a rigid dissector is used in this step, the peritoneum over the rigid instrument can easily be torn and then shortened. The average time taken to perform laparoscopic VASA is ~90 to 100 minutes and is mainly related to level of expertise. Intermediate or advanced surgical skills in laparoscopic pelvic surgery are required before one may attempt laparoscopic VASA. In conclusion, in surgical treatment of pelvic organ prolapse, pelvic organs should be restored to their original anatomic positions to restore their normal functions. In surgical treatment of apical prolapses, defective uterosacral ligaments should be replaced in original anatomic planes to restore normal bladder functions and improve urge incontinence. Laparoscopic approach for VASA also provides better access and identification of pelvic structures and rapid postoperative recovery. No competing financial interests exist. Runtime of video: 5 mins 7 secs

Technique of extraperitoneal uterosacral ligament suspension for apical suspension.

Vaginal vault prolapse can occur alone or in combination with anterior or posterior compartment prolapse. Apical prolapse has shown a strong correlation with anterior wall prolapse and a moderate correlation with posterior wall prolapse. The McCall culdoplasty uses the extraperitoneal vaginal approach to support the vault at the time of hysterectomy. Sacrospinous fixation and ileococcygeus suspension with or without mesh have also been used for the treatment of vaginal vault prolapse. The uterosacral ligaments can also be used to re-suspend the vaginal vault using the extraperitoneal or transperitoneal approach. With the extraperitoneal approach, the peritoneal sac, which can be difficult to access at times, especially when there are dense pelvic adhesions, does not need to be opened. The extraperitoneal approach also carries a lower risk of ureteric injury, as the ureters and the bladder can be retracted from the field using a Breisky-Navratil retractor. This video, which documents the surgical treatment of a woman with a complete vaginal eversion and grade 3 pelvic organ prolapse (POP), was recorded in a live workshop during the 2015 Urogynaecology and Reconstructive Pelvic Surgery Conference, held in Chennai, India, in January 2015. It is aimed at educating interested surgeons in the technique of extraperitoneal uterosacral suspension. This video demonstrates the extraperitoneal approach to uterosacral ligament suspension for apical support in women with vaginal vault prolapse.

Evaluación a dos años de la promontofijación laparoscópica con anclaje de titanio del prolapso de la cúpula vaginal

Objetivos: Analizar la eficacia de la promontofijación laparoscópica con malla y anclaje helicoidal de titanio, en el tratamiento del prolapso de cúpula vaginal, así como describir el estado de salud autorreportado por las pacientes sometidas a la corrección quirúrgica. Diseño: Estudio descriptivo, transversal. Institución: Servicio de Ginecología, Hospital Alberto Sabogal Sologuren, EsSalud, Lima, Perú. Participantes: Pacientes con diagnóstico de prolapso de cúpula vaginal tratadas vía laparoscópica. Intervenciones: Se revisó las historias clínicas de cinco de ocho pacientes con diagnóstico de prolapso de cúpula que fueron intervenidas mediante la técnica de promontofijación laparoscópica, con malla y anclaje helicoidal de titanio, durante el periodo enero a setiembre de 2008. Las pacientes fueron examinadas dos años después de la cirugía y se las evaluó con una escala visual analógica (EVA) que contiene cuatro dimensiones de salud y posibilidad de tres alternativas de respuesta, que orientan en relación a su calidad de vida luego de la cirugía. Principales medidas de resultados: Corrección del prolapso de cúpula y mejora en la calidad de vida. Resultados: La edad media fue 67,2 años, la paridad 4. Se corrigió el prolapso en 60% (3/5); un 60% (3/5) presentó dificultades leves en la realización de sus actividades diarias, 20% (1/5) problemas severos con relación a la sexualidad, 60% (3/2) problemas leves con respecto a dolor vaginal y 80% (4/5) depresión leve, pero básicamente en relación a una demora en atención de sus problemas por la institución. Conclusiones: El porcentaje de cura estuvo por debajo de lo obtenido por otras publicaciones. Se señala la necesidad de un seguimiento más exhaustivo de las pacientes, para solucionar problemas asociados.

Iliococcygeus fixation for the treatment of apical vaginal prolapse: efficacy and safety at 5 years of follow-up.

Sacrocolpopexy is considered the gold standard treatment for vaginal vault prolapse. However, the vaginal approach is very common, with 80-90 % of procedures being performed via this route. The aim of this study was to evaluate the safety and efficacy of iliococcygeus (ICG) fixation in the treatment of vaginal vault prolapse, with a minimum follow-up of 5 years. We prospectively enrolled women with symptomatic vaginal vault prolapse (Pelvic Organ Prolapse Quantification [POP-Q] stage ≥2) who were treated with ICG fixation. Subjective success was defined in the case of Patient Global Impression of Improvement ≤ 2 and an absence of bulging symptoms. Objective success was defined as stage of prolapse < 2 in all compartments. Overall success rate was defined as women without prolapse symptoms, PGI-I ≤ 2, stage of prolapse < 2, and no need for other surgery. All women filled in the Prolapse Quality of Life (P-QOL) questionnaire both at the preoperative visit and at every follow-up visit. Multiple logistic regression was performed to identify factors involved in the risk of recurrent POP. After a median (range) follow-up of 68.8 (60-92) months the subjective, objective, and overall cure rates were 88.6 % (39 out of 44), 84.1 % (37 out of 44), and 84.1 % (37 out of 44) respectively. Only preoperative stage IV vault descensus independently predicted POP recurrence after iliococcygeus fixation (OR: 8.78 [95 % CI: 1.31-9.42]; p < 0.001). Iliococcygeus fixation is a safe and effective surgical technique for the treatment of vaginal vault prolapse with long-lasting effectiveness.

Incidence of adverse events after uterosacral colpopexy for uterovaginal and posthysterectomy vault prolapse

We sought to describe perioperative and postoperative adverse events associated with uterosacral colpopexy, to describe the rate of recurrent pelvic organ prolapse (POP) associated with uterosacral colpopexy, and to determine whether surgeon technique and suture choice are associated with these rates. This was a retrospective chart review of women who underwent uterosacral colpopexy for POP from January 2006 through December 2011 at a single tertiary care center. The electronic medical record was queried for demographic, intraoperative, and postoperative data. Strict definitions were used for all clinically relevant adverse events. Recurrent POP was defined as the following: symptomatic vaginal bulge, prolapse to or beyond the hymen, or any retreatment forPOP. In all, 983 subjects met study inclusion criteria. The overall adverse event rate was 31.2% (95% confidence interval [CI], 29.2-38.6), which included 20.3% (95% CI, 17.9-23.6) of subjects with postoperative urinary tract infections. Of all adverse events, 3.4% were attributed to a preexisting medical condition, while all other events were ascribed to the surgical intervention. Vaginal hysterectomy, age, and operative time were not significantly associated with any adverse event. The intraoperative bladder injury rate was 1% (95% CI, 0.6-1.9) and there were no intraoperative ureteral injuries; 4.5% (95% CI, 3.4-6.0) of cases were complicated by ureteral kinking requiring suture removal. The rates of pulmonary and cardiac complications were 2.3% (95% CI, 1.6-3.5) and 0.8% (95% CI, 0.4-1.6); and the rates of postoperative ileus and small bowel obstruction were 0.1% (95% CI, 0.02-0.6) and 0.8% (95% CI, 0.4-1.6). The composite recurrent POP rate was 14.4% (95% CI, 12.4-16.8): 10.6% (95% CI, 8.8-12.7) of patients experienced vaginal bulge symptoms, 11% (95% CI, 9.2-13.1) presented with prolapse to or beyond the hymen, and 3.4% (95% CI, 2.4-4.7) required retreatment. Number and type of suture used were not associated with a higher rate of recurrence. Of the subjects who required unilateral removal of sutures to resolve ureteral kinking, 63.6% did not undergo suture replacement; this was not associated with a higher rate of POP recurrence. Perioperative and postoperative complication rates associated with severe morbidity after uterosacral colpopexy appear to be low. Uterosacral colpopexy remains a safe option for the treatment of vaginal vault prolapse.

Re: Management of vault prolapse

Key content Vaginal wall prolapse is increasing in incidence with improvement in life expectancy. Conservative and surgical treatments exist. Treatment should be tailored to individual needs depending on prolapse symptoms, sexual function and co-existing medical conditions. Indications, expertise required and complications of different procedures should be explored with available evidence. Learning objectives Recognise the presentation of vaginal vault prolapse. Learn about different options available for the treatment of vaginal vault prolapse. Understand the limitations and complications of different procedures and counsel patients appropriately. Ethical issues Should procedures that improve quality of life be performed in elderly patients with comorbid conditions? Should simpler surgical treatments such as colpocleisis or vaginal surgery be performed to be more cost-effective compared with laparoscopic or robotic procedures? How safe is it to use mesh in vault prolapse by the abdominal or vaginal route?