Abdominal Techniques for Surgical Management of Vaginal Vault Prolapse

SURGICAL TECHNIQUES

William Irvin, MD Abdominal techniques Associate Professor Division of Gynecologic Oncology for surgical management University of Virginia Health System of vaginal vault prolapse Charlottesville, Va Kathie Hullfish, MD Indications, techniques, and evidence-based rationale Director, Division of Reconstructive Pelvic Surgery and Urogynecology University of Virginia Health System range of clinical conditions can sug- Technique Charlottesville, Va gest an abdominal approach for Identify and tag the remnants of the utero- A vaginal vault prolapse procedures. sacral ligaments at the level of the ischial These include, but are not limited to: spines. Once the ureters are identified and • prior unsuccessful vaginal attempts ® isolated,Dowden address Healththe enterocele Media by obliterat- • obligate need for adnexal access ing the cul-de-sac via Halban’s culdoplasty • markedly foreshortened vagina or abdominal McCall’s culdoplasty. • pelvic bony architecturalCopyright limitationsFor personalOpen the peritoneum use only over the vaginal • high risk for surgical failure (eg, athleti- apex and trim it back to the level of the cism, obesity, chronic obstructive pul- endopelvic fascia of the vaginal wall. After monary disease, congenital connective excising the redundant peritoneum of the tissue disorder) vaginal apex, identify and reapproximate IN THIS ARTICLE • desire for uterine preservation the pubocervical fascia of the anterior In Part 1 (November 2005) of this 2- vaginal wall and the rectovaginal fascia of S Abdominal part article, we reviewed the most widely the posterior vaginal wall using interrupt- sacral colpopexy used and the newest vaginal techniques. ed or running nonabsorbable suture. technique Part 2 focuses on the abdominal approach, Then use nonabsorbable sutures to Page 20 and compares vaginal and abdominal suspend each corner of the prolapsed vagi- approaches. na from its respective ipsilateral utero- S sacral ligament. Why correct all defects at once? Page 22 T High uterosacral ligament suspension T Abdominal sacral colpopexy Surgical technique for this procedure for Abdominal sacral colpopexy was first pop- mild to moderate vaginal vault prolapse ularized by Addison and Timmons in the (stage I or II), using a vaginal approach, 1980s, and is the abdominal standard of was described in Part 1, in the November apical prolapse repair due to its long-term issue of OBG MANAGEMENT. Abdominal durability. repair involves the same concepts; like the Abdominal sacral colpopexy can be vaginal approach, it is applicable only to performed with or without uterine extirpa- the patient with mild to moderate vault tion. When a hysterectomy is performed prolapse. It will be less successful if it is per- concomitantly, some surgeons prefer a formed to address complete vault prolapse. supracervical approach, provided there is

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FIGURE 1 no history of cervical dysplasia, because, Abdominal sacral colpopexy technique theoretically, the cervical stump serves as a firm and substantial point of fixation for the INCISION synthetic mesh that will be used to perform the repair. This in turn may diminish the likelihood of postoperative mesh erosion.

Technique Reflect the sigmoid colon as far as possible into the left lateral pelvis to expose the sacral promontory. If it has not already been done, free all adhesions between the colon and pelvic peritoneum to fully mobilize the colon and permit its maximal A longitudinal incision in the peritoneum overlying the sacral promontory retraction out of the pelvic field prior to is extended 6 cm into the cul-de-sac, opening the retrorectal space. making the peritoneal incision. Also make it a point to identify all MESH ATTACHMENT structures at risk during this portion of the procedure—namely, the common iliac vessels, ureters, and middle sacral artery and vein. The left common iliac vein is medial to the left common iliac artery and is par- ticularly susceptible to injury during this phase of the procedure. Make a longitudinal incision in the peritoneum overlying the sacral promontory and extend it approximately 6 cm from the promontory dorsally into the cul-de-sac, The mesh is attached through the fibromuscular thickness of the opening the retrorectal space (FIGURE 1, anterior vaginal wall, excluding the mucosa, with multiple interrupted TOP). Using a fine tonsil forceps and sutures. Though the diagram suggests the use of 2 separate pieces of mesh (one for the anterior and one for the posterior walls), doubling cautery, very gently dissect the retroareolar a single piece of mesh and “fishmouthing” the end to be attached to filmy tissue overlying the anterior longitu- the vagina will accomplish the same goal. dinal ligament away from S1 in thin layers Reprinted from Addison WA, Cundiff GW, Bump RC, Harris RL. Sacral colpopexy is the until the white periosteum of the anterior preferred treatment for vaginal vault prolapse. J Gynecol Tech. 1996;2:69-74. ©1996, with permission from Elsevier. longitudinal ligament overlying S1 is clear- ly exposed. It now becomes very easy to CLOSING THE INCISION visualize the course of the middle sacral artery and vein. With these vessels under direct visualization, place 2 permanent #0 sutures through the periosteum of S1. Do not attempt to place these sutures deeper in the presacral space than the S1 vertebral body, or life-threatening and uncontrollable bleeding may result. If there is no uterus, insert a probe such as an end-to-end anastomotic sizer or handheld Harrington retractor into the vagina and extend it, elongating and elevat- The 6-cm incision is closed over the top of the mesh, retroperitonealizing the prosthesis. ing the vaginal cylinder. It now becomes much easier to identify the interface

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between the bladder and vagina prior to sacral promontory are threaded through making the peritoneal incision. the apex of the mesh prosthesis at a point If the interface remains indistinct, that will allow the vagina to rest comfort- instill 150 cc of saline into the bladder to ably within the pelvis, without undue ten- delineate its boundaries. Then elevate and sion or traction once the sutures are tied incise the vesicouterine peritoneum overly- into place (FIGURE 1, MIDDLE). ing the junction between the bladder and Trim any excess mesh, and close the 6- vaginal apex; this provides access to the cm longitudinal peritoneal incision previ- vesicocervical space. Dissect the bladder ously created in the cul-de-sac. Close the off the anterior vaginal wall in a caudal incision over the top of the mesh, direction until the pubocervical fascia can retroperitonealizing the mesh prosthesis be identified. Do not dissect away the peri- (FIGURE 1, BOTTOM). toneum over the posterior vaginal wall, but leave it intact.

Reconstructive materials T Paravaginal defect repair Although many different materials have The bladder base is intimately associated been described, none have undergone rig- with the anterior vaginal wall via a trian- orous comparisons. In our institution, we gular sheet of pubocervical fascia attached use soft polypropylene (Surgipro; US to and extending from the arcus tendineus Surgical, Norwalk, Conn). fascia pelvis bilaterally. When the apex of Fold a piece of 5-inch mesh over onto the vagina prolapses through the introitus, itself and suture the layers together to cre- as in total vault prolapse, the base of the ate a double-thickness configuration. Then bladder is torn free from these fascial attach- “fishmouth” the caudal end of this mesh ments in the pelvis and herniates through the prosthesis, producing both an anterior and introitus along with the vaginal apex. By def- posterior leaf. With the obturator still inition, a bilateral paravaginal defect will within the vaginal cylinder stretching the result. Thus, surgical repair of total vaginal FAST TRACK vaginal apex, secure the posterior leaf of vault prolapse almost invariably requires Surgical repair the mesh to the posterior vaginal wall with paravaginal defect repair as well. 3 to 5 nonabsorbable #0 sutures. The goal of paravaginal defect repair is of total vaginal Suture placement. Thread each suture ini- to reattach, bilaterally, the anterolateral vault prolapse tially through the posterior leaf of the vaginal sulcus and its overlying endopelvic almost always mesh, placed deeply through the fibromus- fascia to the pubococcygeus and obturator cular thickness of the posterior vaginal internus muscles and fascia at the level of requires wall, then bring it back out through the the arcus tendineus fascia pelvis. paravaginal defect mesh at the same point. Place the sutures in repair, as well a transverse line 1 to 2 cm apart and 3 to Technique 4 cm distal to the vaginal apex. Enter and gently develop the retropubic Once all sutures have been placed, tie space of Retzius, taking care not to disrupt each of them, thereby securing the posteri- the myriad venous anastomotic networks of or leaf of the mesh to the posterior vaginal the plexus of Santorini, located on and wall. Now perform a “mirror” procedure around the bladder. Bluntly mobilize the to secure the anterior leaf of the mesh pros- bladder bilaterally, exposing the lateral thesis to the anterior vaginal wall. Then retropubic spaces, the pubococcygeus and firmly attach the mesh prosthesis to the obturator internus muscles, and the obtura- vaginal apex using several interrupted, per- tor neurovascular bundles. Within each manent sutures. retropubic space, palpate the ischial spine. At this point, the sutures previously Then visualize the arcus, seen as a white lig- placed through the periosteum of the amentous band, as it courses from the ischial

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kinking, with subsequent outflow tract Why correct all defects at once? obstruction. As a result, most patients with complete vault prolapse do not complain of When a patient has complete vault prolapse, she typically has incontinence at the initial presentation. defects in all 3 levels of pelvic support, and thus may need to However, once the anatomic axis of the undergo several different procedures to correct all anatomic vagina is restored and the bladder is defects and restore function. replaced within the pelvis with subsequent In other words, vaginal vault prolapse rarely presents as an straightening of the urethra, occult inconti- isolated defect. It more commonly occurs in conjunction with a nence often is uncovered. Although the cystocele, rectocele, enterocele, or some combination of these.1 patient may have a wonderful anatomic Richter reported that 72% of patients with vaginal vault pro- repair of severe vault prolapse at the com- lapse had a combination of other pelvic floor defects as well.2 pletion of the surgical procedure, she will If all vaginal support defects are repaired at the time of sacral not be satisfied if she suddenly finds herself colpopexy, recurrent vault prolapse is rare. Failures can be mini- floridly incontinent. mized by suturing the suspensory mesh to the posterior vagina Consider formal multichannel cystometrics and anterior vaginal apex over as extended an area as possible. prior to surgery in all women undergoing Also test the sutures once they are placed within the periosteum repair of total vault prolapse. If genuine of the sacral promontory to ensure they will not pull free. stress urinary incontinence is present when the prolapse is reduced, an anti-incontinence procedure can be scheduled at the spine caudally toward the ipsilateral posteri- same time as the surgical repair. A Burch or pubic symphysis. A lateral paravaginal procedure can be performed for type IIA defect representing avulsion of the vagina off or IIB genuine stress incontinence, or a the arcus tendineus fascia pelvis, or of the pubovaginal sling procedure can be per- arcus tendineus fascia pelvis off the obtura- formed for type III stress incontinence. tor internus muscle, can now be visualized. While gently reflecting the bladder Posterior colporrhaphy/ medially with a wide ribbon, insert a few perineorrhaphy FAST TRACK fingers of the nondominant hand into the These procedures are now performed to If all vaginal vagina and elevate the ipsilateral anterolat- treat the remaining rectocele and perineal eral vaginal sulcus. Then place a suture defect, when present. support defects through the fibromuscular thickness of the are repaired lateral vaginal apex, just above the uplifting at the time fingers in the vagina, and then slightly cephalad into the arcus tendineus fascia T Vaginal vs abdominal route of sacral colpopexy, pelvis or obturator internus fascia on the Somewhat surprisingly, the abdominal recurrent vault pelvic sidewall, at a point 1 to 2 cm distal route appears to produce better long-term prolapse is rare to the ischial spine. Place 3 to 5 additional results. In a prospective, randomized con- sutures in a similar fashion at 1-cm inter- trolled trial comparing both routes for the vals. The most distal suture should be repair of total vault prolapse, Benson et al3 placed as close as possible to the pubic found that, after 5 years of follow-up, ramus into the pubourethral ligament. If women managed vaginally had a 6-fold necessary, repeat the procedure on the con- increased incidence of recurrent vault pro- tralateral side. Then tie all sutures into lapse, a 3-fold increased incidence of recur- place, thereby completing the repair. rent cystocele, and twice the reoperation rate, compared with women whose initial repair was abdominal. In the study, 48 women with total T Plan on occult incontinence vault prolapse underwent vaginal bilateral Total vaginal vault prolapse is commonly sacrospinous fixation and paravaginal associated with some degree of urethral defect repair, and 40 underwent abdomi-

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nal sacral colpopexy and paravaginal damage fine branches of the pudendal defect repair. Although the vaginal nerve that innervate and control the approach was associated with a shorter urethral sphincter. Such extensive dis- operative time and decreased hospital stay section is not required for paravaginal in the short term, it necessitated longer repair from the abdominal approach. postoperative catheter use and was associ- • In the vaginal approach, it can be diffi- ated with more urinary tract infections and cult to gain adequate exposure high in postoperative incontinence and a higher the retroperitoneum to reattach the overall failure rate. endopelvic fascia of the vaginal apex to Sze and colleagues4 addressed a similar the arcus at its origin just distal to the question in retrospective fashion, review- ischial spine. ing the medical records of 117 women sur- gically treated for total vault prolapse. Sixty-one women underwent vaginal sacrospinous ligament fixation and Raz T The long view urethropexy, while 56 underwent abdomi- The surgical options described in this arti- nal sacral colpopexy and Burch ure- cle have varying degrees of risk and bene- thropexy. After a mean follow-up of 24 fit. Multicenter, prospective surgical trials months, 33% of the women managed are needed to clarify these risks and bene- vaginally developed recurrent pelvic organ fits and provide physicians and their prolapse, compared with only 19% of the patients with reliable information. women managed abdominally. In addition, Ultimately, pursuit of a surgical “cure” will 26% of the women managed vaginally had be supplanted by sustainable forms of dis- recurrent urinary incontinence, compared ease prevention. Until then, decisions with only 13% of the women managed about prolapse surgery are best left to the abdominally judgment of the surgeon and the desires of A separate randomized, prospective his or her patient. I study by Maher et al5 compared abdominal sacral colpopexy (n = 47) and vaginal REFERENCES FAST TRACK sacrospinous ligament fixation (n = 48) for 1. Herbst A, Mishell D, Stenchever M. Disorders of the Extensive stage II to IV vault prolapse. After a mean abdominal wall and pelvic support. In: Comprehensive Gynecology. 2nd ed. Philadelphia: dissection follow-up of 2 years, subjective and objec- Mosby Year Book; 1992:594–612. tive success rates did not differ significant- 2. Richter K. Massive eversion of the vagina: pathogen- is not required for ly between the 2 routes. esis, diagnosis and therapy of the true prolapse of the vaginal stump. Clin Obstet Gynecol. 1982;25: paravaginal repair 897–912. from the abdominal Why is the abdominal 3. Benson JT, Lucente V, McClellan E. Vaginal versus route more durable? abdominal reconstructive surgery for the treatment approach Any number of reasons may apply: of pelvic support defects: a prospective randomized study with long term outcome evaluation. Am J • The traditional surgical procedure for Obstet Gynecol. 1996;175:1418–1422. vaginal management of total vault pro- 4. Sze EH, Kohli N, Miklos JR, Roat T, Karram MM. A lapse—sacrospinous ligament fixa- retrospective comparison of abdominal sacro- colpopexy with Burch colposuspension versus tion—distorts the axis of the vagina. sacrospinous fixation with transvaginal needle sus- • Native tissues are not as strong as syn- pension for the management of vaginal vault pro- thetic materials. In postmenopausal lapse and coexisting stress incontinence. Int Urogynecol J Pelvic Floor Dysfunct. 1999; women, a repair in which the thin, 10:390–393. atrophic vaginal apex is secured to the 5. Maher CF, Qatawneh AM, Dwyer PL, Carey MP, sacrospinous ligament will not have Cornish A, Schluter PJ. Abdominal SCP or vaginal sacrospinous colpopexy for vaginal vault prolapse: a the same durability as a repair involv- prospective randomized study. Am J Obstet ing mesh. Gynecol. 2004;190:20–26.

• In vaginal paravaginal repair, the exten- The authors report no financial relationships relevant to sive periurethral dissection required can this article.