FORT LAUDERDALE, FLA. — Uterosacral vaginal vault suspension is the treatment of choice for patients with apical prolapse and a low risk of recurrence, Matthew Barber, M.D., said at a symposium on pelvic floor disorders that was sponsored by the Cleveland Clinic Florida.
“This is my vaginal apex operation of choice—I believe in it,” said Dr. Barber of the clinic.
He described the operation as an anatomic procedure, as opposed to a compensatory procedure, which is more suitable for those with a higher risk of recurrence.
Age is probably the most important factor in patient selection; those aged over 60 years tend to have the lowest risk of recurrence.
Other selection criteria include a good pelvic floor and endopelvic fascia and a good caliber vagina.
Patients who are younger and those who have attenuated endopelvic fascia, neuromuscular disease, or compromised vaginal caliber are better candidates for a compensatory repair such as abdominal sacral colpopexy, Dr. Barber said.
The proximal uterosacral suspension procedure that he prefers involves provision of apical support to the anterior and posterior vaginal walls. It is associated with less recurrence than nonanatomic repairs, provides good vaginal depth of 7-10 cm, and can be performed vaginally, abdominally, or laparoscopically.
The goals of the procedure include reapproximation of the superior edge of the anterior fascia with the superior edge of the posterior fascia, and suspension of these to a strong fixed structure—in this case the proximal uterosacral ligament.
In one series involving 46 patients with an average 40-month follow-up, Dr. Barber achieved a cure rate of 90%. At a 15.5-month follow-up preoperative symptoms had improved significantly from baseline: prolapse (100% of patients at baseline to 10% at follow-up), voiding dysfunction (59% to 7%), need for splint to void (17% to 0%), and constipation (26% to 12%).
The percentage of patients with stress urinary incontinence increased during the follow-up from 5% to 15%—but most of these patients were successfully treated postoperatively, Dr. Barber noted.
A major concern with uterosacral vaginal vault suspension is the proximity of the ureters to the uterosacral ligaments. Keep in mind that the higher you go up on the ligament, the stronger it is and the farther away from the ureters you will be, Dr. Barber said.
In another series of 700 consecutive patients who underwent vaginal surgeries for apical prolapse over the past 3 years at the Cleveland Clinic, 37 had no spill—suggesting ureteral obstruction—on cystoscopy with intravenous indigo carmine. Three of the 37 were found to have renal disease, and 2 additional patients had spill initially, but had delayed injury.
The overall intraoperative obstruction rate was 5.1%.
Uterosacral vaginal vault suspension was associated with a higher rate of ureteral obstruction (5.9%) than other procedures used in the series, including proximal McCall's culdoplasty (4.4%), distal McCall's culdoplasty (0.5%), and anterior repair (0.4%), Dr. Barber said at the meeting.
In 83% of the ureteral obstruction cases, the obstruction was relieved by intraoperative suture removal. The true ureteral injury rate was 0.9%, he said.
Due to the risk for ureteral injury with uterosacral vaginal vault suspension, intraoperative cystoscopy is a must.
“Cystoscopy is not perfect, but it is beneficial,” he said, referring to the two cases of delayed diagnosis of obstruction in the 700-patient series.
When no flow is seen on cystoscopy, wait 10 minutes.
“At 8 or 9 minutes I start to worry,” he said, noting that at this time he has a nurse recheck the patient's chart for history of urologic surgery such as nephrectomy.
“My partners and I have both been burned by this before,” he added.
Next, check to be sure indigo carmine dye was actually used. Then consider furosemide (Lasix), and if this doesn't work, consider stent placement or fluoroscopy.
Still no flow? Then begin removing apical suspension sutures sequentially starting with those most distal, followed—if this doesn't work—by removal of the upper anterior repair sutures, he advised.
Reconsider stenting or fluoroscopy at this point if the obstruction remains, and when all else fails address the obstruction via laparotomy and reimplant, he said, noting that it reached this point in only 1 of the 700 patients.