Medical comorbidities. Use a vaginal or obliterative procedure under regional anesthesia if the patient is medically delicate or elderly.
Tissue quality usually improves with preoperative local estrogen, but large fascial defects adjacent to the cuff or perineum may require graft reinforcement.
Colorectal dysfunction frequently coexists in women with vault prolapse. Thus, a woman with extensive rectal prolapse should probably undergo concomitant Ripstein rectopexy and sacrocolpopexy, or a perineal proctosigmoidectomy and vaginal-approach vault suspension.
Careful and consistent preparation
Surgical success depends in great part on developing a clear understanding of anatomic defects and urodynamic dysfunction during the preoperative evaluation, to determine the most appropriate procedures.
Tissue preparation with low-dose estrogen
cream (1 g, two nights per week) is crucial for most postmenopausal women.
Obtain medical clearance, and optimize
perioperative safety by using spinal anesthesia, antiembolism stockings, and prophylactic intravenous antibiotics.
Retain vaginal packing at least 24 hours to prevent stress on sutures due to coughing or vomiting.
Advise patients in advance that, for 6 weeks after surgery, they must avoid overexertion and lifting more than 5 lb.
After 6 weeks, we restart estrogen cream and prescribe routine, daily Kegel exercise.
This involves plicating the uterosacral ligaments in the midline while reefing the peritoneum in the cul-de-sac, resulting in posterior culdoplasty. It usually is performed at the time of vaginal hysterectomy using nonabsorbable sutures to incorporate both uterosacral ligaments, intervening cul-desac peritoneum, and full-thickness apical vaginal mucosa. Multiple sutures may be required if prolapse is extensive.
Generally, we try to place our uppermost suture on the uterosacral ligaments at a distance from the cuff equal to the amount of vault prolapse (POP-Q: TVL minus point D [point C if uterus is absent]).
Be careful not to injure or kink the ureters when placing the suture through the uterosacral ligaments, as the ureters lie 1 to 2 cm lateral at the level of the cervix. We recommend cystoscopy with visualization of ureteral patency.
Uterosacral ligament suspension
Excellent anatomic outcomes have been described when the uterosacral ligaments are reattached to the vaginal apex (similar to the McCall technique).6,7 The physiologic nature of this technique makes it very attractive. It involves opening the vaginal wall from anterior to posterior over the apical defect, and identifying the pubocervical fascia, rectovaginal fascia, and uterosacral ligaments.
Technique. Place 1 permanent 1-0 suture and 1 delayed absorbable 1-0 suture in the posteromedial aspect of each uterosacral ligament 1 to 2 cm proximal and medial to each ischial spine. Then place 1 arm of each permanent suture through the pubocervical and rectovaginal fascia, and 1 arm of each delayed absorbable suture through the same tissue, also incorporating the vaginal epithelium. After repairing all additional defects, tie the sutures to suspend the vault.
When prolapse is extensive, redundant peritoneum can hinder identification of the uterosacral ligaments.
Success rates are 87% to 90%, but ureteral injury is a limiting factor, with rates as high as 11%. Therefore, cystoscopy is essential. Long-term data are lacking.
This safe and simple procedure involves elevating the vaginal apex to the iliococcygeus muscles along the lateral pelvic sidewall. This can be done without a vaginal incision by placing a monofilament permanent suture (polypropylene) full thickness through the vaginal wall into the muscle uni-or bilaterally.
Candidates should not be sexually active, as there will be a suture knot in the vagina. The procedure may be useful in elderly patients for whom complete restoration of vaginal anatomy is not a goal. It also can be performed as a salvage operation in women with suboptimal vault support and good distal vaginal anatomy. In addition, it can be performed following posterior vaginal wall dissection with entry into the pararectal space.
Technique. Place the sutures into the fascia overlying the iliococcygeus muscle, anterior to the ischial spine and inferior to the arcus tendineus fascia pelvis, and incorporate the pubocervical fascia anteriorly and the rectovaginal fascia posteriorly.
Success rates. Shull reported a 95% cure rate of the apical compartment among 42 women, at 6 weeks to 5 years.8 However, the prolapse at other sites was 14%. A randomized trial comparing this procedure to sacrospinous fixation demonstrated similar satisfactory outcomes.9
Sacrospinous ligament fixation
Probably the most commonly performed apical suspension procedure from the vaginal approach is fixation of the apex to the sacrospinous ligaments. Although many describe unilateral fixation, we advocate bilateral fixation to avoid lateral deviation of the vaginal axis (FIGURE 5).
Technique. After entering the pararectal space through a posterior vaginal wall dissection, identify the sacrospinous ligaments and place 2 nonabsorbable sutures through each ligament, rather than around it, as the pudendal vessels pass behind it.