Abstract: Background: Hysterectomy is one of commonest procedures performed in Gynecology. Up to 10% of these patients can present with post hysterectomy vault prolapse. We explore the efficacy of vaginal Sacrocolpopexy in the treatment of this condition. Methods: In a prospective observational study over a period of 7 months, among patients who underwent vaginal Sacrocolpopexy, we noted their demographic data, parity, Pelvic Organ Prolapse-Quantification (POP-Q) staging, intraoperative, postoperative events, and complications. Follow-up was done at 3 months for all patients and at 6 months for 3 patients. Results: Eight patients were studied, all of them had stage 3 or 4 prolapse, 7 underwent vaginal Sacrocolpopexy and one colpocleisis. During post-operative follow up, one patient complained of dyspareunia, one had painful urination, two patients had lower abdominal pain, and three had low backache. Conclusion: Vaginal Sacrocolpopexy is a safe and effective surgical technique for correction of post-hysterectomy vault prolapse.

Padmasri R., MBBS.¹, Priyanka Holla, MBBS.², Keerthi A. V., MBBS^3
1Professor & Head, ²Assistant Professor, 3Assistant Professor, Department of Obstetrics & Gynecology, Sri Madhusudan Sai Institute of Medical Sciences & Research, Muddenahalli, Chikkaballapura.

 

Keywords: Vault Prolapse, Sacrocolpopexy, Vaginal Fixation
Corresponding Author: Dr. Priyanka Holla Email: priyanka.holla@smsimsr.org

1. Introduction

There is no precise definition of post-hysterectomy vault prolapse (PHVP). The joint report by International Continence Society (ICS)/ International Urogynecological Association (IUGA) on female pelvic floor dysfunction defines it as descent of vaginal vault or cuff scar after hysterectomy. When the structures that support the top of the vagina and uterus are not reattached at the time of the initial procedure prolapse of the vaginal vault after hysterectomy may occur [1]. Weakening of these supports over time, will be an additional factor.

Management of PHVP has been a dilemma for decades. A case series from 1960 previously identified the incidence of PHVP as ranging from 0.2% to 43%.[2] More recently, PHVP has been reported to follow 11.6% of hysterectomies performed for prolapse and1.8% for other benign diseases [3]. The frequency of PHVP requiring surgical repair was between 6% and 8%, as estimated in an Austrian study [4].

The preferred classification for pelvic organ prolapse and vault prolapse is the ICS Pelvic Organ Prolapse-Quantification (POP-Q) system, which is the most comprehensive and widely used approach. Initially, a preoperative urodynamic evaluation was considered mandatory for all these patients as the incidence of stress urinary incontinence among them was considered high. The current recommendation states that in continent women doing such studies for women with urinary continence results in unnecessary surgery and is not endorsed [5].

At the time of doing a vaginal hysterectomy, adding a McCall’s culdoplasty seems to be effective in preventing a PHVP in comparison to a vaginal Moschowitz repair or a simple peritoneal closure [6]. Attaching the uterosacral ligaments to the vaginal cuff in both abdominal and vaginal hysterectomies reduces the incidence of vault prolapse [7].

If, at the end of anterior vaginal wall closure, the vault is at the level of the introitus, a prophylactic sacrospinous fixation should be considered. Whether conservative management is effective for a vault prolapse is not clear as most studies have been done in pelvic organ prolapse. However, pelvic floor muscle training was found to be useful in women with grade I and II Pelvic Organ Prolapse (POP) and vault prolapse [8].

The question of whether subtotal hysterectomy can reduce the risk of vault prolapse has not been settled irrefutably. On the contrary, it results in increased incidence of urinary incontinence and prolapse than does total hysterectomy [9]. The decision for a surgical management is dependent on the symptoms and their effects on the quality of life and daily activities, as well as fitness of the woman for surgery.

Sacrocolpopexy is equally effective when performed either through the abdominal route or the vaginal route. Abdominal Sacrocolpopexy has a lower recurrence rate, less dyspareunia and urinary symptoms like incontinence, but it entails a longer, more invasive operative procedure and a slower recovery rate. Vaginal Sacrocolpopexy takes a shorter time to operate, allows quicker recovery, and is less expensive [10]. Laparoscopic Sacrocolpopexy has comparative efficacy to abdominal sacrocolpopexy with lesser intraoperative blood loss [11]. Robotic-assisted sacrocolpopexy is more expensive, available in fewer centers, and requires a longer duration of surgery due to the learning curve [12].

High uterosacral ligament suspension, where the vaginal cuff is suspended at the level of ischial spines has a higher complication rate such as ureteric injury of 10.9%, bowel and bladder injury, and is usually not recommended [13]. Colpocleisis or closure of the vagina can be considered in frail women, those not fit for prolonged surgery, and those not sexually active [14].

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Funding: This research received no external funding.

Institutional Review Board Statement: Not applicable.

Informed Consent Statement: Not applicable.

Data Availability Statement: No new data were created or analyzed during this study. Data sharing is not applicable to this article. Conflicts of Interest: The authors declare no conflicts of interest.

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