You are in: eMedicine Specialties > Obstetrics and Gynecology > Prolapse and Incontinence Enterocele and Massive Vaginal EversionArticle Last Updated: Dec 20, 2007AUTHOR AND EDITOR INFORMATIONSection 1 of 12
  Author: Rony A Adam, MD, Director, Division of Benign Gynecology, Director, Section of Urogynecology and Pelvic Reconstructive Surgery, Assistant Professor, Department of Gynecology and Obstetrics, Emory University School of Medicine Rony A Adam is a member of the following medical societies: American College of Obstetricians and Gynecologists Coauthor(s): Thinh H Duong, MD, Assistant Professor of Obstetrics and Gynecology, Section of Urogynecology and Pelvic Reconstructive Surgery, Grady Memorial Hospital, Atlanta Veterans Affairs Medical Center, Emory University Editors: Robert K Zurawin, MD, Associate Professor, Director of Fellowship Programs, Minimally Invasive Surgery, Department of Obstetrics and Gynecology, Baylor College of Medicine; Chief of Gynecology, Texas Children's Hospital; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Michel E Rivlin, MD, Associate Professor, Coordinator, Quality Assurance/Quality Improvement, Department of Obstetrics and Gynecology, University of Mississippi School of Medicine; Frederick B Gaupp, MD, Consulting Staff, Department of Family Practice, Assumption Community Hospital; Michel E Rivlin, MD, Associate Professor, Coordinator, Quality Assurance/Quality Improvement, Department of Obstetrics and Gynecology, University of Mississippi School of Medicine Author and Editor Disclosure Synonyms and related keywords: enterocele and massive vaginal eversion, uterovaginal prolapse, vaginal vault prolapse, apical compartment defects, pelvic organ prolapse, urogynecology and pelvic reconstructive surgery, female pelvic medicine and reconstructive surgery, prolapse of the womb, apical prolapse, uterine descensus, descent of the vaginal apex, vaginal eversion, pelvic organ prolapse quantification, POP-Q INTRODUCTIONSection 2 of 12
  Massive vaginal vault prolapse (uterovaginal prolapse) is a devastating condition with discomfort and genitourinary and defecatory abnormalities as the primary consequences. References to prolapse of the womb were first made in ancient Egypt, dating back to 1550 BC. Vaginal vault prolapse refers to significant descent of the vaginal apex following a hysterectomy (see Media file 1). Apical prolapse is used to denote prolapse of the vaginal apex with or without the presence of a uterus. Although this obviously is not a new condition, apical prolapse is thought to be increasingly common as life expectancy increases. Prolapse of the vaginal apex may or may not be accompanied by an enterocele. Whereas complete vaginal eversion is obvious, lesser degrees of prolapse and the presence of enterocele are more difficult to discern and require careful evaluation of anterior, posterior, and apical compartment defects. Also, associated functional abnormalities, whether concurrent or potential, must be properly explored, evaluated, and discussed with the patient. ProblemA uniform definition of what constitutes apical prolapse or any pelvic organ prolapse does not exist. Indeed, a degree of uterine descensus is present in many, if not most, women who are multiparous. Not all patients with prolapse are symptomatic, and the degree of prolapse often does not correlate with the degree of symptoms reported by the patient. The pelvic organ prolapse quantification (POP-Q) has been instituted to address this deficiency in defining the extent of prolapse. Specific sites are defined separately on the anterior, posterior, and apical vaginal compartments and are measured with respect to a fixed reference point, the hymen. These measurements can then be categorized into an ordinal staging system ranging from 0-4.
The POP-Q staging system has been validated and demonstrates good interobserver and intraobserver reliability. Although POP-Q staging adequately addresses the extent of prolapse, assumptions about which organ is behind each bulge should be made with caution and should be made only after a complete evaluation. Regarding enterocele, the definition is somewhat more difficult. Previous texts have defined enterocele as any intraperitoneal contents (bowel or mesentery) palpable within the cul-de-sac, as evaluated during an examination in the erect position. A more anatomic definition was proposed by Richardson, who suggested that enterocele occurs when endopelvic fascia does not intervene between the peritoneum and vagina1 (see Media file 2). Recent histologic and MRI studies of enteroceles, however, have challenged this concept. Studies by Tulikangas et al2 and Hsu et al3 show that a distinct break in the fibromuscular layer denoted as the rectovaginal fascia may not necessarily be present. These studies, however, are small in number and further investigation is warranted. Nevertheless, a careful preoperative and intraoperative search for these defects is necessary for proper diagnosis. FrequencySwift reported on the frequency of different stages of pelvic organ prolapse based upon the POP-Q staging system.4 In a routine gynecologic clinic population, most women had stage 1 or stage 2 prolapse (43.3% and 47.7%, respectively), few women had stage 0 or stage 3 prolapse (6.4% and 2.6%, respectively), and no women had stage 4 pelvic organ prolapse. Samuelsson et al report a prevalence of 30.8% for any prolapse, using the Baden-Walker halfway system, in a study of the general population in Sweden.5 Vaginal vault prolapse is thought to occur postoperatively in 0.5% of hysterectomy cases, whether they are performed vaginally or abdominally. EtiologySwift reported that significant trends for increasing prolapse were found with advancing age, parity, postmenopausal status, previous hysterectomy, and prior corrective surgery for prolapse.4 Multivariate analysis in a study performed by Samuelsson et al revealed independent statistical associations with age, parity, maximal birth weight, and pelvic floor muscle strength.5 Such associations were not found regarding the weight or hysterectomy status. The precise etiology regarding pelvic organ prolapse remains elusive. Theories include diminished sacral nerve function and/or defects in collagen. PathophysiologyDeLancey describes the anatomy of vaginal vault prolapse in terms of 3 levels of support (see Media file 3).6
The conditions of enterocele and vaginal eversion represent failures of level I support, although other compartments may be affected. Uterovaginal prolapse does not denote intrinsic uterine disease and, therefore, may not necessarily require a hysterectomy in all cases. It should be noted, however, that no evidence proves or disproves the benefit of hysterectomy at the time of apical suspension. Apical prolapse occurs because of tearing or attenuation of the cardinal-uterosacral ligament complex. This results in failure to support the upper vagina and/or uterus over the pelvic diaphragm, which should be in a near-horizontal plane in a woman in the erect position. Level I support is considered most important in maintaining adequate overall pelvic support. Richardson describes an enterocele in anatomic terms, as a break in the integrity of endopelvic fascia at the vaginal apex7 (see Media file 4). Normally, posthysterectomy enterocele is precluded by the apposition of pubocervical and rectovaginal fascia (collectively termed endopelvic fascia) at the apex. Anterior, apical, and posterior enteroceles have been described based upon the location of the fascial defect and the location of the ensuing herniation of bowel. Apical enterocele is the most common enterocele and, by definition, can develop only after a hysterectomy. Apical enterocele may present with or without vaginal vault prolapse (see Media files 5-7). Anterior enteroceles are rare and may occur following sacrospinous ligament fixation, when the proximal vaginal tube is pulled somewhat posteriorly, creating a potential space in the anterior compartment. Because they present as a protrusion of the anterior vaginal wall, they may be the major cause of some cystoceles. In women with an intact uterus, posterior enteroceles have been described. These are due to tearing of the proximal rectovaginal fascia from its attachment to the cardinal-uterosacral ligament complex, which results in descent of the peritoneal contents down the posterior aspect of the vagina (see Media file 8). Posterior enterocele is usually accompanied by significant uterovaginal prolapse and prolapse of other compartments as well. Recently, histologic studies by Tulikangas et al failed to find breaks in the fibromuscular layer in women who underwent surgical correction for enterocele compared with controls (women who did not have pelvic organ prolapse).2 Admittedly, the authors' findings did not correlate with their subjective clinical findings of thinning of the vaginal wall in enteroceles. Hsu et al similarly found a lack of difference in vaginal wall thickness on MRI studies of patients with prolapse and their normal controls.3 The numbers in these studies, however, were small and further investigation is needed before this controversy is fully resolved. ClinicalPatients may present with an obvious vaginal bulge that is visualized or felt by the patient. Conversely, the patient may report a vague sense of pelvic heaviness or a sensation that something is about to fall out. The bulging is often noted to be worse toward the end of the day, as compared with when the patient first wakes up, or when the patient is straining at defecation or urination. When vaginal epithelium remains exteriorized, it undergoes cornification and, often, ulceration, which can result in significant pain and infection. Functional difficulties may be encountered during coitus. Defecation may be difficult; associated constipation is very common. Incomplete bladder emptying also is common, and, in severe cases, complete obstruction may be observed. Voiding dysfunction may result in frequent urinary tract infections and, occasionally, overflow incontinence. Due to kinking of the urethra, occult (potential) stress incontinence and even intrinsic sphincter deficiency may be present. A history of stress incontinence that spontaneously improved and/or resolved as the prolapse progressively worsened is especially concerning for the presence of occult stress incontinence. Although rare, severe pelvic prolapse may result in ureteral kinking with the potential for hydroureter, hydronephrosis, and subsequent renal damage. A detailed history is required to evaluate the patient. Information regarding any functional problems that may be caused by the prolapse should be ascertained. Essential to the preoperative evaluation and surgical decision-making is the review of any prior pelvic surgery, including obtaining operative reports, especially if surgery was performed for prior pelvic floor dysfunction. A commitment to treat all associated pelvic floor defects requires a careful and comprehensive urogynecologic examination. A diligent search for all pelvic support defects and repair of these defects increases the likelihood for surgical success. The apical, anterior, and posterior compartments are evaluated separately, with and without straining and/or coughing in the supine position and again in the erect position, preferably with an empty bladder. The POP-Q exam is helpful for quantifying the extent of prolapse and accurate follow-up. Carefully evaluate the rectovaginal septum for integrity, strength, and thickness along its entire length. Look for any signs of enterocele, such as bowel peristalsis, along the upper vagina or near the apex. Look for any obvious pubocervical/rectovaginal detachments at the periphery of an apical bulge. Evaluate the cul-de-sac in the supine and standing positions, with and without Valsalva maneuvers. INDICATIONSSection 3 of 12
Treatment of pelvic organ prolapse is indicated if it is symptomatic or is causing associated morbidity. Asymptomatic prolapse, with minor degrees of protrusion that cause no other problems, must be discussed with the patient but does not necessarily require treatment. In the older population, even extensive prolapse may be asymptomatic from the patient's point of view, but questioning her family or caregiver may reveal troublesome symptoms, and further evaluation may reveal significant resultant morbidity. Offer conservative management to these patients as the initial management option. Conservative management may include observation with mild degrees of asymptomatic prolapse or a pessary fitting. Surgical management may be considered in appropriate candidates if conservative therapies fail or are declined by the patient. RELEVANT ANATOMYSection 4 of 12
The cardinal-uterosacral ligaments are localized thickenings of the endopelvic fascia that invest the pelvic organs. The same endopelvic fascia that is anterior to the vagina is called pubocervical; posteriorly, it is termed rectovaginal fascia or Denonvillier fascia. Laterally, the endopelvic fascia attaches the lateral vagina to the arcus tendineus fascia pelvis to provide paravaginal support of the entire length of the anterior compartment, whereas the distal rectovaginal fascia attaches laterally to the aponeurosis of levator ani.8 The integrity of the vaginal apex following hysterectomy depends on the fusion of the pubocervical fascia with the rectovaginal fascia. Surgically, the uterosacral ligaments lie medial to the ureters in the pelvis. The proximal uterosacral ligament fans out and attaches to the lateral aspect of the sacrum. MRI studies show slight variations in the attachment of the uterosacral ligament, although most overlay the sacrospinous ligament/coccygeus muscle. The proximal vagina usually points into the hollow of the sacrum towards sacral levels 3 and 4 (S3, S4) and maintains a near-horizontal plane when the woman stands erect. Although the term fascia is frequently used to denote the surgically significant layer used for pelvic reconstruction, histologically, it is a fibromuscular layer with varying amounts of smooth muscle, collagen, and elastin that is located deep to the epithelium. CONTRAINDICATIONSSection 5 of 12
Pessary use is contraindicated in the presence of vaginal ulceration and breakdown or in the presence of an active vaginal infection. Severe vaginal atrophy is best treated prior to starting pessary use, in the absence of contraindications for estrogen use. The evaluation of a patient for surgical repair is a topic that is too broad for this article. However, one should tailor the proposed operation to the specific defects noted preoperatively, taking into consideration the patient's overall health and prior surgical history. The chosen approach, whether vaginal, abdominal, laparoscopic, or robotically-assisted should be selected with careful consideration of these patient-related points, in addition to the surgeon's level of skill and available local resources. Appropriate consultations and referrals during the preoperative evaluation can ensure the highest degree of success and safety. WORKUPSection 6 of 12
Lab Studies
Imaging Studies
Diagnostic Procedures
TREATMENTSection 7 of 12
Medical therapySupporting the epithelial environment in the vagina with estrogen, if no contraindication exists, helps minor symptoms of vaginal irritation and discomfort. Estrogen assists the healing process if ulceration is present and prepares the vagina for subsequent pessary use. Short-term topical preparations are preferred because of their rapid effect and limited systemic absorption. The authors use conjugated equine estrogens or estradiol cream 2-3 times a week for at least 4-6 weeks until an effect can be noted. Subsequent to, or in conjunction with, estrogen therapy (depending upon the severity of the prolapse), a pessary may be offered. A tampon can occasionally be used, but only in mild cases. Because of the variety of shapes and sizes of pessaries, the variability in the extent and type of prolapse being treated, and the differences in the patient's anatomy, inform the patient that the initial fitting may require several adjustments. A complete discussion of all available pessaries and their fitting is beyond the scope of this article, but the following observations may be helpful.
Surgical therapySurgery to repair enterocele and apical prolapse should address the underlying defect-specific pathophysiology of the patient's condition and should restore normal anatomy. This includes addressing all 3 levels of vaginal support as discussed previously (see Pathophysiology), with restoration of the normal vaginal axis and the integrity of the endopelvic fascia in all of its compartments. This article is limited to discussing these surgical principles as they relate to management of the failure of level I (apical) support. Pelvic reconstructive procedures can be vaginal, abdominal, laparoscopic, or a combination of these. Surgical techniques can be reconstructive, with the aim of restoring anatomy and maintaining the potential for coitus, or surgical techniques can be destructive procedures that eliminate prolapse at the expense of potential coital function. Preoperative detailsPreoperative bowel preparation is employed using a combination of magnesium citrate and a Fleet enema on the night prior to surgery. The use of volume agents such as GoLYTELY is discouraged because a large amount of residual fluid in the bowel usually occurs, which interferes with adequate visualization. A first-generation cephalosporin is administered as a preoperative antibiotic about 30 minutes prior to the time of the first incision. All reconstructive procedures begin with careful examination under anesthesia, and a Foley catheter is placed after the patient is appropriately prepped and draped. Some physicians advocate catheters with 30-cc balloons for better palpation of the bladder neck, although 10-cc balloons also seem to work well. Intraoperative detailsWhen including hysterectomy as a treatment modality for uterovaginal prolapse, preservation, restoration, and strengthening of pelvic support is of primary importance. Pay particular attention to reattachment of the cardinal-uterosacral ligament complex to the posterolateral vaginal apex (reestablishing its continuity with the rectovaginal fascia), with appropriate shortening of the ligament for adequate support. Specifically in cases of uterovaginal prolapse, the use of permanent sutures is preferable. Culdoplasty is performed per surgeon preference. The most commonly performed culdoplasties are the McCall, Moschcowitz, and Halban methods. Although not described in this article, the McCall culdoplasty approximates the uterosacral ligaments in the midline. The external McCall stitch also incorporates the posterior vaginal apex. The Moschcowitz culdoplasty closes the pelvic peritoneum with purse-string sutures that incorporate both anterior and posterior peritoneum along with the uterosacral ligaments. The Halban culdoplasty shortens each uterosacral ligament using a reefing stitch, with vertical purse-string sutures interposed between the uterosacral sutures. Other procedures exist but are generally variations of these procedures. Culdoplasty serves to close the posterior cul-de-sac and further direct the vaginal apex toward the hollow of the sacrum. It does not, however, address the underlying endopelvic fascial defects at the vaginal apex, as discussed previously. Adequate closure of the cuff serves to reestablish continuity of the endopelvic fascia at the apex by reapproximating pubocervical fascia with rectovaginal fascia at the most proximal end. The combined effect of proper orientation of the upper vagina in a near-horizontal plane (in the erect position) and the reestablishment of endopelvic fascial integrity as described constitutes both the treatment and prevention of enterocele. All significant pelvic floor defects need to be addressed during this surgery to decrease the likelihood of recurrence. Repair of pelvic floor defects may be performed vaginally and may include anterior colporrhaphy, paravaginal repair, posterior colporrhaphy, and/or perineorrhaphy as required. Vaginal approaches Vaginal approaches to reconstruction of the vaginal vault (following prior hysterectomy) include sacrospinous ligament fixation (unilateral or bilateral), bilateral iliococcygeus fascia suspension, or the uterosacral vaginal vault suspension. Each of these reconstructive procedures addresses level I (apical) support. Procedures such as the Le Fort partial colpocleisis or colpectomy with colpocleisis are useful in particular situations, but they are not considered reconstructive techniques. Sacrospinous ligament fixation begins with incision of the posterior vagina in the midline or just lateral to the midline to the level of the vaginal apex. If an enterocele is encountered, it may be completely dissected and opened. The bowel contents are reduced, and the redundant peritoneum is excised. Alternatively, the sac may be left as is, since the most important part of the repair is the proper identification and reapproximation of the endopelvic fascial defect at the apex, preferably with permanent sutures. The rectovaginal space is then dissected laterally, and the rectal pillar is perforated to gain access to the pararectal space in a position overlying the ischial spine. The space is developed, the sacrospinous ligament within the coccygeus muscle is palpated, and the surrounding area is cleared off gently. Several instruments are available to penetrate the ligament for adequate suspension, including the Deschamps ligature carrier, the Miya Hook (CooperSurgical, Inc, Trumbull, Conn) the Nichols-Veronikis ligature carrier (BEI Medical Systems Company, Inc, Teterboro, NJ), the Capio device (Boston Scientific Corporation, Natick, Mass) (see Media file 9), and the EndoStitch (U.S. Surgical, Norwalk, Conn). Take care to avoid injury to the inferior gluteal artery, pudendal neurovascular bundle, and the sciatic nerve (see Media file 10). Avoid dissection superior to the coccygeus muscle and lateral to the ischial spine. Do not place retractors beyond the sacrospinous ligament and never pass the ligature carrier/needle posterior to the ligament because of risk of vascular injury of the inferior gluteal artery. The ligature carrier should pierce the ligament 1.5-2 finger breadths medial to the ischial spine, without encircling the coccygeus muscle (see Media file 11). Two sutures are used, with at least one that is permanent. They are sutured to the muscularis of the vagina, incorporating rectovaginal fascia but excluding vaginal mucosa because of the high incidence of granulation tissue at the site of the surgical knots of permanent suture. A second stitch can be delayed absorbable and brought out through the vaginal epithelium (see Media file 12). Avoid suture bridging when tying down these sutures. Some physicians have advocated bilateral sacrospinous ligament fixation for a more durable repair. The authors prefer bilateral sacrospinous attachment in defect-directed repair and reconstruction of the rectovaginal septum when adequate uterosacral ligaments are not found. Exercise clinical judgment intraoperatively to determine whether this can be accomplished without undue tension. Consider the potential benefits in view of the potential increase in risk, both from intraoperative injury and the long-term effect on vaginal anatomy. Uterosacral vaginal vault suspension with fascial reconstruction aims to restore normal level I anatomy (see Media file 13). This does not result in lateral deviation of the proximal vagina or in the posterior displacement observed with sacrospinous ligament fixation. Uterosacral ligament reattachment may be performed vaginally by the transperitoneal approach as depicted below, but it can also be accomplished retroperitoneally without the need to open the enterocele sac. Once the posterior vagina is opened, the enterocele sac is identified and excised, the peritoneal cavity is entered, and the uterosacral ligaments are identified distally and are gradually "walked up" toward the sacrum using Allis clamps. Identification may be aided by inserting a finger rectally and palpating the proximal rectovaginal fascia. The proximal aspect of the ligament at the level of the ischial spine is used for resuspension to exclude the defect that is responsible for the prolapse. Permanent sutures are used to grasp and hold each ligament separately in a helical bite; anterior compartment defects can be addressed at this stage. The ligaments are sutured to the rectovaginal fascia laterally near the apex and also incorporated into the proximal lateral cervicovaginal fascia anteriorly without midline plication. The authors prefer at least 2 stitches in each uterosacral ligament with reapproximation of the pubocervical and rectovaginal fascia across the vaginal apex to correct or prevent enterocele. Posterior colpoperineorrhaphy may be performed as needed. Take care to ensure the integrity of the ureters by carefully palpating the uterosacral ligament, staying medial to the ureter, and liberally using cystoscopy with intravenous indigo-carmine dye. Le Fort partial colpocleisis involves retention of the uterus, and, therefore, should be preceded by dilatation and curettage (D&C). This procedure may be performed under local or regional anesthesia to accommodate a patient who is frail. Rectangular strips of both anterior and posterior vagina are obtained, extending from 2 cm distal to the cervix to the level of the bladder neck anteriorly and similarly on the posterior vaginal wall. Sufficient vagina is left laterally to fashion bilateral canals for drainage (see Media file 14). Dissection should leave adequate endopelvic fascia anteriorly and posteriorly to retain strong tissue for reapproximation. Excellent hemostasis is required and achieved by electrocautery. Some authors prefer plication of the bladder neck (eg, Kelly plication) at this stage, even if no demonstrable or occult stress incontinence has been demonstrated preoperatively. The anterior and posterior denuded vaginal walls are sutured with either an interrupted or continuous delayed absorbable suture in a progressive manner to invert the prolapsed vagina. The lateral mucosal edges are reapproximated so that lateral tunnels are formed throughout the length of the vagina on either side. If actual or occult incontinence has been demonstrated preoperatively, a tension-free vaginal tape (TVT) or transobturator tape (TOT) may be performed by adding a midline vaginal incision at this time and continuing as per routine for TVT or TOT. For posthysterectomy vault prolapse, a colpectomy with colpocleisis is performed in a similar fashion, except that no mucosa-lined tunnels are created. The entire vaginal mucosa is dissected off in strips, and the vaginal endopelvic fascia is progressively inverted by concentric purse-string sutures of delayed absorbable material once meticulous hemostasis is achieved. The urethra and bladder neck are managed in the same way as described for a Le Fort procedure. Recently, various minimally invasive, trocar-based vaginal kits have become popular in the management of vaginal vault prolapse. Although several are on the market, no well-designed comparison studies are available to determine their place in the management of pelvic organ prolapse. Abdominal approaches to vaginal vault suspension include sacral colpopexy or uterosacral reattachment with fascial reconstruction. The abdominal approach allows for concomitant abdominal procedures to be performed, including paravaginal repair, Burch colposuspension, or suburethral sling (depending upon associated pelvic floor defects, preoperative urodynamics, concomitant pelvic pathology, and medical history). Often, concurrent vaginal surgery is required to complete adequate reconstruction. In either technique, carefully exclude enterocele and repair the enterocele if found. When performing defect-specific repair, this is accomplished abdominally by incising the peritoneum at the vaginal cuff and identifying the endopelvic fascia. If a break is found, it is repaired with interrupted permanent sutures (see Media file 15). Conversely, a traditional Moschcowitz or Halban procedure is recommended by some urogynecologists. Abdominal sacral colpopexy may be performed with fascia but is most often performed with a permanent mesh, such as Mersilene or Prolene. The authors prefer a Y configuration, with the distal end of the graft attached to the anterior and posterior aspects of the vaginal cuff and spacing allowed between the crux of the Y and the vaginal cuff (see Media file 16). This decreases the amount of mesh in contact with the vagina, which may be important in the prevention of subsequent erosion. Reperitonealization is important to avoid subsequent entrapment of the bowel within the mesh. Formal culdoplasty, such as a traditional Moschcowitz or Halban procedure, has been advocated, although the authors have not found it necessary as long as the enterocele has been repaired as described and the vagina is attached to level S3 and not higher. Take care to avoid damage to the bladder and rectum during dissection, as well as the ureters, particularly on the right side. Cautiously proceed with the dissection in the presacral space and pay attention to avoid damage to the midsacral vessels. Avoid putting tension on the vagina with the mesh in place. Recent data from the colpopexy and urinary reduction efforts (CARE) randomized trial evaluated the use of Burch colposuspension at the time of sacrocolpopexy in women who were stress continent. Patients who received a prophylactic Burch colposuspension were about half as likely to develop stress urinary incontinence after the surgery. No differences were noted in the development of postoperative urgency symptoms in the 2 groups.9 High uterosacral reattachment is performed using the same principles discussed previously. A relaxing incision medial to the ureter occasionally may be helpful to avoid damage or distortion to the ureter, but is usually not necessary. Reconstruction of the continuity of endopelvic fascia is the cornerstone of therapy. The authors find a Moschcowitz or Halban culdoplasty unnecessary. Maintain an adequate hiatus between the sigmoid and vagina after the sutures are tied by allowing 2 finger breadths. Avoid upward tension on the vagina. As discussed previously, the uterosacral vaginal vault suspension with fascial reconstruction may be performed vaginally or abdominally. Using the same principles, this procedure is amenable to the laparoscopic approach as well (see Media file 20). Similarly, sacral colpopexy has also been reported via the laparoscopic approach. These are useful surgical approaches if the surgeon takes care not to alter the operation in a way that would fundamentally change and weaken the reconstruction. Postoperative detailsThe authors strongly recommend following all reconstructive surgical procedures with IV indigo-carmine dye and cystoscopy. Intraoperative identification and immediate repair of ureteral injury is associated with reduced morbidity and an improved outcome. Postoperatively, stool softeners have been suggested, although they are not mandatory unless a concomitant anal sphincteroplasty has been performed or the patient has a propensity for developing severe constipation. If stool softeners are indicated, administer them for 2 weeks. Follow-upPatients usually are seen 2 weeks and 6 weeks following surgery. For long-term follow-up, they are observed every 6-12 months, as needed. For excellent patient education resources, visit eMedicine's Women's Health Center. Also, see eMedicine's patient education article Prolapsed Uterus. COMPLICATIONSSection 8 of 12
Hemorrhage; operative site infection; and damage to the bowel, bladder, and ureters are the most common complications during reconstructive pelvic surgery, regardless of the route or method chosen. Dyspareunia also may develop, especially when posterior vaginal incisions are employed. Additional complications shared by all pelvic surgeries, such as thromboembolism, cardiac events, or pneumonias, require meticulous preoperative and postoperative management and adequate prevention strategies (see Preoperative Details and Postoperative Details). Of particular concern to the urogynecologist is the development of postoperative urinary retention and severe constipation, which are less affected by the actual vault suspension and more affected by the preoperative and postoperative management and concurrent surgical procedures. Sacrospinous ligament fixation can result in severe hemorrhage from the inferior gluteal artery, internal pudendal vessels, or the hypogastric venous plexus. Damage to these structures is best avoided as delineated above (see Sacrospinous ligament fixation). In the event of such hemorrhage, initial packing is most beneficial, with individual and careful ligation using clips or suture. Hypogastric artery ligation is only helpful if the internal pudendal artery is hemorrhaging. The most common vessel injured is the inferior gluteal artery. Another complication of sacrospinous ligament fixation is buttock pain on the side of fixation. This occurs in 15% of patients and usually resolves spontaneously by 6 weeks, requiring reassurance and nonsteroidal anti-inflammatory agents. Other possible complications of sacrospinous ligament fixation include damage to the sciatic nerve, rectal injury, vaginal stenosis, and subsequent defects of anterior compartments. Damage to the sciatic nerve is possible and necessitates removal of the offending suture. Rectal injury may occur and is best avoided by adequate medial retraction of the rectum during the procedure. Vaginal stenosis may occur if excessive amounts of the vagina are removed during anterior and/or posterior colporrhaphy concurrent with sacrospinous ligament fixation. Because of the posterior displacement of the upper vagina, patients are prone to subsequent anterior compartment defects at a rate of approximately 8%. Colpocleisis is a safe procedure and, in fact, is used in patients who otherwise may not be good surgical candidates for more extensive reconstruction. Immediate complications are rare but may include bleeding, infection, urinary retention, and urgency. Postoperative stress incontinence may occur in 10% of cases when the vesical neck and/or urethra are not adequately supported. To avoid this, if true occult or obvious SUI exists preoperatively, a TVT or TOT may be included in the procedure, or, if no incontinence is demonstrable, a suburethral Kelly plication may prevent future incontinence. Abdominal sacral colpopexy may result in life-threatening hemorrhage from the presacral venous plexus. Such bleeding may be particularly difficult to control because of extensive anastomosis, lack of venous valves, and retraction of the vessels into the sacral bone when they are completely severed. Because of the likelihood that packing with laparotomy packs may exacerbate bleeding upon their removal and further shearing of these delicate veins, careful application of pressure with a gloved finger is the initial maneuver to arrest such hemorrhaging. Bleeding may be stopped by clips, cautery, or suture; maintain keen awareness of the location of the iliac vessels, ureters, and rectum. If these measures are unsuccessful, sterile stainless steel or titanium thumbtacks may be used at the point of bleeding from a retracted presacral vessel. Bone wax has also been used successfully in the management of such bleeding. Other early complications of abdominal sacral colpopexy include mesh infection, bowel obstruction, and ileus. Mesh erosion is a late complication and occurs in 3-7% of cases. Suspect the diagnosis of mesh infection in a patient following abdominal sacral colpopexy with mesh at any interval when the patient reports persistent vaginal discharge, bleeding, and/or dyspareunia. Conservative measures using estrogen vaginal cream may be tried first, although results have been disappointing. Some physicians advocate an abdominal approach to remove the entire mesh. Dissection in this circumstance tends to be quite difficult because of scarring and should be attempted only if a more conservative vaginal approach has failed or is associated with postoperative infection. If possible, leaving the sacral attachment is prudent because of the potential for severe hemorrhage from the scarred presacral space. Vaginally excising the eroded mesh as deep as is safely accessible, undermining and freshening the edges of the involved vagina, and closing it primarily with delayed absorbable sutures generally is preferable. Recurrence of apical prolapse usually is not observed following mesh excision, although it may be related to close temporal proximity to the original surgery. Despite this, do not delay management of mesh erosion. OUTCOME AND PROGNOSISSection 9 of 12
Sacrospinous ligament fixation was reviewed by Sze and Karram.10 They report an overall failure rate of 19%, a reoperation rate for recurrent prolapse of 2.7%, and a reoperation rate for apical recurrence of 1.8%. Abdominal sacral colpopexy has an overall failure rate of less than 10%, as reported by multiple studies. Destructive operations, such as the Le Fort procedure, also have a success rate of over 90%. Benson et al reported the first randomized comparison between abdominal and vaginal approaches to pelvic floor defects.11 They reported a reoperation rate of 12% (5 of 42) for recurrent apical prolapse when performed vaginally and a reoperation rate of 2.6% (1 of 38) when performed abdominally. They report unsatisfactory results leading to reoperation in 33% of the vaginal group versus reoperation in 16% of the abdominal group, with a mean follow-up of 2.5 years (range of 1-5.5 y). Maher et al also performed a randomized prospective trial comparing sacrospinous ligament fixation with abdominal sacral colpopexy in posthysterectomy vaginal vault prolapse.12 Follow-up averaged 2 years postsurgery and showed a subjective success rate of 94% in the abdominal group and 91% in the vaginal group with objective cure rates of 76% in the abdominal group and 69% in the vaginal group. These differences were not statistically significant. The abdominal approach showed longer operative times, slower return to normal activity, and increased costs compared with the vaginal approach. These 2 studies have conflicting outcomes. Thus, further studies are needed before any definitive conclusions can be made. FUTURE AND CONTROVERSIESSection 10 of 12
Few well-controlled comparative studies regarding the treatment of apical prolapse are available in the literature. The concept of defect-specific repair in female pelvic reconstructive surgery is one that has been embraced by many, but not all, urogynecologists and pelvic surgeons. Whether long-term outcomes are improved using this concept remains to be determined through well-designed studies with long-term follow-up. Newer trocar-based kits may present potential improvement in correction of impaired endogenous tissue; however, they invariably require implanting large amounts of mesh. Their long-term use, efficacy, and safety remain to be determined. The surgeon managing these complex problems of the pelvic floor should be proficient in a variety of procedures and approaches so that the patient may be fitted with the surgery that is the most appropriate for her specific set of problems. MULTIMEDIASection 11 of 12
REFERENCESSection 12 of 12
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