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THE JOURNAL OF FEMALE
URINARY INCONTINENCE


Surgical Techinique
 
 
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Laparoscopic sacrocolpopexy for the treatment Vaginal Vault Prolapse

Paulo R. Kawano, Oscar E. H. Fugita, Hamilto A. Yamamoto,
Aparecido D. Agostinho, Rodrigo Guerra, João L. Amaro.

Urology Department - Botucatu Medical School
São Paulo State University - UNESP

Pelvic organ prolapse affects about 50% of parous women over 50 years of age, with a lifetime prevalence risk of 30–50%1.  Risk factors include prior genital prolapse, multiparity, obesity and post hysterectomy patients2.
Traditionally, prolapse is treated surgically but most procedures, such as vaginal hysterectomy, are associated with recurrent prolapse such that up to a third of patients require further surgery1,3. It can occur after abdominal or vaginal hysterectomy in as many as 2–45% of patients4.
Vaginal vault prolapse is a defect in the condensation of endopelvic fascia in the area of the vaginal apex, also referred to as the cardinal-uterosacral complex4 or DeLancey’s level one support5. The etiology of pelvic organ prolapse and vaginal vault prolapse is considered to be multifactorial, but an increased rate of vaginal vault prolapse has been described when abdominal or vaginal hysterectomy has been performed for some reason6. In this case, the prolapse results secondary to weakness or detachment of the sacrouterine–cardinal ligament complex (SULC) from the vaginal cuff.
It commonly presents with other vaginal defects such as cystocele, complex enterocele, and rectocele that should be addressed at the same time7.
Sacrocolpopexy with mesh interposition is one of the most effective surgical procedures for treating pelvic organ prolapse, especially in women who wish to remain sexually active.  From a tactical point of view sacrocolpopexy is aimed at reconstituting an adequate, long-lasting system of support and suspension of the uterus and/or vagina by replacing the weakened and/or detached native fascial tissue with a synthetic non-absorbable prosthesis6. This intervention was described originally by Ameline and Huguier in 1957 whereas the first paper reported in literature concerning the use and results of laparoscopic sacrocolpopexy was that of Nezhat et al. in 19948.
Laparoscopic sacrocolpopexy offers a minimally invasive treatment for this pathology and the choice of the laparoscopic approach to sacrocolpopexy is justified to reduce morbidity, hospitalization and recovery time, along with an optimum cosmetic appearance9
In this video we present the laparoscopic technique step by step to treatment of vaginal prolapse. After laparoscopic access, an incision was made in the peritoneum to dissect the anterior vaginal wall and the promontory. The polypropylene mesh is inserted in the abdominal cavity and the suture is started between the anterior vaginal wall and one edge of this mesh.  The other edge is attached into promontory enough to reduce the vaginal vault polypropylene but without tension to avoid erosion. Finally, it is important to incise the posterior peritoneum to create a space to bury the polypropylene mesh under this peritoneum to avoid intestinal injury.
In conclusion, laparoscopic sacrocolpopexy is a safe and feasible surgical option to treatment of vaginal vault prolapses.

 
 
 
References
 
  1. Elneil S, Cutner AS, Remy M, Leather AT, Toozs-Hobson P, Wise B: bdominal sacrocolpopexy for vault prolapse without burial of mesh: a case series. BJOG 2005; 112(4):486-9.
  2. Jim Ross, Mark Preston: Laparoscopic sacrocolpopexy for severe vaginal vault prolapse: five year outcome. J Min Inv Gynecol 2005; 12:221-6.
  3. Olsen AL, Smith VJ, Bergstrom JO, Colling JC, Clark AL. Epidemiology of surgically managed pelvic organ prolapse and urinary incontinence. Obstet Gynecol 1997; 89: 501–6.
  4. Flynn BJ, Webster GD. Surgical management of the apical vaginal defect. Curr Opin Urol 2002; 12:353–58.
  5. DeLancey JO. Anatomic aspects of vaginal eversion after hysterectomy. Am J Obstet Gynecol 1992; 166:1717–28.
  6. Nygaard IE, McCreery R, Brubaker L, Connolly A, Cundiff G, Weber AM, et al. Abdominal Sacrocolpopexy: A Comprehensive Review. Obstet Gynecol 2004; 104(4):805-23.
  7. Mourtzinos A, Raz S. Repair of vaginal vault prolapse and pelvic floor relaxation using polypropylene mesh. Curr Opin Obstet Gynecol 2006; 18(5):555-59.
  8. Nezhat CH, Nezhat F, Nezhat C. Laparoscopic sacral colpopexy for vaginal vault prolapse. Obstet Gynecol 1994; 84:885–88.
  9. Wattiez A, Mashiach R, Donoso M. Laparoscopic repair of vaginal vault prolapse. Curr Opin Obstet Gynecol 2003; 15(4):315-19.