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Choosing the best technique for vaginal vault prolapse

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Place the first suture 2 cm medial to the ischial spine, and the second suture 1 cm medial to the first. Then pass each suture through the underside of the vaginal apex—in the midline if the procedure is done unilaterally and under each apex if it is bilateral. When tied, the sutures suspend the vaginal apex by approximating it to the ligament, ideally without a suture bridge.

We use CV-2 GoreTex (WL Gore and Associates, Flagstaff, Ariz) sutures passed through the ligaments with a Miya hook, and we reinforce the underside of the vaginal apex with a rectangular piece of Prolene mesh (Ethicon, Somerville, NJ) if the mucosa is thinned.

Success rates are 70% to 97%.10,11 A significant concern is the nonanatomic posterior axial deflection of the vagina. Many investigators have reported an anterior compartment prolapse rate of up to 20% after fixation, likely secondary to increased force on the anterior compartment with increases in abdominal pressure. This is especially likely if a concomitant anti-incontinence procedure is performed.

Other complications include hemorrhage, vaginal shortening, sexual dysfunction, and buttock pain.

FIGURE 5 Bilateral sacrospinous fixation avoids lateral vaginal deviation

With bilateral fixation of the vault to the sacrospinous ligaments, the vaginal axis is more horizontal. It may be reinforced to enhance longevity. Reprinted with permission of The Cleveland Clinic Foundation.

Posterior IVS vault suspension

This novel, minimally invasive technique uses the posterior intravaginal slingplasty (Posterior IVS; Tyco/US Surgical, Norwalk, Conn). First described as infracoccygeal sacropexy, it was introduced as an outpatient procedure in Australia. Concerns about postoperative vaginal length and risk of rectal injury led to poor acceptance. The procedure was modified by a few US surgeons to enhance safety and vaginal length.

Technique. Enter the pararectal space in a fashion similar to that of sacrospinous fixation. A specially designed tunneler device delivers a multifilament polypropylene tape through bilateral perianal incisions. Secure the tape to the vaginal apex, and adjust it to provide vault support.

We modified this procedure to create neoligaments analogous to cardinal ligaments, by directing the tunneler through the iliococcygeus muscles in close proximity to the ischial spines and arcus tendineus. The resultant vaginal axis is physiologic, and vaginal length is normalized.

By combining this technique with perineoplasty and attaching the rectovaginal and pubocervical fascia to the tape, all levels of pelvic support are repaired once the vault is positioned by pulling on the perianal tape ends.

The new Apogee technique (American Medical Systems, Minnetonka, Minn) uses a similar perianal approach with monofilament polypropylene mesh.

Success rates. Preliminary success rates are 88% to 100%, and complication rates are minimal.12 Vaginal length averages 7 to 8 cm. Most initially reported complications involved graft erosion or rejection; shifting from nylon to polypropylene graft material reduced this problem.

Abdominal procedures

Sacral colpopexy

Considered the gold standard, the sacral colpopexy vaginal vault suspension technique has a consistent cure rate above 90%.13 It may be the ideal procedure for pelvic floor muscle weakness and/or attenuated fascia with multiple defects, for women for whom optimal sexual function is critical, and for those with other indications for abdominal surgery.

A graft is placed between the vagina and the sacral promontory to restore vaginal support (FIGURE 6). Materials have included autologous and synthetic materials. We use polypropylene mesh because of its high tensile strength, biocompatibility, low infection rate, and low incidence of erosion. Biologic grafts such as cadaveric fascia lata have increased failure rates due to graft breakdown.

The resultant vaginal axis is the most physiologic of all vault reconstructive procedures. This procedure appears to have the best longevity of all vault suspension procedures. It can be performed laparo-scopically at selected centers.

Technique. First, access the presacral space overlying the sacral promontory, taking care not to disturb the presacral and middle sacral vessels. We perform this step first to avoid potential periosteal tissue contamination. We routinely use 2 bone anchors to secure the mesh—making sterility imperative. Bone anchors reduce periosteal tissue trauma and decrease risk of potentially life-threatening hemorrhage.

Mobilize the bladder from the anterior vaginal apex. Repair any apical fascial defects, restoring continuity of the pubocervical and rectovaginal fascia, which often detach from the apex. Using 2-0 Prolene sutures, suture the y-shaped graft to both the anterior and posterior vaginal walls, incorporating all fascial edges.

Culdoplasty follows; this obliterates the cul-de-sac to prevent subsequent enterocele formation.

Next, place the graft in a tension-free manner, creating a suspensory bridge from the apex to the sacral promontory. Irrigate copiously. Close the peritoneum over the graft along its entire length.

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