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Choosing the best technique for vaginal vault prolapse

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Follow with any anti-incontinence and paravaginal support procedures as well as posterior colporrhaphy as needed.14,15

Major complications include hemorrhage, usually involving periosteal perforators along the sacrum. Graft erosion may affect up to 5% to 7% of sacral colpopexies.

FIGURE 6 Mesh bridge aids vault suspension

Abdominal sacrocolpopexy with a mesh bridge from the vaginal apex to the sacral promontory. Reprinted with permission of The Cleveland Clinic Foundation.

Uterosacral ligament suspension

In this procedure, which can be performed open or laparoscopically, the remnants of the uterosacral ligaments suspend the vaginal apex. The laparoscopic procedure is simple, especially if the uterus is in place.

Technique. Identify the course of the ureters in relation to the ligaments, and use nonabsorbable sutures to incorporate both of the uterosacral ligaments, peritoneum, and the vaginal apex—including the pubocervical and rectovaginal fascia (FIGURE 7).

Place multiple sutures (include the posterior vaginal wall) to obliterate the cul-de-sac and prevent enterocele development.

Success rates. Long-term data are minimal, but outcomes should be similar to the vaginal-approach culdoplasty.

FIGURE 7 Suspension from uterosacral ligaments

Laparoscopic uterosacral ligament suspension incorporating both uterosacral ligaments and cervix or vaginal cuff.

Reprinted with permission of The Cleveland Clinic Foundation.

Obliterative procedures

LeForte colpocleisis or colpectomy/vaginectomy are the simplest treatments for advanced prolapse in elderly women who are not—and will not be—sexually active.16

We prefer the LeForte colpocleisis, in which rectangular segments of the anterior and posterior vaginal walls are denuded of their epithelium, followed by approximation of the rectangles to one another.

Success rates exceed 95%, and safety is maintained if spinal anesthesia is used in conjunction with a high perineoplasty.

Dr. Biller reports no relevant financial relationships. Dr. Davila reports research support from AMS and Tyco/US Surgical. He also serves as a consultant to AMS, and as a speaker for AMS and Tyco/US Surgical.

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