Abdominal techniques for surgical management of vaginal vault prolapse

Plan on occult incontinence

Total vaginal vault prolapse is commonly associated with some degree of urethral kinking, with subsequent outflow tract obstruction. As a result, most patients with complete vault prolapse do not complain of incontinence at the initial presentation. However, once the anatomic axis of the vagina is restored and the bladder is replaced within the pelvis with subsequent straightening of the urethra, occult incontinence often is uncovered. Although the patient may have a wonderful anatomic repair of severe vault prolapse at the completion of the surgical procedure, she will not be satisfied if she suddenly finds herself floridly incontinent.

Consider formal multichannel cystometrics prior to surgery in all women undergoing repair of total vault prolapse. If genuine stress urinary incontinence is present when the prolapse is reduced, an anti-incontinence procedure can be scheduled at the same time as the surgical repair. A Burch procedure can be performed for type IIA or IIB genuine stress incontinence, or a pubovaginal sling procedure can be performed for type III stress incontinence.

Posterior colporrhaphy/perineorrhaphy

These procedures are now performed to treat the remaining rectocele and perineal defect, when present.

Vaginal vs abdominal route

Somewhat surprisingly, the abdominal route appears to produce better long-term results. In a prospective, randomized controlled trial comparing both routes for the repair of total vault prolapse, Benson et al³ found that, after 5 years of follow-up, women managed vaginally had a 6-fold increased incidence of recurrent vault prolapse, a 3-fold increased incidence of recurrent cystocele, and twice the reoperation rate, compared with women whose initial repair was abdominal.

In the study, 48 women with total vault prolapse underwent vaginal bilateral sacrospinous fixation and paravaginal defect repair, and 40 underwent abdominal sacral colpopexy and paravaginal defect repair. Although the vaginal approach was associated with a shorter operative time and decreased hospital stay in the short term, it necessitated longer postoperative catheter use and was associated with more urinary tract infections and postoperative incontinence and a higher overall failure rate.

Sze and colleagues⁴ addressed a similar question in retrospective fashion, reviewing the medical records of 117 women surgically treated for total vault prolapse. Sixty-one women underwent vaginal sacrospinous ligament fixation and Raz urethropexy, while 56 underwent abdominal sacral colpopexy and Burch urethropexy. After a mean follow-up of 24 months, 33% of the women managed vaginally developed recurrent pelvic organ prolapse, compared with only 19% of the women managed abdominally. In addition, 26% of the women managed vaginally had recurrent urinary incontinence, compared with only 13% of the women managed abdominally

A separate randomized, prospective study by Maher et al⁵ compared abdominal sacral colpopexy (n=47) and vaginal sacrospinous ligament fixation (n=48) for stage II to IV vault prolapse. After a mean follow-up of 2 years, subjective and objective success rates did not differ significantly between the 2 routes.

Why is the abdominal route more durable?

Any number of reasons may apply:

• The traditional surgical procedure for vaginal management of total vault prolapse—sacrospinous ligament fixation—distorts the axis of the vagina.
• Native tissues are not as strong as synthetic materials. In postmenopausal women, a repair in which the thin, atrophic vaginal apex is secured to the sacrospinous ligament will not have the same durability as a repair involving mesh.
• In vaginal paravaginal repair, the extensive periurethral dissection required can damage fine branches of the pudendal nerve that innervate and control the urethral sphincter. Such extensive dissection is not required for paravaginal repair from the abdominal approach.
• In the vaginal approach, it can be difficult to gain adequate exposure high in the retroperitoneum to reattach the endopelvic fascia of the vaginal apex to the arcus at its origin just distal to the ischial spine.

The long view

The surgical options described in this article have varying degrees of risk and benefit. Multicenter, prospective surgical trials are needed to clarify these risks and benefits and provide physicians and their patients with reliable information. Ultimately, pursuit of a surgical “cure” will be supplanted by sustainable forms of disease prevention. Until then, decisions about prolapse surgery are best left to the judgment of the surgeon and the desires of his or her patient.

The authors report no financial relationships relevant to this article.