Introduction
Vaginal vault (apical) prolapse refers to descent of the upper part of the vagina, it should be differentiated from the enterocoele, where bowel bulges through the upper part of the posterior wall of the vagina. The condition is distressing to patients, who experience vaginal bulge, urinary and/or bowel symptoms, backache and limitation of movement as well as sexual dysfunction. These problems reduce the quality of life for elderly patients and are restricting for younger and more active ones
Prevention
All patients with vaginal vault prolapse have had a prior hysterectomy, which offers an opportunity to try to avoid such a problem. Vault prolapse should, therefore, be seen as potential consequence of hysterectomy, unless something is done to prevent it.
McCall's culdoplasty has been recognised as a preventive measure during vaginal hysterectomy. The technique entails obliteration of the posterior cul-de-sac by continuous sutures from the uterosacral ligament of one side to that on the other side. It is important to identify the highest point of the sac so as to ensure its complete obliteration. The uterosacral ligaments are then approximated in the midline and fixed to the vaginal vault. It maintains vaginal length, as well as the horizontal direction of its upper part, which ensures its closure under pressure. A prophylactic sacrospinous fixation is unnecessary, unless there is marked uterovaginal prolapse such that the uterosacrals are too weak to provide any support.
A modified culdoplasty can be performed during abdominal hysterectomy described by “Moschowitz” and “Halban” by obliterating cul-de-sac by multiple purse-string or anterioposterior sutures respectively. This entails fixing the uterosacrals and cardinal ligaments to the vaginal vault, obliterating the posterior cul-de-sac and plicating both uterosacral ligaments.
It is important that the uterosacrals are identified prior to dividing them from the uterus, as they become difficult to discern after that. Whilst this can be done by suturing, it is probably better to clamp them separately close to the uterus; a step that also helps locating the posterior fornix.2
Management Options
Principles of management are:
It is extremely important to determine preoperatively whether lower urinary tract dysfunction, sexual dysfunction and defecatory dysfunction exist. Urinary dysfunction may be masked in patients with advanced pelvic organ prolapse by obstructing or kinking the urethra. Thus, reductive manoeuvres aimed at simulating what surgery will accomplish should be used in the hope of identifying those patients who will require an anti-incontinence procedure in conjunction with their pelvic reconstructive surgery. It is also important to initiate local oestrogen therapy preoperatively in patients who have urogenital atrophy. Operations for post-hysterectomy vaginal vault prolapse.
Type of Surgery | Examples |
|---|---|
Vaginal | • Sacrospinous/iliococcygeous • Uterosacral suspension • Le Fort's operation • Colpocleisis/colpectomy/vaginectomy |
Abdominal | • Moschowitz/Halban procedure • Sacrocolpopexy • Rectus sheath colpopexy |
Abdomino-perineal | • Zacharin's procedure |
Tape | • Posterior intravaginal slingoplasty (IVS) |
Laparoscopic | • Laparoscopic sacrocolpopexy • Laparoscopic uterosacral suspension • Laparoscopic sacrospinous fixation • Laparoscopic paravaginal repair |
Mesh | • Prolift and Apoges |
There is no general consensus on which is the best procedure. The procedure that the surgeon ultimately chooses depends upon factors like:
We believe that it is important for the surgeon to have a variety of operative approaches available for the individual patient as all have their pros and cons. The ultimate goal of pelvic reconstructive surgery should be kept in mind beforehand as:
Pessaries control the prolapse, yet they require regular changing, which might be inconvenient for those leading an active life. They are also reserved for elderly, frail and medically unfit patients.
The vaginal approach to pelvic prolapse has the advantage of decreased operative time, decreased incidence of adhesion formation, and quicker recovery time.
Obliterative procedures including partial Le Fort colpocleisis and colpectomy; can be used in elderly fragile patients who are no longer sexually active and have medical problems.
Similarly, abdomino-perineal operations, such as Zacharin's procedure, are complex and have a lower success rate than sacrocolpopexy. 3Sacrospinous or iliococcygeus fixation, as well as abdominal Sacrocolpopexy are the commonly performed procedures even can be done laparoscopically.
VAGINAL PROCEDURES FOR VAULT SUSPENSION
Enterocoele Repair
Enterocele, which is frequently associated with vault prolapse even misidentified as vault prolapse should be identified. Principle is that enterocoele sac should be separated from posterior vagina opened then excised at the level of its neck and defect is closed with purse-string sutures.
McCall Culdoplasty
McCall described his technique of surgical correction of enterocoele at the time of vaginal hysterectomy as it is the enterocoele which if not identified and managed at the time of first surgery leads to early recurrence of symptoms same as vaginal vault prolapse. He used several non-absorbable sutures to obliterate the enterocoele sac called as “Internal McCall sutures” by approximating both uterosacral ligaments and several bites of posterior peritoneum together.
Delayed absorbable sutures were then inserted through the full thickness of the posterior vagina just lateral to the midline, passed through each uterosacral ligament and back out the posterior vaginal wall on the opposite side of midline for supplementing the initial internal McCall sutures. Additional external sutures may be placed if required by the amount of prolapse. The internal sutures are then tied and the external sutures are tied after the vaginal cuff is closed. This simple procedure obliterates the cul-de-sac, supports the vaginal apex, and lengthens the posterior vaginal wall.
Sacrospinous Ligament Fixation of Vault
The sacrospinous ligament is a cordlike structure that exists within the body of the coccygeus muscle. It attaches medially to the sacrum and coccyx and laterally to the ischial spine. The complex is collectively called the coccygeous-sacrospinous ligament (CSSL) complex. The CSSL is best identified by palpating the ischial spine and tracing the finger like ligamentous structure medially and posteriorly towards the sacrum. Knowledge of pelvic neurovascular anatomy is must for this procedure as sciatic nerve lies superior and lateral to the sacrospinous ligament. Superior to the ligament lies the inferior gluteal vessels and the hypogastric venous plexus. The pudendal nerve and vessels pass directly posterior to the ischial spine. In this surgery apex of the vaginal vault or the most dependent part of the prolapse is attached to the right sacrospinous ligament, two fingers medial to the ischial spine, using aneurysm needle avoiding injury to nearby structures.
Good quality of tissue is required for the success of surgery and this can be tested as—the surgeon should be able to gently move the patient with traction of the sutures passed through sacrospinous ligament. Obtaining adequate exposure can be difficult in few cases, and vascular complications, when encountered, may be life-threatening. In authors view a prophylactic sacrospinous fixation is unnecessary, unless there is marked uterovaginal prolapse or the uterosacrals are too weak to provide any support.
Iliococcygeus Fascia Suspension
In this surgery vaginal cuff suspension and posterior colporrhaphy are approached by excising a diamond-shaped section of tissue from the perineum and introitus. The vaginal epithelium is then freed from the 4rectum and rectovaginal fibromuscular vaginal wall, and the dissection is carried laterally to the levators and cephalad to the cuff. The iliococcygeus muscle is identified lateral to the rectum and anterior to the ischial spine. The surgeon then uses the nondominant hand to press the rectum down and medially. A suture is placed just anterior to the ischial spine. Both ends of the suture are then passed through the ipsilateral vaginal apex. The same procedure is repeated on the patient's opposite side. If delayed absorbable suture is used, it should be passed through the full thickness of the vagina. If nonabsorbable suture is used, a pulley stitch similar to that described for sacrospinous fixation should be used. The sutures are then held to be tied after posterior colporrhaphy is finished.
Complications
ABDOMINAL PROCEDURES TO SUSPEND THE VAGINA
For Enterocoele
Transabdominally two procedures of enterocoele repair or prophylaxis has been described “Moschowitz” and “Halban culdoplasty”.
When the posterior cul-de-sac is found to be deep, enterocoele was prevented by sewing the posterior cul-de-sac closed with either sequential, concentric purse-string sutures placed from the caudal posterior cul-de-sac to the level of the uterosacral ligaments, incorporating peritoneum over the sacrum (Moschowitz procedure), if necessary, or by closing the cul-de-sac by sewing the posterior vaginal wall from its most caudal to most cephalad position to the rectum back to front in parallel rows (Halban culdoplasty).5
Abdominal Colpopexy
For abdominal suspension of vault with the slings we have two major options, first is anterior suspension to the rectus sheath which forms a dynamic suspension (ventro-colpopexy or Ventro-suspension). Ventro-suspension almost similar to the modified Gilliams operation. Another is posterior suspension with the sacral promontory (Sacral-colpopexy). Sacral colpopexy is a widely accepted transabdominal procedure that suspends the vaginal vault to the anterior longitudinal ligament of the spine at the level of the first sacral vertebra using natural or synthetic grafts. Sacrocolpopexy is a better choice because of its ability to maintain normal vaginal anatomy, length, direction and its durability. Long-term success rates range near 90%. Most surgeons use sacral colpopexy as their primary surgery for all cases of post-hysterectomy vault prolapse.
LAPAROSCOPIC APPROACH TO VAGINAL SUSPENSION
The techniques and concepts described abdominally can also be approached via laparoscopy. The laparoscopic approach to these procedures requires patience, attention to detail, and the realization that there is a steep learning curve. It is our belief that the operation and subsequent outcomes should not be compromised for the purpose of having achieved the operation by this approach. Therefore, the surgical measures taken to achieve the underlying concepts should not be significantly altered or changed.
OBLITERATIVE PROCEDURES
Le Fort Partial Colpocleisis
At times, a patient may be sufficiently bothered by uterovaginal or vault prolapse but they are poor candidates for major reconstructive surgery because of their overall medical condition. An obliterative procedure may then be a good approach for these women. A Le Fort procedure is an option even if the patient has her uterus and is no longer sexually active.
It is not frequently opted as:
The vaginal mucosa is injected with 0.025% Marcaine with 1:200,000 epinephrine just below the epithelium. A Foley catheter with a 30-cc balloon is placed in the bladder for identification of the bladder neck. Mark out the areas that are to be denuded both anteriorly and posteriorly. The area should extend 2 cm proximal to the tip of the cervix to 4–5 cm below the external meatus. A mirror image on the posterior aspect of the cervix should also be marked out and removed by sharp dissection.
The surgeon should leave the maximum amount of fibromuscular vaginal wall behind on the bladder and rectum. Heamostasis is an absolute must.
The cut edges of the anterior and posterior vaginal wall are sewn together with interrupted delayed absorbable sutures. The uterus and vaginal apex are gradually turned inward. After the vagina has been inverted, the superior and inferior margins of the rectangle can be sutured.
Colpectomy and Colpocleisis
For patients with post-hysterectomy vault prolapse who do not desire coital function and for whom operative time is to be kept at a very minimum, a colpectomy and colpocleisis can be done to treat the prolapse. To perform this operation, the vaginal mucosa is completely excised from the underlying endopelvic fibromuscular vaginal wall. A series of purse-string sutures are used to invert the prolapse and endopelvic fibromuscular vaginal wall. Once the prolapse is reduced, a posterior colpoperineorrhaphy and levatorplasty is done.