| December 2004 · Vol. 16, No. 12 SURGICAL TECHNIQUES
Choosing the best technique for vaginal vault prolapse
Two experts tell how to identify the condition, select the best repair for the patient, and restore anatomic integrity.
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Fast Track
Hypertrophy can cause cervical prolapse without vault prolapse.
Use a vaginal or obliterative procedure under regional anesthesia in the medically delicate or elderly.
Cystoscopy is essential with uterosacral ligament suspension—ureteral injury rate is as high as 11%.
Anterior compartment prolapse is more likely with a concomitant anti-incontinence procedure.
Sacral colpopexy vault suspension technique has best longevity.
Place multiple sutures (include posterior vaginal wall) to obliterate the cul-de-sac and prevent enterocele.
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Daniel
Biller,
MDClinical Fellow, Department of Gynecology, Section of Urogynecology and Reconstructive Pelvic Surgery, Cleveland Clinic Florida, Weston G.
Willy
Davila,
MDChairman, Department of Gynecology Head, Section of Urogynecology and Reconstructive Pelvic Surgery, Cleveland Clinic Florida, Weston
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KEY POINTS
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Look for vault prolapse in any woman who has an advanced degree of vaginal prolapse.
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Goals of surgery: to normalize support of all anatomic compartments; alleviate clinical symptoms; and optimize sexual, bowel, and bladder function.
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If sexual function is critical to the patient, a sacrocolpopexy should be the primary surgical option.
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Preoperative low-dose estrogen cream is crucial in most postmenopausal women.
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Identifying vault prolapse can be difficult in a woman with extensive vaginal prolapse, and operative failure is likely if support to the apex is not restored.
Because this condition is so challenging to identify, many women undergoing anterior and/or posterior colporrhaphy likely have undiagnosed vault prolapse. This may contribute to the 29.2% rate of reoperation in women who undergo pelvic floor reconstructive procedures.1
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