Management of Vault prolapse

Based on RCOG guide linesDr.V.Ravimohan

www.mrcogexam.net

Definition

post-hysterectomy vaginal prolapse

descent of the vaginal cuff scar below a point that is 2 cm less than the total vaginal length

above the plane of the hymen International Continence Society International Continence Society

Prevention

• McCall culdoplasty at the time of vaginal hysterectomy is a recommended measure to prevent enterocele formation- Grade A

• What is McCall culdoplasty?approximating the uterosacral ligaments using continuous suturesto obliterate the peritoneum of the posterior cul-de-sac as high as possible

Prevention

• Suturing the cardinal and uterosacral ligaments to the vaginal cuff at the time of hysterectomy is a recommended measure to avoid vault prolapse—Grade B

• Sacrospinous fixation at the time of vaginal hysterectomy is recommended when the vault descends to the introitus during closure- Grade B

Assessment

• Assessment of the woman should be comprehensive and objective

addressing quality of life looking for all pelvic floor defects should be based on standard tools

What is POPQ?

• Pelvic organ prolapse quantification• Image is on http://tinyurl.com/5xnjo9

POPQ

• Six sites • reference to the plane of the hymen • measured in centimeters – above or proximal to the hymen (negative

number) – below or distal to the hymen (positive number) • with the plane of the hymen defined as zero.

Point A

• The anterior and posterior points A (Aa, Ap) are located on the midline vaginal wall 3 cm proximal to the hymen (range ±3 cm).

Point B

• The anterior and posterior points B (Ba, Bp) represent the maximum extent of prolapse of the anterior and posterior vaginal wall (range -3 cm to total vaginal length [tvl]).

Point C &D

• Point C represents the position of the cervix or vaginal cuff, and point D, the posterior fornix.

• The genital hiatus (gh) is measured from the external urethral meatus to the posterior midline hymen• The perineal body (pb) is measured from the posterior

midline hymen to the midanal opening.

occult stress incontinence

• Assessment – a full bladder – after reducing theprolapse with a pessary or

sponge holder• not currently validated by evidence • is not a substitute for adequate patient counselling

about this complication. The role of prophylactic surgery for occult stress

incontinence is unclear

Indirect recurrence

• post-hysterectomy vaginal vault prolapse may be associated anterior or posterior vaginal wall prolapse

• Failure to address such defects at the same time will lead to women presenting with recurrent prolapse from those defects left without support (indirect recurrence).

• performing repair of all defects at the same time Vs repairing such defects in a separate setting at a later stage no studies

Conservative management

• The role of conservative measures for post-hysterectomy vaginal vault prolapse is unclear. Grade C

– Pelivic floor exercise-no evidence– Pesarry(ring/shelf)-change every 6–8 months

» Interference with sexual intercourse» Ring pessaries tend to fail in women with deficient

perineum» Local estrogen can be used to improve atrophic changes

Surgical procedures

• Anterior and posterior repair along with obliteration of the enterocele sac are inadequate for posthysterectomy vaginal vault prolapse.-Grade C

-does not support the vaginal vault -risks vaginal narrowing andshortening, and thus

dyspareunia, especially when posterior repair is carried out

Surgical procedures

• Abdominal sacrocolpopexy Vs sacrospinous fixation– sacrospinous fixation may have a higher failure

rate but has lower postoperative morbidity

Sacrospinous fixation

• Image is on http://tinyurl.com/4s8yu9

Sacrocolpopexy

• Image is on http://tinyurl.com/4jkzro

Sacroxcolpopexy Sacrospinous fixation

significantly longer operating time operating time and hospital staywere shorter

slower return to normal activity

highercost

posterior vaginal wall prolapse following abdominal sacrocolpopexy.

combined rate of apical and anteriorvaginal wall prolapse was significantly higher

a lower rate of recurrence

longer catheter use, more urinary tract infection and more

urinary incontinence.

more intraoperative blood loss

moresexual dysfunction

Cochrane review

Sacroxcolpopexy Sacrospinous fixation

less dyspareunia Shorter operation time

a lower rate of recurrence Quicker return to normal activitiescheaper

continence surgery be performed at the time of sacrocolpopexy?

• It is not clear whether prophylactic continence surgery is beneficial in women who are urodynamically

• continent and it should not be routinely recommended.

unilateral or bilateral sacrospinous fixation?

• There is no evidence to recommend bilateral or unilateral sacrospinous fixation.

iliococcygeus fixation

• Iliococcygeus fixation does not reduce the incidence of anterior vaginal wall prolapse associated with vaginal sacrospinous fixation and should not be routinely recommended.

iliococcygeus fixation….

• It involves bilateral fixation of the vaginal vault to the iliococcygeus fascia

• Iliococcygeus fixation is done – To reduce the exaggerated retroversion of the

vagina, and thus the subsequent increase in anterior vaginal wall prolapse

– to avoid the risk of injury to pudendal and sacral nerves and vessels associated with sacrospinous fixation

vaginal uterosacral ligament suspension

• Caution is advised with vaginal uterosacral ligament suspension– effective– risk of ureteric injury(10.9%)

laparoscopic procedures

• Laparoscopic sacrocolpopexy appears to be as effective as open sacrocolpopexy (B)

• The ureters are particularly at risk during laparoscopic uterosacral ligament suspension.(B)

• There is insufficient evidence to judge the value of other laparoscopic techniques.(C)

Sacrocolpopexy-Open Vs Laparoscopy

open laparoscopy

an enhanced view of the pelvis, which facilitates a moreanatomical repair

less scarring

reduced postoperative morbidity

shorter stay

requires skill, training and longer operating time, although operating time shortens with greater experience.

Colpocleisis

• closure of the vagina• is a safe and effective procedure • Success rates of 97% and above• considered for those women – Frail women– can also be performed under local anaesthesia,

which suits frail women– who do not wish to retain sexual function.

Sling procedures

• should not be used without adequate patient counselling and special provisions for audit and research.(B)

• short operating time • can be done in those considered unfit for

major surgery

total mesh reconstruction

• There is insufficient evidence to judge the safety and effectiveness of total mesh reconstruction

Vault suspension to the anterior abdominal wall

• Vault suspension to the anterior abdominal wall can be a simple measure. However, there are not enough studies assessing this technique to judge its value.(B)

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