Repairing posthysterectomy vaginal vault prolapse: little data available.(Gynecology)

ST. LOUIS -- There is little in the way of evidence to guide the management of posthysterectomy vaginal vault prolapse and postrepair recurrence of vault prolapse, but the problems will require increasing attention, Dr. Patrick Hogston said at the 13th International Pelvic Reconstructive and Vaginal Surgery Conference.

As life expectancy increases, the number of women requiring treatment for these conditions will increase, said Dr. Hogston of St. Mary's Hospital in Portsmouth, England.

Currently, an estimated 12% of women who undergo hysterectomy for vault prolapse continue to have prolapse following the surgery, and 2% who undergo hysterectomy for other indications experience postsurgical prolapse. One study suggested that 30% of prolapse repairs are repeat operations, he said at the conference, which was sponsored by the Society of Pelvic Reconstructive Surgeons and Emory University.

The few data that are available provide some information on how to proceed in patients with postsurgical or recurrent prolapse. First, they highlight preventive options, such as avoiding colposuspension. Colposuspension is a common procedure for surgical treatment of stress incontinence, and is considered a predisposing factor in nearly 20% of cases of vaginal vault prolapse.

Also, a culdoplasty technique described in 1957 and later modified has been shown in at least one study to help prevent posthysterectomy prolapse. The technique, which involves the use of separate sutures placed through the full thickness of the vaginal mucosa, peritoneum, and uterosacral ligaments, obliterates the culde-sac and suspends the vault by the uterosacral ligaments. It was shown in a study of nearly 700 women to have an 85% success rate at 9 years.

Those cases that do require postsurgical repair can be technically challenging, and should be managed by an experienced surgeon, according to Dr. Hogston.

Vaginal approaches to repair include culdoplasty and uterosacral ligament suspension, sacrospinous fixation, intravaginal slingplasty (IVS), and fixation of the vagina to the iliococcygeus ligament. Sacrospinal fixation is particularly popular, and recent data suggest it is best performed with an anterior approach via the paravaginal space.