Management of Vault prolapse Based on RCOG guide lines Dr.V.Ravimohan www.mrcogexam.net

Definition post-hysterectomy vaginal prolapse descent of the vaginal cuff scar below a point that is 2 cm less than the total vaginal length above the plane of the hymen International Continence Society

post-hysterectomy vaginal prolapse

descent of the vaginal cuff scar below a point that is 2 cm less than the total vaginal length above the plane of the hymen

International Continence Society

Prevention McCall culdoplasty at the time of vaginal hysterectomy is a recommended measure to prevent enterocele formation- Grade A What is McCall culdoplasty? approximating the uterosacral ligaments using continuous sutures to obliterate the peritoneum of the posterior cul-de-sac as high as possible

McCall culdoplasty at the time of vaginal hysterectomy is a recommended measure to prevent enterocele formation- Grade A

What is McCall culdoplasty?

approximating the uterosacral ligaments

using continuous sutures

to obliterate the peritoneum of the posterior cul-de-sac as high as possible

Prevention Suturing the cardinal and uterosacral ligaments to the vaginal cuff at the time of hysterectomy is a recommended measure to avoid vault prolapse— Grade B Sacrospinous fixation at the time of vaginal hysterectomy is recommended when the vault descends to the introitus during closure- Grade B

Suturing the cardinal and uterosacral ligaments to the vaginal cuff at the time of hysterectomy is a recommended measure to avoid vault prolapse— Grade B

Sacrospinous fixation at the time of vaginal hysterectomy is recommended when the vault descends to the introitus during closure- Grade B

Assessment Assessment of the woman should be comprehensive and objective addressing quality of life looking for all pelvic floor defects should be based on standard tools

Assessment of the woman should be comprehensive and objective

addressing quality of life

looking for all pelvic floor defects

should be based on standard tools

What is POPQ? Pelvic organ prolapse quantification Image is on http://tinyurl.com/5xnjo9

Pelvic organ prolapse quantification

Image is on http://tinyurl.com/5xnjo9

POPQ Six sites reference to the plane of the hymen measured in centimeters above or proximal to the hymen (negative number) below or distal to the hymen (positive number) with the plane of the hymen defined as zero.

Six sites

reference to the plane of the hymen

measured in centimeters

above or proximal to the hymen (negative number)

below or distal to the hymen (positive number)

with the plane of the hymen defined as zero.

Point A The anterior and posterior points A (Aa, Ap) are located on the midline vaginal wall 3 cm proximal to the hymen (range ±3 cm).

The anterior and posterior points A (Aa, Ap) are located on the midline vaginal wall 3 cm proximal to the hymen (range ±3 cm).

Point B The anterior and posterior points B (Ba, Bp) represent the maximum extent of prolapse of the anterior and posterior vaginal wall (range -3 cm to total vaginal length [tvl]).

The anterior and posterior points B (Ba, Bp) represent the maximum extent of prolapse of the anterior and posterior vaginal wall (range -3 cm to total vaginal length [tvl]).

Point C &D Point C represents the position of the cervix or vaginal cuff, and point D, the posterior fornix. The genital hiatus (gh) is measured from the external urethral meatus to the posterior midline hymen The perineal body (pb) is measured from the posterior midline hymen to the midanal opening.

Point C represents the position of the cervix or vaginal cuff, and point D, the posterior fornix.

The genital hiatus (gh) is measured from the external urethral meatus to the posterior midline hymen

The perineal body (pb) is measured from the posterior midline hymen to the midanal opening.

occult stress incontinence Assessment a full bladder after reducing theprolapse with a pessary or sponge holder not currently validated by evidence is not a substitute for adequate patient counselling about this complication. The role of prophylactic surgery for occult stress incontinence is unclear

Assessment

a full bladder

after reducing theprolapse with a pessary or sponge holder

not currently validated by evidence

is not a substitute for adequate patient counselling about this complication.

The role of prophylactic surgery for occult stress incontinence is unclear

Indirect recurrence post-hysterectomy vaginal vault prolapse may be associated anterior or posterior vaginal wall prolapse Failure to address such defects at the same time will lead to women presenting with recurrent prolapse from those defects left without support (indirect recurrence). performing repair of all defects at the same time Vs repairing such defects in a separate setting at a later stage no studies

post-hysterectomy vaginal vault prolapse may be associated anterior or posterior vaginal wall prolapse

Failure to address such defects at the same time will lead to women presenting with recurrent prolapse from those defects left without support (indirect recurrence).

performing repair of all defects at the same time Vs repairing such defects in a separate setting at a later stage no studies

Conservative management The role of conservative measures for post-hysterectomy vaginal vault prolapse is unclear. Grade C Pelivic floor exercise- no evidence Pesarry(ring/shelf)- change every 6–8 months Interference with sexual intercourse Ring pessaries tend to fail in women with deficient perineum Local estrogen can be used to improve atrophic changes

The role of conservative measures for post-hysterectomy vaginal vault prolapse is unclear. Grade C

Pelivic floor exercise- no evidence

Pesarry(ring/shelf)- change every 6–8 months

Interference with sexual intercourse

Ring pessaries tend to fail in women with deficient perineum

Local estrogen can be used to improve atrophic changes

Surgical procedures Anterior and posterior repair along with obliteration of the enterocele sac are inadequate for posthysterectomy vaginal vault prolapse.-Grade C -does not support the vaginal vault -risks vaginal narrowing andshortening, and thus dyspareunia, especially when posterior repair is carried out

Anterior and posterior repair along with obliteration of the enterocele sac are inadequate for posthysterectomy vaginal vault prolapse.-Grade C

-does not support the vaginal vault

-risks vaginal narrowing andshortening, and thus dyspareunia, especially when posterior repair is carried out

Surgical procedures Abdominal sacrocolpopexy Vs sacrospinous fixation sacrospinous fixation may have a higher failure rate but has lower postoperative morbidity

Abdominal sacrocolpopexy Vs sacrospinous fixation

sacrospinous fixation may have a higher failure rate but has lower postoperative morbidity

Sacrospinous fixation Image is on http://tinyurl.com/4s8yu9

Image is on http://tinyurl.com/4s8yu9

Sacrocolpopexy Image is on http://tinyurl.com/4jkzro

Image is on http://tinyurl.com/4jkzro

more sexual dysfunction more intraoperative blood loss longer catheter use, more urinary tract infection and more urinary incontinence . a lower rate of recurrence combined rate of apical and anterior vaginal wall prolapse was significantly higher posterior vaginal wall prolapse following abdominal sacrocolpopexy. higher cost slower return to normal activity operating time and hospital stay were shorter significantly longer operating time Sacrospinous fixation Sacroxcolpopexy

Cochrane review Sacrospinous fixation Sacroxcolpopexy cheaper Quicker return to normal activities a lower rate of recurrence Shorter operation time less dyspareunia

continence surgery be performed at the time of sacrocolpopexy? It is not clear whether prophylactic continence surgery is beneficial in women who are urodynamically continent and it should not be routinely recommended.

It is not clear whether prophylactic continence surgery is beneficial in women who are urodynamically

continent and it should not be routinely recommended.

unilateral or bilateral sacrospinous fixation? There is no evidence to recommend bilateral or unilateral sacrospinous fixation.

There is no evidence to recommend bilateral or unilateral sacrospinous fixation.

iliococcygeus fixation Iliococcygeus fixation does not reduce the incidence of anterior vaginal wall prolapse associated with vaginal sacrospinous fixation and should not be routinely recommended.

Iliococcygeus fixation does not reduce the incidence of anterior vaginal wall prolapse associated with vaginal sacrospinous fixation and should not be routinely recommended.

iliococcygeus fixation…. It involves bilateral fixation of the vaginal vault to the iliococcygeus fascia Iliococcygeus fixation is done To reduce the exaggerated retroversion of the vagina, and thus the subsequent increase in anterior vaginal wall prolapse to avoid the risk of injury to pudendal and sacral nerves and vessels associated with sacrospinous fixation

It involves bilateral fixation of the vaginal vault to the iliococcygeus fascia

Iliococcygeus fixation is done

To reduce the exaggerated retroversion of the vagina, and thus the subsequent increase in anterior vaginal wall prolapse

to avoid the risk of injury to pudendal and sacral nerves and vessels associated with sacrospinous fixation

vaginal uterosacral ligament suspension Caution is advised with vaginal uterosacral ligament suspension effective risk of ureteric injury( 10.9%)

Caution is advised with vaginal uterosacral ligament suspension

effective

risk of ureteric injury( 10.9%)

laparoscopic procedures Laparoscopic sacrocolpopexy appears to be as effective as open sacrocolpopexy (B) The ureters are particularly at risk during laparoscopic uterosacral ligament suspension.(B) There is insufficient evidence to judge the value of other laparoscopic techniques.(C)

Laparoscopic sacrocolpopexy appears to be as effective as open sacrocolpopexy (B)

The ureters are particularly at risk during laparoscopic uterosacral ligament suspension.(B)

There is insufficient evidence to judge the value of other laparoscopic techniques.(C)

Sacrocolpopexy-Open Vs Laparoscopy requires skill, training and longer operating time, although operating time shortens with greater experience. shorter stay reduced postoperative morbidity less scarring an enhanced view of the pelvis, which facilitates a more anatomical repair laparoscopy open

Colpocleisis closure of the vagina is a safe and effective procedure Success rates of 97% and above considered for those women Frail women can also be performed under local anaesthesia, which suits frail women who do not wish to retain sexual function.

closure of the vagina

is a safe and effective procedure

Success rates of 97% and above

considered for those women

Frail women

can also be performed under local anaesthesia, which suits frail women

who do not wish to retain sexual function.

Sling procedures should not be used without adequate patient counselling and special provisions for audit and research.(B) short operating time can be done in those considered unfit for major surgery

should not be used without adequate patient counselling and special provisions for audit and research.(B)

short operating time

can be done in those considered unfit for major surgery

total mesh reconstruction There is insufficient evidence to judge the safety and effectiveness of total mesh reconstruction

There is insufficient evidence to judge the safety and effectiveness of total mesh reconstruction

Vault suspension to the anterior abdominal wall Vault suspension to the anterior abdominal wall can be a simple measure. However, there are not enough studies assessing this technique to judge its value.(B)

Vault suspension to the anterior abdominal wall can be a simple measure. However, there are not enough studies assessing this technique to judge its value.(B)

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