barrest.gif (471 bytes)

Abdominal Approach.

The most commonly used abdominal approach to vaginal vault prolapse involves a sacro-colpopexy. This procedure utilizes a mesh bridge to attach the vaginal apex to the sacral promontory. The ideal candidate for an abdominal sacro-colpopexy is a reproductive age woman who is sexually active and can safely undergo an abdominal procedure. Although the success rate of a sacro-colpopexy exceeds 90 percent, the actual surgical procedure can be rather challenging and should only be performed by those experienced with the technique and its potential complications. Most remarkably, bleeding from the pre-sacral plexus can result in life threatening hemorrhage. If the suspending mesh is sutured to the sacral promontory, care must be taken in placement of the sutures so as to not to tear small blood vessels. I believe a significant improvement in this technique involves utilization of bone anchors for attachment of the sutures to the sacral promontory. The area of trauma to the presacral connective tissue is small, especially when pressure-driven bone anchors are used as compared to screw-in anchors are used. Thus, the risk of bleeding is minimized and a firm attachment to the sacral promontory is achieved. Typically, 2 to 4 bone anchors are required to achieve this purpose. If bleeding does occur, pressure should be applied on the bleeding area and time given to allow for coagulation. Although uni- or bipolar cautery can be utilized, further bleeding can persist. Sterile tacs can also be used. Alternatively, if a blood vessel is visible it can be ligated individually. Other techniques involve cauterizing a piece of rectus muscle over the bleeding site to result in coagulation of the blood vessel. In our series of over 50 sacro-colpopexies utilizing bone anchors, we have not encountered problematic bleeding.

Attachment of the suspension mesh to the vaginal wall requires three to four rows of permanent sutures. It is important to attach the mesh posteriorly as well as anteriorly along the vaginal apex. An enterocele is usually present and should be ligated once a mesh is in place. I typically plicate the uterosacral ligaments in the midline in order to achieve obliteration of the enterocele. The mesh is then attached to the bone anchor sutures and laid in a fairly loose fashion as excessive tension can increase a risk of erosion.

Post-operative care should allow for slow resumption of normal activities. Post-operative ileus is not an uncommon occurrence after a sacro-colpopexy. A sacro-colpopexy is can be followed by a a paravaginal repair or retropubic urethropexy such as a Burch colposuspension. Once the vault is suspended, most patients will also require a rectocele repair and/or perineoplasty.

Vaginal Approach.

The vaginal approach to vaginal vault prolapse is the sacrospinous fixation. This involves attachment of the vaginal apex to the mid section of the sacrospinous ligament on either side of the midline. This technique is very attractive due to its vaginal route. The resulting vaginal apex is somewhat more horizontal and thus should not be performed in somebody for whom sexual activity is very important. However, in the elderly, or in a patient who requires a vaginal procedure for urinary incontinence such as a sling procedure, a sacrospinous fixation is the treatment of choice.

The technique involves exposure of the sacrospinous ligament through a posterior vaginal incision and entry into the para-rectal space. Care must be taken to expose the ligament along its entire course. I prefer to perform the procedure bilaterally. This results in a more physiologic support mechanism. The sacrospinous ligaments are thus identified on either side of the midline. In order to enhance the strength of the repair, a small piece of synthetic mesh material can be sutured to the underside of each vaginal apex (Fig. 2) (6). Two permanent sutures, such as CV-2 Gortex suture are then placed through the mesh and the underlying vaginal fascia being careful not to perforate the full thickness of the vaginal wall. The two sutures can then be elevated to their ipsilateral sacrospinous ligament with a Miya hook or Deschamps suture carrier. Other usable instruments include the Capio (Laurus) device. When placing the suture through the sacrospinous ligament care should be taken to avoid placing it in close proximity to the ischial spine. The Sciatic and Pudendal nerves lay in close proximity, as does the Pudendal vasculature. Thus, the suture should be placed along the mid and medial aspect of the ligament. Care must also be taken to not dissect behind the ligament in order to avoid vascular damage. The suture should be placed through the most superior aspect of the ligament, exiting along its anterior aspect. Once the sutures have been placed bilaterally, the upper 1/3 to 1/2 of the vaginal mucosa is closed prior to tying the elevating sutures. If a specific fascial defect is noted, it should be repaired at this time. It is not uncommon to find a superior transverse fascial defect resulting in the presence of an enterocele.

Complications associated with sacrospinous fixations are few. If the surgeon performs this procedure on a regular and frequent basis the dissection can be quite bloodless. Care must be taken to not penetrate the ligament too deeply or too laterally. Additional reconstructive procedures can then be performed, including cystocele and rectocele repairs and suburethral sling procedures. If the vaginal apex is narrow a unilateral procedure can be performed.

Vaginal vault prolapse repair in the advanced elderly woman.

Since vaginal vault prolapse increases in incidence with aging, it is not uncommon to find a delicate elderly woman presenting with symptomatic vaginal vault prolapse. Surgical treatment may carry a significant risk in patients such as this. Thus, simplicity is the key in addressing this type of vaginal vault prolapse. The preferred approach is a vaginal obliterative procedure to eliminate the presence of the vaginal canal. A LaForte colpocleisis entails removing a rectangular piece of vaginal mucosa along the anterior vaginal wall as well as a rectangular piece off the posterior wall and suturing the denuded areas in the midline (Fig. 3). This obliterates the mid portion of the vaginal canal. If the cervix is present two small canals are left for drainage of any secretions. The endometrium must be evaluated pre-operatively in patients who will undergo a colpocleisis leaving the uterus in-situ. The fact that the vaginal canal will be obliterated must be clearly discussed with the patient pre-operatively. This procedure is likely not appropriate for women who may become sexually active due to remarriage or development of new personal relationships. Since the incidence of erectile dysfunction is high in this age population of men, sexual activity is frequently not a significant issue. In order to enhance the success of a colpocleisis, a perineoplasty should be performed at the end of the procedure.
The success rate of a colpocleisis is essentially 100%. Failure factors would include development of a hematoma or infection along the suture line.

Post-operative care.

Healing can be further enhanced by limitation of any exertional activities for six to twelve weeks post-operatively and performance of pelvic floor exercises after healing has been completed at approximately six weeks. Low dose local estrogen cream can be used in order to enhance healing and optimize mucosal integrity.

Conclusions.

Vaginal vault prolapse is a rather commonly occurring type of vaginal "hernia". Although there are non-surgical effective treatments, surgery represents the primary therapeutic and curative option. Various individual characteristics are helpful in selecting the approach for the vaginal vault suspension. Bladder function evaluation should be performed prior to the surgical procedure in order to prevent post-op incontinence.

Both vaginal and abdominal reconstructive surgical procedures carry very high success rates (greater than 90%). The elderly, delicate woman also has simple and safe surgical options available for her. Choice of surgical approach should be based on the procedure best indicated for the individual patient.