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Vault prolapse treated by sacrocolpopexy.

Objective. To evaluate the success rate of sacrocolpopexy in 153 patients with stage 3 and 4 vault prolapse.

Methods. A retrospective review was done on 153 patient records from a database in a urogynaecological unit. For the sacrocolpopexy procedure, semi-absorbable mesh was placed along the anterior and posterior vaginal walls, and attached to the anterior longitudinal ligament of the sacrum.

Results. The median age was 65 years and parity 3.0; 94% of the patients were white. Previous surgery for prolapse was reported by 48% of the patients and 25% were on thyroid hormone treatment. The vault prolapse was stage 3 in 81 patients (52.9%) and stage 4 in 72 (47.1%). At surgery, the mesh extended from the vaginal vault to the sacrum in 7 patients (4.6%). In the remaining 146 patients (95.4%) the mesh was attached to the posterior vaginal wall and in 133 (86.9%) a second strip of mesh was fixed to the anterior vaginal wall. Follow-up was possible in 149 patients (97.4%), with a median of 29 months. Recurrent prolapse (any type) occurred in 22 patients (14.4%) and 12 had repeat surgery for recurrent prolapse (7.8%). In total, 25 patients (16.3%) had repeat surgery for any indication.

Conclusions. Vault prolapse is difficult to treat owing to absence of support of the upper vagina, but sacrocolpopexy delivered acceptable results.

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Vaginal vault prolapse is accompanied by marked prolapse of the bladder and rectum. Nichols described vault prolapse as a variant of enterocele. (1)

The incidence of total vault prolapse is probably rising owing to increased life expectancy and the more active lifestyle of women today. In 1973, Birnbaum (2) estimated the incidence of post-hysterectomy vaginal vault prolapse to be 900 to 1 400 per year in the USA.

The pathophysiology of vault prolapse is not completely understood. Since it commonly occurs after hysterectomy, separation of the uterosacral and transverse cervical ligaments are probably of major importance, together with other defects in all the layers of the pelvic floor. (3) The implication is that comprehensive repair of all the defects and not merely the prolapsed vault is necessary for complete repair of vault prolapse.

Sacrospinous fixation (SSF) of the vault is a popular and probably the most common form of surgical repair of vault prolapse. In over 2 000 reported cases, the cure rate varied from 8% to 97% with a mean of 80-90% if vault support is the only measure of success. (4) The problem with SSF is that it focuses on the vault only without taking other defects into account, and it deviates the vagina slightly posteriorly. As a result, postoperative anterior vaginal prolapse and urinary stress incontinence may occur, but in practice these problems are not too common (about 27% and 12% respectively). (5)

Abdominal sacrocolpopexy, however, is favoured by many in the recent literature. (6-9) A Cochrane review reported improved results from abdominal sacrocolpopexy compared with SSF, with less postoperative vault prolapse, dyspareunia and repeat surgery. (10) However, it was found that sacrocolpopexy was more expensive with an increased morbidity. (10) Abdominal sacrocolpopexy may also be done laparoscopically. (11-13)

In view of the current emphasis on abdominal sacrocolpopexy, we decided to review our own results with this procedure.

Patients and methods

We reviewed 153 patients from our urogynaecological database at Universitas Academic Hospital. Inclusion criteria were stage 3 and 4 vaginal vault prolapse repaired with semi-absorbable mesh. We had completed our learning curve for performing abdominal sacrocolpopexy when starting to use semi-absorbable mesh. The types of mesh used were Vypro[R] (polyglactin/polypropylene) and Ultrapro[R] (poliglecaprone/polypropylene) (both Johnson & Johnson, Brussels, Belgium).

Urinary symptoms and signs were based on careful clinical evaluation, as few patients had urodynamic evaluation. For the staging of prolapse the POP-Q system was used. (14)

All procedures were by means of laparotomy. Initially mesh was inserted from the vaginal vault to the sacrum (S1), but before long we extended the mesh along the posterior vaginal wall. In some cases mesh was also inserted between the bladder and vagina. Both strips of mesh were fixed proximally to the sacrum. The majority of patients received a Burch colposuspension, primarily for support of the anterior vaginal wall. Mobilisation of the rectum was also done in most patients, whereby the peritoneum medial to the rectum was opened, followed by exploration of the presacral space and anterior mobilisation of the rectum. Once the mesh was in place, the rectum was pulled upwards and fixed to the mesh (rectopexy). The peritoneum was always closed over the mesh, leaving the mesh retroperitoneally. Where a defective perineal body was diagnosed, a perineal repair was done.

All patients received prophylactic antibiotics (2 g intravenous cefoxitin preoperatively, followed by 1 g IV 12-hourly x 2). Postoperatively an indwelling transurethral catheter was removed on the 2nd day, unless circumstances necessitated otherwise.

Data capturing was done by completion of a data form when the patient was discharged from hospital. These forms were reviewed at weekly meetings, after which the data were entered into a database (Epi-Info version 6,0, Centers for Disease Control, Atlanta, GA, USA). Follow-up data were entered into the same database.

Results

The median age and parity were 65 years and 3.0, respectively. Most patients were white (94%) and 48% reported previous surgery for urinary incontinence or pelvic organ prolapse. A quarter of the patients were on thyroid hormone therapy.

Almost all patients (90%) complained of a protrusion through the vagina. Bladder symptoms were present in 56% of the patients, mainly urinary stress incontinence (38%) and overactive bladder symptoms (28%). Constipation was present in 27% and difficulty with defaecation (where digital assistance was needed) in 27%. Anal incontinence was present in 3% and dyspareunia in 1%. Lower abdominal and back pain were reported by 13% and 18% of patients, respectively.

The findings at gynaecological examination are summarised in Table I and the surgical procedures in Table II. Vypro[R] mesh was used in 122 patients (79.7%) and Ultrapro[R] in 31 (20.3%).

A urethral urinary catheter was inserted in 137 patients (89.5%) and a suprapubic catheter in 15 (9.8%) (in 1 patient (0.7%) no catheter was inserted). In 51% of the patients the catheter was removed on the 2nd postoperative day, in 16% on day 3 and in 13% on day 1. The longest a catheter remained in place was 14 days.

Intraoperative complications occurred in 9 patients (5.9%). Bowel injury occurred in 3 patients and bladder injury in 2, 1 patient developed severe hypotension intraoperatively, and 3 had blood loss of more than 1 litre. One of these had a hypoxic incident about 18 hours postoperatively and died in the intensive care unit. The exact cause of death was unknown.

Immediate postoperative complications occurred in 16 patients (10.5%). These included pneumonia (4), wound sepsis (3), increased bladder residual volume (3), haematoma (2), urinary tract infection (1), perineal pain (1), hypertensive crisis (1) and 1 patient who developed renal failure for unknown reason and received temporary dialysis.

Of the 153 patients, 149 (97.4%) were followed up for a median duration of 29 months (range 1-63 months). Repeat prolapse, stage 2 to 4, occurred in 22 patients (14.4%). Included were 4 anterior compartment prolapses (2.6%), 11 vault prolapses (7.2%), 7 enteroceles (4.6%), 12 posterior compartment prolapses (7.8%) and 1 rectoenterocele (0.1%). Some patients had more than one type of prolapse. Repeat surgery was done in 12 patients (8.1% of 149). Included were repeat sacrocolpopexy (4), posterior (3) and anterior (1) repair, tension-free vaginal tape (TVT) (12) (7.8%), mesh removal (1), incisional hernia repair (1) and release of vaginal ridges (2) (some patients had more than one procedure). One patient died 2 days after surgery due to acute sepsis, septic shock and cardiac failure. The mortality rate in this series was therefore 1.3% (2 cases). Two other patients died more than 2 years after the prolapse repair, 1 of colon cancer and 1 of lung disease.

Stress urinary incontinence was reported by 34 patients (22.2%), of whom 12 had TVT procedures as mentioned above. Overactive bladder symptoms occurred in 36 patients (23.5%). Obstructed defaecation persisted in 17 patients (11.1%), but in all cases it was less of a problem than it had been preoperatively. Mild to moderate constipation was experienced by 44 patients (28.8%). Postoperative dyspareunia was present in 3 patients (2%) and mesh erosion occurred in 11 (7.2%). Almost all erosions were minor but in 1 patient the mesh was expelled completely. Three patients in addition to the one reported above developed small incisional hernias which did not need repair. One patient developed stenosis of the upper vagina, but she was not sexually active.

Other long-term complications (8 patients, 5.2%) included severe constipation (4), bowel instability (constipation and diarrhoea in succession) (1) and anal incontinence (1).

Discussion

Recurrence of prolapse was fairly common in this study (14.4%) compared with two previous reports from our unit. (15, 16) The first dealt with stage 3 and 4 prolapse of any kind with a recurrence rate of 8%, and the second with uterine prolapse treated by sacrocolpopexy with a recurrence rate of 10%. However, the follow-up periods in these two reports were shorter (median 8.5 and 20 months respectively) than in this study (median 29 months), which may explain the lower recurrence rates in the previous reports. While some studies have reported cure rates superior to ours (90% or more), (6, 12) Hilger et al., in a report on long-term follow-up, reported failures in 26% of their cases (13.7 years' follow-up). (17)

As our experience increased, we tended to increase the length of the mesh along the anterior and posterior vaginal walls. We had the impression that the larger the contact area between mesh and vagina, the less likelihood that they would separate with recurrent prolapse. However, in a report where only the vaginal vault was suspended, vaginal prolapse (anterior, posterior) occurred in 42% while the vault remained suspended in 92% of cases (66 months' follow-up). (11) This report supports our view that in vault prolapse more than just the vaginal vault should be suspended. However, how far distally the mesh should extend is not clear. Ross and Preston (18) were of the opinion that where the posterior mesh extended to the perineal body, the incidence of recurrent posterior compartment prolapse was decreased.

Even though two-thirds of our patients received a Burch colposuspension, 22.2% reported stress urinary incontinence postoperatively. Our primary indication for a Burch colposuspension was additional support of the anterior vaginal wall, but we used it for preoperative stress incontinence as well. Baessler and Stanton (19) found no difference in terms of recurrent prolapse whether a Burch colposuspension was done or not. However, they only looked at posterior compartment prolapse. Cosson et al. (20) also investigated the role of a Burch colposuspension. In their opinion, it did not make a difference in terms of urinary incontinence postoperatively. However, in a recent randomised controlled trial Brubaker et al. demonstrated a significant protective effect by Burch colposuspension on postoperative urinary stress incontinence during sacrocolpopexy. (21)

Of our patients 2 died shortly after surgery. In our previous two reports, involving 198 patients, there were no deaths. (15, 16) The true mortality rate for sacrocolpopexy by laparotomy should therefore be around 0.5% or less, which is significant in view of the benign nature of prolapse.

Another aspect of this report that requires comment is a fairly high rate of complications, intraoperatively and shortly after surgery. Although no specific complication stood out, we would recommend the following:

1. The selection of patients is important since those with prolapse are often elderly and, in our experience, almost always obese. Patients with concomitant medical problems do not qualify for sacrocolpopexy by laparotomy.

2. At surgery, the dissection must be precise to minimise tissue damage and bleeding. For example, in a patient who has had a hysterectomy it may be difficult to find the exact plane of cleavage between the bladder and vagina. We open the bladder and, with a finger in it and while pulling the vaginal vault from the bladder with a lever in the vagina, it is easy to find the right plane with minimal bleeding.

3. Dissection between the vagina and bladder or rectum involves the risk of postoperative haematoma formation, which may lead to different complications. Once we started to use hydrodissection together with a vasoconstrictor, with postoperative vaginal tamponade, the problems of postoperative anaemia and haematoma formation decreased. For hydrodissection we use 200 ml saline with 10 IU ornipressin. This is liberally injected between the bladder or rectum and vagina prior to surgical dissection. Vaginal tamponade is applied for 48 hours postoperatively.

In conclusion, in the recent literature a move was noted away from sacrospinous colpofixation towards abdominal sacrocolpopexy with mesh for vaginal vault prolapse. Our report on sacrocolpopexy showed reasonable results, but refinement is necessary to decrease morbidity while improving the results. Laparoscopic sacrocolpopexy might be more feasible in view of these patients' fairly advanced age.

We thank Mrs Karen Fouche for preparing this manuscript.

(1.) Nichols DH, Randall CL. Vaginal Surgery. Baltimore: Williams &Wilkins, 1996.

(2.) Birnbaum SJ. Rational therapy for the prolapsed vagina. Am J Obstet Gynecol 1973; 115: 411-419.

(3.) DeLancey JOL. Anatomic aspects of vaginal eversion after hysterectomy. Am J Obstet Gynecol 1992; 166: 1717-1728.

(4.) Slack MC. Sacrospinous colpopexy for support of the vaginal apex. In: Cardozo L, Staskin D, eds. Textbook of Female Urology and Urogynaecology. London: ISIS Medical Media, 2001.

(5.) Paraiso MF, Ballard LA, Walters MD. Pelvic support defects and visceral and sexual function in women treated with sacrospinous ligament suspension and pelvic reconstruction. Am J Obstet Gynecol 1996; 175: 1423-1431.

(6.) Ng CC, Han WH. Comparison of effectiveness of vaginal and abdominal routes in treating severe uterovaginal or vault prolapse. Singapore Med J 2004; 45: 475481.

(7.) Deval B, Haab F. What's new in prolapse surgery? Curr Opin Urol 2003; 13: 315323.

(8.) Rane A, Lim YN, Withey G, Muller R. Magnetic resonance imaging findings following three different vaginal vault prolapse repair procedures: a randomised study. Aust NZ J Obstet Gynaecol 2994; 44: 135-139.

(9.) Sze EH, Meranus J, Kohli N, Miklis JR, Karram MM. Vaginal configuration on MRI after abdominal sacrocolpopexy and sacrospinous ligament suspension. Int Urogynecol J 2001; 12: 375-379.

(10.) Maher C, Baessler K, Glazener CM, Adams EJ, Hagen S. Surgical management of pelvic organ prolapse in women. Cochrane Database of Systematic Reviews 4: CD004014, 2004.

(11.) Higgs PJ, Chua HL, Smith AR. Long term review of laparoscopic sacrocolpopexy. BJOG 2005; 112: 1134-1138.

(12.) Wattiez A, Mashiach R, Donoso M. Laparoscopic repair of vaginal vault prolapse. Curr Opin Obstet Gynecol 2003; 15: 315-319.

(13.) Gadonneix P, Ercoli A, Salet-Lizee D, et al. Laparoscopic sacrocolpopexy with two separate meshes along the anterior and posterior vaginal walls for multicompartment pelvic organ prolapse. J Am Assoc Gynecol Laparosc 2004; 11: 29-35.

(14.) Bump RC, Mattiasson A, Bo K, et al. The standardization of terminology of female pelvic organ prolapse and pelvic floor dysfunction. Am J Obstet Gynecol 1996; 175: 10-17.

(15.) Cronje HS. Colposacrosuspension for severe genital prolapse. Int J Gynecol Obstet 2004; 85: 30-35.

(16.) Cronje HS, De Beer JAA. Abdominal hysterectomy and Burch colposuspension for uterovaginal prolapse. Int Urogynecol J 2004; 15: 257-260.

(17.) Hilger WS, Poulson M, Norton PA. Long-term results of abdominal sacrocolpopexy. Am J Obstet Gynecol 2003; 189: 1606-1610.

(18.) Ross JW, Preston M. Laparoscopic sacrocolpopexy for severe vaginal vault prolapse: five-year outcome. J Minim Invasive Gynecol 2005; 12: 221-226.

(19.) Baessler K, Stanton SL. Sacrocolpopexy for vault prolapse and rectocele: do concomitant Burch colposuspension and perineal mesh detachment affect the outcome? Am J Obstet Gynecol 2005; 192: 1067-1072.

(20.) Cosson M, Boukerrou M, Narducci F, Occelli B, Querleu D, Crepin G. Long-term results of the Burch procedure combined with abdominal sacrocolpopexy for treatment of vault prolapse. Int Urogyn J 2003; 14: 104-107.

(21.) Brubaker L, Cundiff GW, Fine P, et al. Abdominal sacrocolpopexy with Burch colposuspension to reduce urinary stress incontinence. N Engl J Med 2006; 354: 1557-1566.

H S Cronje, MB ChB, MMed (O et G), FCOG (SA), MD

J A A de Beer, MB ChB, MMed (O et G)

Division of Urogynaecology, Department of Obstetrics and Gynaecology, University of the Free State, Bloemfontein
Table I. Findings at gynaecological examination * (N=53)

 Stage 2 Stage 3 Stage 4

Prolapse N % N % N %

Cystocele 22 14.4 44 28.8 26 17.0
Vault prolapse -- -- 81 52.9 72 47.1
Uterine prolapse 11 7.2 67 43.8 46 30.1
Enterocele 13 8.5 50 32.7 17 11.1

* Staging according POP-Q system. (14)

Table II. Summary of surgical procedures (N=153)

Procedure N %
1. Sacrocolpopexy with mesh *:
 Less than 6 cm on ant. vagina 99 64.7
 6 cm or more along ant. vagina 34 22.2
 From vault to sacrum 7 4.6
 Posteriorly from mid-vagina to sacrum 27 17.6
 Posteriorly from perineal body to sacrum 119 77.8
2. Mobilisation of rectum 127 83.0
3. Burch colposuspension 103 67.3
4. Perineal repair 107 69.9
5. Transvaginal tape for stress incontinence 8 5.2
6. Sacrospinous colpopexy 3 2.0

* Some patients received mesh both posteriorly and anteriorly
to the vagina.
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Article Details
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Title Annotation:RESEARCH ARTICLE
Author:Cronje, H.S.; de Beer, J.A.A.
Publication:South African Journal of Obstetrics and Gynaecology
Article Type:Report
Geographic Code:1USA
Date:Oct 1, 2007
Words:2900
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Next Article:Combined abdominal sacrocolpopexy and Burch colposuspension for the treatment of stage 3 and 4 anterior compartment prolapse.
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