30 O B .GYN. NEWS • December 1, 2007

M ASTER C LASS A Vaginal Approach to Prolapse

n a recent Master Class the pubic bones and the . Posterior to the spine is searcher and much-sought-after lecturer. As this year’s sci- (OB.GYN. NEWS, Aug. 1, the with the overlying coccygeus entific program chairman of the American Association I2007, p. 24), abdominal muscle. The sacrospinous ligament marks the posterior of Gynecologic Laparoscopists’ Global Congress of Min- sacral colpopexy via a laparo- limit of the pelvic diaphragm. imally Invasive Gynecology, I invited Dr. Sand to present scopic approach was featured Because he is a nationally recognized expert in the vagi- a surgical tutorial on the vaginal approach to prolapse. for the treatment of vaginal nal approach to pelvic floor prolapse, I have asked Dr. Pe- Just as the participants found his discussion interesting and vault prolapse. However, for ter Sand to discuss vaginal vault suspension, the evolu- informative, I am sure our readers will feel the same. ■ the gynecologic surgeon who tion of the procedure, and the prevailing literature that BY CHARLES E. is more adroit with vaginal compares this technique with abdominal sacral colpopexy. DR. MILLER is clinical associate professor, University of MILLER, M.D. surgery, sacrospinous vaginal Dr. Sand is currently a professor of ob.gyn. at North- Chicago and University of Illinois at Chicago and President vault suspension also offers a western University, Chicago, and the director of urogy- of the AAGL. He is a reproductive endocrinologist in private safe and effective remedy for this disorder. As a review, necology and reconstructive pelvic surgery at Evanston practice in Schaumburg, Ill., and Naperville, Ill., and the the is located approximately halfway between (Ill.) Northwestern Healthcare. Dr. Sand is a prolific re- medical editor of this column. Sacrospinous Vaginal Vault Suspension: Variations on a Theme

aginal vaginal vault suspension involves a poste- sacrospinous liga- Vvault pro- rior vaginal incision, perforation of the ment. lapse is one of rectal pillars, and blunt dissection of the A short Breisky- the most fre- pararectal space anterior to the ligament. Navratil retractor quently occur- In the original posterior approach de- can then be placed ring types of scribed by Dr. Nichols, two Allis clamps at the 10 o’clock pelvic organ are placed at the level of the hymenal ring, position, resting on prolapse, and approximately 1 cm from the midline, the ischial spine. By BY PETER with our aging and a dilute vasopressin solution can be maintaining your SAND, M.D. population, it used to infiltrate underneath the posteri- right index finger AND S is a problem or vaginal wall to within 1 cm of the apex against the ischial for which increasing numbers of women of the . The scalpel is used to make spine, you can then ETER . P R

likely will seek treatment. Dr. Christo- a transverse incision between the Allis insert a long D pher F. Maher and his associates have es- clamps, and then the Metzenbaum scissors Breisky-Navratil re- timated the incidence of posthysterecto- are used to dissect underneath the vaginal tractor directly op- OURTESY my vaginal vault prolapse requiring epithelium in the midline, vertically to posing the short re- C surgery to be 36 per 10,000 person-years. within 1 cm of the apex of the vagina. tractor over the Metzenbaum scissors are used to free the endopelvic A variety of operations now exists for The Metzenbaum scissors can be used ventral surface of connective tissue from the vaginal epithelium. the treatment of vaginal vault prolapse to spread beneath the vaginal epithelium your finger, against and the reestablishment of apical sup- and smooth muscle to free the underlying the ischial spine with its posterior edge just bilized, the Deschamps ligature carrier port—from abdominal sacral colpopexy endopelvic connective tissue from its at- anterior to the coccygeus muscle. can be rotated counterclockwise—in an and abdominal uterus sacral suspensions, tachments on the undersurface of the Sweeping this long retractor counter- arc exactly opposite to that in which it was to sacrospinous vaginal vault suspensions, vaginal epithelium and smooth muscle. clockwise immediately across the coc- placed—to withdraw the posterior end of sacrospinous hysteropexies, and iliococ- (See photo.) The scissors can then be used cygeus muscle, keeping its posterior blade the suture. cygeal vaginal vault suspensions. to make a vertical incision in the posteri- in contact with the muscle throughout, Care should be taken to identify the All options have been described in the or vaginal wall to about 1-2 cm away from will mobilize the rectal and pararectal fat posterior end of the suture and differen- literature as being effective operations the vaginal apex. medially and expose the coccygeus mus- tiate it from the anterior end. This may be with minimal complications and varying Placement of Allis clamps—or self-re- cle and sacrospinous ligament. This re- accomplished through the use of a degrees of success, but the optimal ap- straining retractor hooks—on the incised tractor should be held at approximately straight hemostat on one end and the proach for vaginal vault prolapse remains edges of the vaginal epithelium and the 2 o’clock position, creating a 60- to 90- placement of a curved hemostat across a subject of debate. Unfortunately, many smooth muscle can allow for exposure and degree angle with the other Breisky- both ends of the suture. surgeons are not comfortable with vaginal resection of the endopelvic connective Navratil retractor. (The exact angle will de- (When we perform the surgery, we use surgery, despite the safety, speed, and ef- tissue from the undersurface of the vagi- pend on the angle of the pubic arch.) a straight hemostat to identify the poste- fectiveness that sacrospinous vaginal vault nal epithelium and smooth muscle later- At this point, the right-angle Haney re- rior end of suture on the patient’s right suspension and its modifications can pro- ally to the level of the rectal pillars. This tractor can be placed at approximately side, or the lateral suture, and a straight vide in experienced hands. may be facilitated by countertraction from the 7 o’clock position over the coccygeus Kocher clamp to identify the posterior Sacrospinous vaginal vault suspension your assistant, using tissue forceps on the muscle and then, with posterior traction, end on the patient’s left side.) was originally described by Dr. Paul endopelvic connective tissue. withdrawn distally until it pops down in The Breisky-Navratil retractors can then Zweifel in Germany in 1892. It was “re- Once this dissection is complete, the is- front of the coccygeus muscle, exposing be slowly withdrawn one at a time to al- discovered” in 1951 by Dr. I.A. Amreich in chial spine on the patient’s right side may this muscle and sacrospinous ligament. low for observation of the entire para- Austria, modified by Dr. J. Sederl, and be palpated, and—with either sharp dis- A Deschamps ligature carrier then can vaginal space and assessment for any then studied and described extensively in section with the tips of the Metzenbaum be inserted through the middle of the bleeders, which can be easily grasped and 1968 by fellow Austrian Dr. K. Richter. scissors or blunt dissection with the oper- coccygeus muscle and rotated clockwise to electrocoagulated or sutured. The operation received more attention ator’s right index finger—the endopelvic expose its tip around the sacrospinous lig- The suture can then be placed on the when Dr. C.L. Randall and Dr. D.H. connective tissue can be swept from ante- ament. The initial bite should be placed 1 undersurface of the apex of the vagina by Nichols reported on it (Obstet. Gynecol. rior-lateral to medial of the ischial spine cm medial to the ischial spine to avoid the use of a free Mayo needle. The anterior 1971;38:327-32). Since then, the posterior across the coccygeus muscle to remove the pudendal complex. A second suture can arm of the lateral suture can be placed ap- approach to sacrospinous vaginal vault fatty tissue that overlies the ischial spine then be placed 1-2 cm medial to the first, proximately 1-2 cm away from the right suspension that was described by Dr. and the sacrospinous ligament. again with care taken to place it through apex of the vagina in a figure-eight fash- Nichols has been modified, and an alter- The entire coccygeus muscle with its an- the middle of the coccygeus muscle and ion, and this one arm of the suture can be native approach through the anterior com- terior sacrospinous ligament should be not posterior to this muscle, where it tied to itself with a loose surgeon’s knot. partment of the vagina has been devel- palpated, and the rectum and pararectal at- could injure the vessel and of the The same process can be followed with oped and described. Several newer devices, tachments mobilized bluntly with the in- pudendal complex. the left or medial anterior arm of the sec- in the meantime, have offered improved dex finger from lateral to medial. This is When the Deschamps ligature carrier is ond sacrospinous suture, 1-2 cm away safety and simplicity. a relatively blood-free plane, and such a brought through the muscle, a colpotomy from the left apex of the vagina, and tied maneuver is possible with minimal bleed- or nerve hook can be used to mobilize one down in the same fashion. Care needs to The Original Posterior Approach ing so long as the affecting finger remains end of the suture and withdraw it back out be taken on the patient’s left side to place The posterior approach to sacrospinous anterior to the ischial spine and into the operative field. Once this is mo- Continued on following page

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Continued from previous page anatomical reconstruction of the vaginal Anterior sacrospinous suspension is an ies that have compared vaginal sacro- vault, and may avoid deviation of the approach that we have pursued and de- spinous colpopexy with abdominal sacral the suture approximately 0.5 cm further vagina to the right or the left side. scribed in order to address possible short- colpopexy for the treatment of upper vagi- away from the apical edge of the vagina, Instead of placing two sutures on one comings or limitations of the convention- nal prolapse. as this suture will traverse a longer dis- sacrospinous ligament, a single suture can al posterior approach—chiefly, recurrence The two prospective, randomized trials tance to reach the sacrospinous ligament. be placed on the right sacrospinous liga- of anterior vaginal wall prolapse and a that appear to be most often cited and re- Now the sutures can be retracted ante- ment at its midportion and on the left deep posterior angle and narrowing of ferred to—a study by Dr. Christopher F. riorly, and a rectocele repair and/or ente- sacrospinous ligament at its midportion. the upper one-third of the vaginal vault. Maher published in 2004 and a study by rocele repair can be performed as needed. These sutures are attached to the right and Whereas posterior suspension uses a Dr. J. Thomas Benson published in 1996— After successful completion of such re- left apex of the vagina, respectively. posterior vaginal incision and pararectal were quite different in their scope and pairs, excess vaginal epithelium and This approach, the thinking goes, allows dissection, anterior suspension uses an an- methodology (Am. J. Obstet. Gynecol. smooth muscle can be resected as indi- for a wider width of the vaginal apex in terior vaginal incision, perforation into 2004;190:20-6; 1996;175:1418-21). cated and the posterior vaginal wall closed the posthysterectomy patient, as well as the right retropubic space, and dissection Dr. Benson’s group reported data for 80 with either interrupted sutures or a run- good lateral support. of the ipsilateral paravaginal space from women with uterovaginal or vault pro- ning, locking suture approximately Often, a bilateral sacrospinous ligament the level of the bladder neck to the ischial lapse and concluded that the abdominal halfway down the pos- suspension may be spine, to create a wide space to accom- approach was more effective, but this terior vaginal wall. augmented by bilater- modate the vaginal vault. study involved the use of multiple con- At this point, the al paravaginal defect In our experience—Dr. Harvey A. Win- comitant procedures that may have con- sacrospinous sutures repairs performed kler, Dr. Janet E. Tomeszko, and I first re- founded the outcomes. should be tied down, through the vagina, ported on the technique in 2000—the an- Needle suspensions of the bladder neck with the suture on the with or without the terior approach appears to reduce were used in the vaginal surgery group, patient’s right lateral use of an adjuvant postoperative proximal vaginal narrowing compared with retropubic urethropexies side tied down first. graft. The dissection and lateral deviation of the upper vagina in the abdominal surgery group. Needle The posterior arm of for placement of these by avoiding passage through the rectal suspensions have been associated with a the sacrospinous su- sutures is identical to pillars (Obstet. Gynecol. 2000;95:612-5). significant increased risk of subsequent re- ture should be taken in the ipsilateral dissec- The technique involves opening the an- current cystocele and have affected the the nondominant tion for sacrospinous terior vaginal wall and separating the en- high recurrent prolapse rate for the vagi- hand, and slow trac- vaginal vault suspen- dopelvic connective tissue on the patient’s nal surgery group. tion should be applied sion, just described, on right from the pubic ramus at the level of The outcomes for both groups in the while the apex of the the patient’s right side; the bladder neck to the ischial spine, ex- Benson study were very poor and marked- vagina is guided back The dissection finger is placed it also can be per- posing the paravesical and pararectal ly different from other results in the liter- into position in the adjacent to the suture site. formed on the pa- space. The sacrospinous ligament is iden- ature, which makes it difficult to general- , toward the tient’s left side, with tified and isolated through this space. ize these outcomes to other populations. right sacrospinous lig- care taken to mobilize Two permanent sutures are placed ap- Dr. Maher’s study was better designed ament. the rectum medially proximately 2 cm apart through the liga- and has been more reflective of my expe- Once the excess (which is often a more ment, anchored with pulley stitches un- rience and the experience of many other slack is taken up by challenging task on derneath the vaginal epithelium and surgeons. His group reported on 95 mobilization of this the patient’s left side). smooth muscle, and tied down to the lig- women with posthysterectomy vaginal suture, the suture may Bilateral suspension ament. vault prolapse, and concluded that both be tied down, with to the sacrospinous lig- surgeries are highly effective and signifi- care taken to leave no ament has not, how- An Evolution in Instrumentation cantly improve the patient’s quality of life. gap between the vagi- ever, been compared The Deschamps ligature carrier is the de- Similarly, in the same year of Dr. Ben- nal apex and the directly to unilateral vice originally used for applying sutures son’s publication, Dr. P.J. Hardiman and sacrospinous liga- sacrospinous vaginal through the coccygeus muscle and Dr. H.P. Drutz reported that in a case se- ment. This suture is The upper vaginal vault is sutured vault suspension. sacrospinous ligament. However, because ries of 130 sacrospinous vaginal vault sus- then held while the to the sacrospinous ligament. Sometimes, when the ligature carrier is delivered posterior- pensions and 80 abdominal sacral second suture is mobi- scarring exists in the laterally to anterior-medially, there always colpopexies, the failure rate in terms of lized in the same fash- midline from prior has been concern about potential damage the recurrent vault prolapse was 2.4% ion and then tied vaginal hysterectomy, to the pudendal artery, vein, and nerve. with the vaginal approach and 1.3% with down similarly. or when an enterocele With the advent of newer devices that the abdominal approach (Am. J. Obstet. Retraction of the repair has been per- deliver the suture in a limited arc from the Gynecol. 1996;175[3, pt. 1]:612-6). undersurface of the formed, there may be anterior to posterior direction, the risk of They concluded that both approaches

closed posterior vagi- AND indentation in the damage to the pudendal complex has been were associated with a low incidence of nal wall will allow for S midline of the vaginal significantly minimized and the need for complications and recurrent vault pro- visualization of the ETER vault, creating a some- extensive dissection is often unnecessary. lapse. . P sacrospinous sutures, R what Y-shaped vagina. The newer devices have thus improved not Although it was not a randomized trial, which can be cut ap- D In a report pub- only the safety of the procedure but also the Hardiman-Drutz study is noteworthy proximately 1 cm lished in 1997, Dr. J.F. its simplicity, and they have reduced the and the outcomes are more comparable above the knot. The Pohl and Dr. J.L. operative time required. with real-life experience. I believe that sur- posterior vaginal wall Frattarelli concluded The first of these devices described for geons who are expert at performing both MAGES COURTESY may be closed, and I that bilateral suspen- applying sutures in a defined arc from an- surgeries find them to be equally success- perineorrhaphy per- Vaginal wall suturing is done at the sion is feasible in many terior to posterior was the Miya hook, de- ful, with the vaginal approach having less formed as indicated. upper portion of the vaginal apex. patients, but that it re- scribed by Dr. F. Miyazaki. morbidity. The choice of su- quires significant in- Another new device, the Capio device, Success, in most cases, has been de- tures is up to the individual operator. Al- traoperative judgment both as to its feasi- is a push-and-catch suture delivery system fined through rates of recurrent apical or though Dr. Nichols originally described bility and as to the width of the vaginal that allows the suture to be delivered over anterior vaginal prolapse, and few studies using delayed-absorbable sutures, later in cuff that will allow a bilateral suspension a defined arc into a catch device. The Ca- have addressed anatomical outcomes his career he changed to using one Gore- without tension (Am. J. Obstet. Gynecol. pio device has enabled placement of more directly relevant to vaginal func- Tex suture and one polyglycolic acid su- 1997;177:1356-61). sacrospinous sutures through palpation tion, such as length, axis, and sexual satis- ture. He informed me that his reason for In our practice, we tend to prefer right- and without direct visualization of the lig- faction. this was that the permanent suture would sided vaginal vault suspensions in which ament. This further limits the need for dis- We are challenged by the lack of uni- offer longer-lasting strength, whereas the we utilize either an anterior approach or section of the perirectal space, potentially versally accepted standards for quantifying delayed-absorbable suture would create a posterior approach, with a left-sided il- improving safety and reducing blood loss. such outcomes, but nevertheless, such more inflammatory response and possibly iococcygeus vaginal vault suspension. This Other authors have described using the outcomes should be pursued. elicit more scarring. requires less dissection and less risk of Schutt device, which also delivers a suture In a study reported in 2001 (with Dr. R. bleeding, as the sutures are placed lateral from anterior to posterior in a defined arc Goldberg as lead author), we found that Variations of the Original Approach to the ischial spine. to improve the safety and speed of the pro- sexual function was well preserved re- Some surgeons have suggested that a bi- It also creates a vagina with further cedure. gardless of the sacrospinous suspension lateral attachment of the vaginal apex— cephalad elevation of the right vaginal technique, with equally low rates of post- or attachment of the cervix, when the apex than the left vaginal apex, as well as Evolving Research operative dyspareunia in both groups (Ob- uterus is preserved—may offer a superior an ample apical width. At this time, there are relatively few stud- stet. Gynecol. 2001;98:199-204). ■