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.
- Look for vault prolapse in any woman who has an advanced degree of vaginal prolapse.
- Goals of surgery: to normalize support of all anatomic compartments; alleviate clinical symptoms; and optimize sexual, bowel, and bladder function.
- If sexual function is critical to the patient, a sacrocolpopexy should be the primary surgical option.
- Preoperative low-dose estrogen cream is crucial in most postmenopausal women.
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
This article reviews the anatomy of apical support, tells how to identify vaginal vault prolapse during the physical exam, and outlines effective surgical options—both vaginal and abdominal—for its correction. We focus on accurate pelvic assessment as the basis for planning the surgery.
Vaginal stability is fragile
The stability of vaginal anatomy is precarious, since it depends on a series of interrelationships between both dynamic and static structures. When the relationships between the ligaments and fascia at the vaginal apex or vault are impaired, vault prolapse ensues.
Thanks to cadaveric and radiographic studies, our understanding of the complexities of vaginal anatomy has improved considerably; still, the area of vaginal support we least understand is the coalescence of ligaments and fascia at the vaginal apex or vault.
Grade II prolapse, at least, in 64.8%
An analysis of Women’s Health Initiative enrollees with an intact uterus found that 64.8% had at least grade II prolapse (ie, leading edge of prolapse at –1 to +1 cm from the hymen) according to the Pelvic Organ Prolapse Quantification System (POP-Q).2 Approximately 8% of enrollees had a point D (vaginal apex) of greater than –6 cm, suggesting some degree of vault prolapse.
Hysterectomy appears to contribute. The incidence is about 1% at 3 years; 5% at 17 years.3
In the United States, approximately 30,000 vaginal vault repairs were performed in 1999.
Normal support structure
Several support structures coalesce at the vaginal apex. If the cervix is present, it serves as an obvious strong attachment site (FIGURE 1). In hysterectomized women, the structures may lack a strong attachment site, resulting in weakness and prolapse.
FIGURE 1 Vaginal support system
The coalescence of both sets of ligaments forms the uterosacral-cardinal ligament complex at the vaginal apex, which is likely crucial to vault support. Reprinted with permission of The Cleveland Clinic Foundation.
2 sets of ligaments determine support
Uterosacral ligaments—peritoneal and fibromuscular tissue bands extending from the vaginal apex to the sacrum—are the principal support for the vaginal apex, despite their apparent lack of strength.
The role of the cardinal ligaments—which extend laterally from the apex to the pelvic sidewall, adjacent to the ischial spine—is less clear. Since they lie proximal to the ureters, restoring vault support by shortening or reattaching them to the apex is a less attractive option.
The coalescence of these 2 sets of ligaments forms the complex that likely maintains vault support.
In hysterectomized women, locating the attachment of this complex to the vaginal cuff (seen on the exam as apical “dimples”) is key to identifying vault prolapse.
New view of cystoceles, rectoceles
The fibromuscular tissue layer underlying the vaginal epithelium envelops the entire vaginal canal, extending from apex to perineum and from arcus tendineus to arcus tendineus.
As the aponeurosis does for the abdominal wall, the endopelvic fascia maintains integrity of the anterior and posterior vaginal walls. If the fascial layer detaches from the vaginal apex, a true hernia can develop in the form of an enterocele—anterior or posterior—further weakening vault integrity (FIGURE 2).
Reconstructive surgeons are beginning to view cystoceles and rectoceles as a detachment of the endopelvic fascia from the vaginal apex. Thus, it is critical to restore anterior and posterior vaginal wall fascial integrity from apex to perineum by reattaching the endogenous fascia to the vaginal apex, or by placing a biologic or synthetic graft.
FIGURE 2 Apical defects contribute to vault prolapse
Vault prolapse is often associated with defects of the apical fascia, represented here by dark lines, which must be addressed during vault reconstruction. Reprinted with permission of The Cleveland Clinic Foundation.
Specific technique, tools to help identify prolapse
Any patient with an advanced degree of vaginal prolapse should be assessed for vault prolapse using a careful, structured pelvic exam. In many cases, this can be difficult, even if the uterus is present.
Necessary tools include a bivalved speculum and a right-angle retractor, or the posterior blade of another gynecologic speculum.
When the uterus is present
An exteriorized cervix does not necessarily mean vault prolapse; this may occur with substantial cervical hypertrophy, while the apex remains well supported (FIGURE 3).
Exam technique. Place the right-angle speculum blade in the posterior fornix, inserting it to its full extent, and ask the patient to perform a Valsalva maneuver. If vault prolapse is present, the uterus will descend further as the speculum is slowly removed; reinsertion of the speculum will resuspend the uterus. If the vault is well supported, the cervix will remain in place despite Valsalva efforts.
Assess the degree of vault prolapse during this examination, to determine whether a McCall culdoplasty will restore vault support.
If uterine suspension is performed in a woman with substantial cervical hypertrophy, cervical prolapse may persist, necessitating partial amputation (Manchester procedure).
FIGURE 3 Exteriorized cervix does not necessarily mean vault prolapse
Cervical prolapse may be associated with vault prolapse (left) or simply represent cervical hypertrophy without vault prolapse (right). Reprinted with permission of The Cleveland Clinic Foundation.
In the hysterectomized patient
The goal of physical exam is to identify the apical scar tissue (cuff) resultant from the hysterectomy. In most women, the cuff is visible as a transverse band of tissue firmer than the adjacent vaginal walls. If the woman has extensive prolapse, the tissue is stretched and thus not as obvious.
Exam technique. Use a bivalved speculum to visualize the apex. In women with extensive prolapse, redundant vaginal tissue may impede visualization. Fortunately, the sites of previous attachment of the uterosacral-cardinal ligament complex can usually be identified as “dimples” on either side of the midline at the cuff (FIGURE 4).
Use both right-angle speculum blades, or 1 blade along the anterior vaginal wall and the index and middle fingers of your other hand along the posterior vaginal wall, to identify the dimples. Then place the tip of the speculum between the dimples, elevate the vault while the patient performs a Valsalva effort, and determine the degree of vault prolapse. This can be confirmed by digital exam by identifying the dimples by tact and elevating them to their ipsilateral ischial spines.
FIGURE 4 Identifying the vault in the hysterectomized patient
Posthysterectomy vault prolapse can be identified by looking for “dimples” at the apex, which represent sites of previous uterosacral-cardinal ligament complex attachment. Reprinted with permission of The Cleveland Clinic Foundation.
Which exam findings point to which technique?
The importance of accurate pelvic assessment is impossible to overemphasize. Besides determining the degree and type of prolapse present, the exam enhances surgical planning. Fascial tears or defects are usually identifiable during careful vaginal exam as areas of sudden change in the thickness of the vaginal wall.
By the end of the pelvic exam, we usually have developed a surgical plan for the prolapse repair, pending urodynamic assessment to determine the best anti-incontinence procedure, if necessary.
What are the surgical goals?
Objectives are to normalize support of all anatomic compartments; alleviate clinical symptoms; and optimize sexual, bowel, and bladder function—without precipitating new support or functional problems.
Abdominal versus vaginal approach
Most surgeons prefer a vaginal approach to pelvic reconstruction. However, this decision should be based on the patient’s individual variables.
If sexual function is critical to the patient, a sacrocolpopexy should be the primary option. Note that age does not always predict the importance of sexual function.
Vaginal length. If the vaginal apex (dimples) reaches the ischial spines with ease, a vaginal procedure should suffice. If it does not reach the spines, or extends far above, an abdominal sacrocolpopexy or obliterative procedure may more be appropriate.
Previous reconstructive procedures. Keep in mind that the area around the sacral promontory, or sacrospinous ligaments, may be difficult or risky to reach due to scarring and fibrosis. This is doubly important in this age of commonplace graft use.
Large paravaginal defects. Vaginal repairs can be technically difficult, and long-term outcomes have not been reported. An abdominal approach is probably better if substantial paravaginal defects are present.
Medical comorbidities. Use a vaginal or obliterative procedure under regional anesthesia if the patient is medically delicate or elderly.
Tissue quality usually improves with preoperative local estrogen, but large fascial defects adjacent to the cuff or perineum may require graft reinforcement.
Colorectal dysfunction frequently coexists in women with vault prolapse. Thus, a woman with extensive rectal prolapse should probably undergo concomitant Ripstein rectopexy and sacrocolpopexy, or a perineal proctosigmoidectomy and vaginal-approach vault suspension.
Careful and consistent preparation
Surgical success depends in great part on developing a clear understanding of anatomic defects and urodynamic dysfunction during the preoperative evaluation, to determine the most appropriate procedures.
Tissue preparation with low-dose estrogen
cream (1 g, two nights per week) is crucial for most postmenopausal women.
Obtain medical clearance, and optimize
perioperative safety by using spinal anesthesia, antiembolism stockings, and prophylactic intravenous antibiotics.
Retain vaginal packing at least 24 hours to prevent stress on sutures due to coughing or vomiting.
Advise patients in advance that, for 6 weeks after surgery, they must avoid overexertion and lifting more than 5 lb.
After 6 weeks, we restart estrogen cream and prescribe routine, daily Kegel exercise.
This involves plicating the uterosacral ligaments in the midline while reefing the peritoneum in the cul-de-sac, resulting in posterior culdoplasty. It usually is performed at the time of vaginal hysterectomy using nonabsorbable sutures to incorporate both uterosacral ligaments, intervening cul-desac peritoneum, and full-thickness apical vaginal mucosa. Multiple sutures may be required if prolapse is extensive.
Generally, we try to place our uppermost suture on the uterosacral ligaments at a distance from the cuff equal to the amount of vault prolapse (POP-Q: TVL minus point D [point C if uterus is absent]).
Be careful not to injure or kink the ureters when placing the suture through the uterosacral ligaments, as the ureters lie 1 to 2 cm lateral at the level of the cervix. We recommend cystoscopy with visualization of ureteral patency.
Uterosacral ligament suspension
Excellent anatomic outcomes have been described when the uterosacral ligaments are reattached to the vaginal apex (similar to the McCall technique).6,7 The physiologic nature of this technique makes it very attractive. It involves opening the vaginal wall from anterior to posterior over the apical defect, and identifying the pubocervical fascia, rectovaginal fascia, and uterosacral ligaments.