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OBGMANAGEMENT

William Irvin, MD Surgical management Associate Professor Division of Gynecologic Oncology University of Virginia of vaginal vault prolapse Health System Charlottesville, Va Choosing the right procedure is a judgment call, based on Kathie Hullfish, MD the patient’s age, desire for coitus, and overall health. Director, Division of Reconstructive Pelvic Surgery and Urogynecology University of Virginia irst, the good news: We have numer- ing of the pathophysiology of genital pro- Health System Charlottesville, Va ous techniques to choose from to lapse, improved preoperative assessment, F repair prolapse of the vaginal vault, and more effective and durable repair which affects as many as 50% of parous techniques. women.1 The bad news: Most of the data on these techniques are anecdotal or retro- spective, not the result of randomized, con- trolled trials. Few investigators have com- ❚ Why prolapse occurs pared the vaginal and abdominal Pelvic support involves a complex inter- approaches. play of anatomic, histologic, genetic, and So how should we decide on a proce- electrophysiologic factors that, although dure? It is a judgment call, ultimately. After incompletely understood, are frequently IN THIS ARTICLE taking into account the patient’s age, func- disrupted. For example, MacLennan et al2 tional status, comorbidities, desire for reported that 46.2% of women aged 15 to ❙ Classic vs modified coitus, and surgical history, the surgeon 97 years experience dysfunc- McCall culdoplasty must weigh the risks and benefits of the tion; a large retrospective study by Olsen 3 Page 27 procedures that seem most appropriate. and colleagues found that 11.1% of Part 1 of this 2-part article reviews what is women undergo surgery for prolapse by ❙ Benefits known about the most widely used and the age of 80, and 29.2% of these women newest vaginal techniques: require repeat surgery. of high uterosacral • sacrospinous fixation, Here’s what we know about the anato- ligament • iliococcygeal fixation, my of pelvic support: suspension • modified McCall culdoplasty, Page 28 • high suspension serve as with fascial reconstruction, and secondary supports • posterior intravaginal slingplasty The and upper third of the (infracoccygeal sacropexy). are held in place over the levator plate by In Part 2, next month, we focus on the the fibers of the (cardinal and abdominal approach, and survey the data uterosacral ligaments) and paracolpium. comparing vaginal and abdominal repairs. These fibers arise from a broad area on the Unfortunately, success and failure rates pelvic sidewall overlying the fascia of the are still poorly defined because of a lack of piriformis muscle, the sacroiliac joint, and standardization, and because techniques lateral sacrum. The fibers represent con- and materials continually change. This densations of the endopelvic fascia of the underscores the need for better understand- pelvis, acting as suspensory ligaments that

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run in a predominantly vertical direction FIGURE 1 to insert into the lateral upper third of the 2 “pulley stitches” vagina and lateral and posterolateral secure the apex aspect of the cervical portion of the uterus. In the normal, healthy pelvis, these Sacrospinous suspensory ligaments represent secondary ligament support mechanisms and are not routinely under tension.

Ischial spine Pelvic-floor muscles play leading role Gosling4 argued that pelvic floor muscle tone is more crucial to normal positioning of the pelvic viscera than are the fascial and ligamentous supports of the pelvic organs. Specifically, the pubococcygeus, iliococcygeus, and puborectalis muscles collectively define the levator ani of the pelvic floor. Fusion of the right and left bel- Place 2 nonabsorbable monofilament “pulley lies of the levator ani, behind the rectum stitches” to secure the vaginal apex to the ligament. and anterior to the coccyx, creates a mus- cular platform known as the levator plate. tal tract and improvement in quality of life. This plate provides indirect support for the Surgery can be reconstructive or upper genital tract by acting as a platform obliterative. Reconstructive surgery can against which the upper vagina and other be performed vaginally, abdominally, or pelvic viscera are compressed during a combination of both. increases in intra-abdominal pressure. Contraction of the levator ani pulls the levator plate toward the posterior symphy- FAST TRACK ❚ Vaginal techniques sis pubis, minimizing the size of the uro- Successful surgery genital hiatus through which the rectum, Proponents of the vaginal approach argue vagina, and exit the pelvis on their that, by avoiding the need for laparotomy, supports the vault way to the perineum. Weakness in the it results in fewer complications, less blood and corrects any muscular pelvic floor—whether caused by loss and postoperative discomfort, a short- enterocele, disuse, pudendal nerve damage, or muscu- er hospital stay, and less expense.5 lar trauma—increases the size of the uro- cystocele, genital hiatus, and the pelvic organs begin Sacrospinous ligament fixation or rectocele to prolapse through it. The sacrospinous ligaments extend from Ultimately, constant tension on the lig- the ischial spines on either side to the lower amentous supports of the pelvic organs portion of the sacrum and coccyx. exceeds their tensile strength, and pelvic Fixation of the vaginal apex to 1 or both of organ prolapse results. the sacrospinous ligaments is an option for posthysterectomy vault prolapse. Goals of surgery Technique. Nichols6 described the need to Successful surgery achieves effective and penetrate the right rectal pillar into the sustained vault support, obliterates any pararectal space near the ischial spine. enterocele sac, and repairs the cystocele The next step is grasping the ligament and rectocele that occur in approximately and muscle with a long Babcock clamp. two thirds of women with vault prolapse. Place two #2 polyglycolic sutures through The broader goals: anatomic and func- the sacrospinous ligament, 1.5 to 2 fin- tional restoration of the lower female geni- gerbreadths medial to the ischial spine.

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Attach 1 end of the suture to the under- posterior colporrhaphy. Develop the rec- surface of the posterior vaginal wall at the tovaginal spaces bluntly and bilaterally— apical area. When the posterior colpor- laterally toward the levator muscles and rhaphy reaches the midportion of the posteriorally toward the ischial spines. Use vagina, tie the sacrospinous suspension the nondominant hand to depress the rec- sutures, firmly attaching the vaginal tum downward and medially, and place a apex to the surface of the coccygeal- single #0 polyglycolic suture deep into the sacrospinous ligament complex with no iliococcygeus muscle and fascia at a point intervening suture bridge (FIGURE 1). 1 to 2 cm caudad and posterior to the Modifications. The most notable modifica- ischial spine. Then pass both ends of the tion is the Miyazaki technique, which sub- suture through the ipsilateral posterior stitutes the Miya hook for the DesChamps vaginal apex and hold them with a hemo- ligature carrier. The Miya hook is report- stat. Repeat the procedure contralaterally. edly safer for the pudendal complex, Usually no needs which may lie up to 5.5 cm medial to the excision because the upper vagina is ischial spine.7 The path of the Miya hook attached bilaterally, resulting in good vagi- avoids Alcock’s canal and its neurovascu- nal length and circumference. When poste- lar pudendal bundle. rior colporrhaphy is completed and the The Caprio ligature carrier (Boston posterior vaginal wall is closed, tie both Scientific, Boston, Mass) is also useful for iliococcygeal-fixation sutures in place. the placement of sacrospinous sutures; Complications. Shull and colleagues11 stud- unlike the Miya hook, however, the Caprio ied 42 women who underwent suspension ligature carrier is a disposable instrument of the vaginal cuff to iliococcygeus fascia and thus is not reusable. and repair of coexisting pelvic support Potential complications of sacrospinous lig- defects. Of these women, 2 (5%) had ament fixation include hemorrhage, recurrence of their cuff prolapse during pudendal nerve injury, rectal or bladder follow-up, one of whom required further injury, and recurrent anterior vaginal wall surgery (she also had recurrence of an FAST TRACK prolapse. inguinal hernia that had been repaired at Iliococcygeus Outcomes. Follow-up studies in women the original surgery). The other patient, undergoing this procedure report a rough- who had undergone 5 previous pelvic pro- fixation places ly 20% incidence of recurrent or persistent cedures, developed asymptomatic prolapse less tension anterior vaginal wall relaxation, or symp- of the cuff halfway to the . Six addi- on the anterior tomatic cystocele, within 1 year after the tional patients had loss of support at other surgery. Alteration of the vaginal axis in an sites in the follow-up period, one of whom vaginal wall exaggerated posterolateral direction after required repeat surgery. Ninety-five per- this procedure is thought to place undue cent of women experienced no persistence tension on the anterior segment of the or recurrence of cuff prolapse 6 weeks to 5 vaginal wall and predispose women to years after the procedure. prolapse at a site opposite the repair.8,9 Meeks and colleagues12 also applied the Inmon technique in 110 women with Iliococcygeal fixation posthysterectomy vault prolapse or total Inmon10 was the first to describe a tech- uterine procidentia. In both studies, the nique in which the everted vaginal apex most commonly reported complications is secured to the iliococcygeal fascia included hemorrhage (1.2%), bladder/rec- bilaterally, just below the ischial spine. tal perforation (1.2%), and recurrent vault He performed this technique successfully prolapse (8%). in 3 women with atrophied uterosacral Benefits. In comparison with sacro- ligaments. spinous ligament fixation, iliococcygeus Technique. Open the posterior vaginal wall fixation is technically easier and places in the midline, as if preparing to perform a less tension on the anterior vaginal wall.

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Modified McCall culdoplasty FIGURE 2 Symmonds and colleagues13 described this Classic vs modified approach to symptomatic vaginal vault McCall culdoplasty prolapse. Technique. Excise an elliptical wedge of mucosa from the anterior and posterior walls of the prolapsed vagina to narrow the vault and allow access to the lateral fascial supports of the vagina and rec- tum. The width and length of the excised wedges are determined by the desired dimensions of the reconstructed vagina. After isolating and excising the entero- cele sac, place up to 3 modified McCall stitches, each one slightly higher than its predecessor. Each suture should incorpo- rate the full thickness of the posterior vagi- nal wall, the cul-de-sac peritoneum, the In the classic McCall culdoplasty shown here, only the distal-most suture incorporates the posterior remains of the uterosacral-cardinal com- vaginal wall. With the “modified” technique, how- plex bilaterally, and the fascial tissue later- ever, all sutures incorporate the full thickness of al and posterior to the upper vagina and the posterior vaginal wall, as well as the cul-de-sac peritoneum, the remnants of the uterosacral-car- rectum (FIGURE 2). dinal complex bilaterally, and the fascial tissue later- Once they are in place, tie the sutures al and posterior to the upper vagina and rectum. in the opposite order in which they were placed. These stitches fix the prolapsed FIGURE 3 vaginal vault to the uppermost portion of Suspend apical corners the endopelvic fascia at the same time as bilaterally they accomplish a high closure of the cul- de-sac peritoneum. FAST TRACK The evidence. Sze and Karram5 found an In the modified 11.5% incidence of recurrent vault pro- lapse and an associated 22% incidence of McCall procedure, new-onset dyspareunia. sutures penetrate ❙ High uterosacral ligament suspension the posterior with fascial reconstruction vaginal wall This approach is based on the observations ❙ of Richardson,14 who suggested that the the cul-de-sac endopelvic fascial supports (uterosacral/car- peritoneum dinal complex) do not stretch and attenu- ❙ remnants of the ate over time, as some have hypothesized, but break at definable points. By identify- uterosacral- ing these points, the surgeon can reattach cardinal complex the prolapsed vagina to the intact utero- The corners of the vaginal apex are suspended from the cardinal-uterosacral complex bilaterally, ❙ fascial tissue lateral sacral complex cephalad to the break. with all sutures placed posterior and medial to the Technique. Grasp the vaginal apex with 2 ischial spines. Copyright 1998 by C.G. Bachofen. and posterior Allis clamps and incise it with a scalpel. If to the upper an enterocele sac is present, dissect it off string suture about the neck of the hernia vagina and rectum the vaginal epithelium to the neck of the to close the peritoneal defect. If an anteri- hernia, open it, and then excise it. Place a or colporrhaphy or sling is required, per- delayed absorbable or permanent purse- form them at this time.

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FIGURE 4 palpate the ischial spines transperitoneally. Suture placement Once the spines are identified, the rem- penetrates multiple layers nants of the uterosacral ligaments can be identified posterior and medial to the spines and can be palpated transperi- PCF USL toneally or transrectally. Remember that PS B the ureters are also quite close to the ischial spines at this location, running along the lateral pelvic sidewall 2 to 5 cm ventral and lateral to the ischial spines. After identifying the uterosacral liga- AD ments, grasp their remnants with Allis clamps and place 2 to 3 delayed absorb- able or permanent sutures through the rec- tovaginal fascia of the inner posterior vagi- RVF R nal wall epithelium at one lateral vaginal apex, through the ipsilateral plicated uterosacral ligament complex, and then Sagittal view of correct suture placement. through the pubocervical fascia of the PS = pubic symphysis, B = bladder, PCF = anterior vaginal wall of the ipsilateral vagi- pubocervical fascia, USL = uterosacral ligaments, AD = apical defect, RVF = rectovaginal fascia, R = nal apex. Hold these sutures while per- rectum. Copyright 1998 by C.G. Bachofen. forming the same procedure contralateral- ly (FIGURE 3). Close the apex and tie these FIGURE 5 sutures in place, suspending the corners of Suspend the fascia the vaginal apex from the uterosacral com- from uterosacral ligaments plex bilaterally, and restoring the continu- ity of the paracervical ring (FIGURES 4, 5). Benefits of this technique include: FAST TRACK PS • creation of an anatomically appro- Benefits of high PCF priate and correctly positioned mid- B line vaginal axis, uterosacral USL • preservation of adequate vaginal ligament length, suspension • reduced risk of nerve injury, and ❙ • restored continuity of the paracervical creates an ring when the pelvic pararectal, utero- anatomically RVF R sacral, and pubocervical fascia are correct midline reapproximated circumferentially. Suspension of pubocervical Risks include the potential for ureteral vaginal axis and rectovaginal fascia to uterosacral ligaments kinking or obstruction. Thus, it is prudent ❙ preserves vaginal to perform cystoscopy after this procedure length Sagittal view after tying of sutures. Note restoration to rule out occult injury. of the normal anatomic axis. ❙ less risk PS = pubic symphysis, B = bladder, Posterior intravaginal slingplasty PCF = pubocervical fascia, USL = uterosacral liga- of nerve injury ments, RVF = rectovaginal fascia, R = rectum. This investigative technique, also known ❙ Copyright 1998 by C.G. Bachofen. as infracoccygeal sacropexy, is a mini- restores continuity mally invasive, transperineal approach to of paracervical ring Place a moist laparotomy pad in the vaginal vault prolapse. The anatomic and cul-de-sac, and insert and elevate a Deaver physiologic concepts are similar to those retractor to remove the intestines from the of the tension-free vaginal tape cul-de-sac and improve exposure. Next, (Gynecare, Somerville, NJ) in the treat-

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ment of stress incontinence. However, 5. Sze EHM, Karram MM. Transvaginal repair of vault prolapse: a review. Obstet Gynecol. 1997;89:466–475. because it is a new procedure, further 6. Nichols D. Sacrospinous fixation for massive eversion evaluation is needed before it can be of the vagina. Am J Obstet Gynecol. 1982;142: 901–904. adopted into clinical practice. 7. Miyazaki FS. Miya hook ligature carrier for sacro- spinous ligament suspension. Obstet Gynecol. This is an outpatient surgery. 1987;70:286–288. Technique. Use a narrow tunneling device 8. Morley G, DeLancey JO. Sacrospinous ligament fixa- tion for eversion of the vagina. Am J Obstet Gynecol. to pass a synthetic nonabsorbable tape 1988;158:872–878. through each pararectal space via a small 9. Shull BL, Capen CV, Riggs MW. Preoperative analysis of site specific pelvic support defects in 81 women perineal incision, and make a small vaginal treated with sacrospinous ligament suspension and incision to secure the tape to the vault. pelvic reconstruction. Am J Obstet Gynecol. 1992;166:1764–1771. The evidence. In the initial case series of 10. Inmon WB. Pelvic relaxation and repair including 93 patients,15 1 rectal perforation and 1 prolapse of vagina following . South rectal tape erosion were noted. The cure Med J. 1963;56:577–582. 11. Shull BT, Capen CV, Riggs MW. Bilateral attachment rate was 91% in short-term follow-up in of the vaginal cuff to iliococcygeus fascia: an effec- ■ tive method of cuff suspension. Am J Obstet a small number of patients. Gynecol. 193;168:1669–1673. 12. Meeks GR, Washburne JF, McGehrer RP. Repair of REFERENCES vaginal vault prolapse by suspension of the vagina to iliococcygeus (prespinous) fascia. Am J Obstet 1. Beck RP. Pelvic relaxational prolapse. In: Principles Gynecol. 1994;171:1444–1449. and Practice of Clinical Gynecology. New York: John 13. Symmonds RE, Williams TJ, Lee RA, Webbs MJ. Wiley and Sons; 1983:667–685. Posthysterectomy enterocoele and vaginal vault pro- 2. MacLennan AH, Taylor AW, Wilson DH, Wilson D. lapse. Am J Obstet Gynecol. 1981;140:852–859. The prevalence of pelvic floor disorders and their 14. Richardson AL. The anatomic defects in rectocoele relationship to gender, age, parity, and mode of and enterocoele. J Pelvic Surg. 1995;1:214–218. delivery. Br J Obstet Gynecol. 2000;107:1460–1470. 15. Farnsworth BN. Posterior intravaginal slingplasty 3. Olsen AL, Smith VJ, Bergstrom JO. Epidemiology of (infracoccygeal sacropexy) for severe posthysterec- surgically managed and uri- tomy vaginal vault prolapse: a preliminary report on nary incontinence. Obstet Gynecol. 1997; 89:501–506. efficacy and safety. Int Urogynecol J. 2002;13:4–8. 4. Gosling JA. The structure of the bladder neck, ure- thra and pelvic floor in relation to female urinary The authors report no financial relationships relevant to incontinence. Int Urogynecol J. 1996;7:177–178. this article.

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