Vaginal Vault Suspension
- Author: G Willy Davila, MD; Chief Editor: Christine Isaacs, MD more...
Vaginal prolapse is the herniation of the pelvic organs to or beyond the vaginal walls. It is reported to be the most common reason for hysterectomy in women over age 50 and that a half million procedures are performed for prolapse in the United States annually. The number of women with pelvic organ prolapse who are managed without hospitalization and surgery and the number of women with prolapse who never seek medical treatment is not known. Incidence and prevalence estimates based on surgical procedure rates almost certainly underestimate the magnitude of the problem.
Maintenance of normal vaginal anatomy depends on the interrelationships of intact pelvic floor neuromusculature, ligaments, and fascia. This complex relationship of vaginal support is perhaps least understood at the vaginal apex or vault. Without proper identification and correction of vaginal vault prolapse, surgical correction of the other vaginal compartments is recognized to likely fail. This in part contributes to the 29.2% reoperation rate of women who undergo pelvic floor reconstruction.
In a nonhysterectomized woman, the vault, or apex, is located posterior and superior to the cervix (see the image below). After a hysterectomy, the scar site assumes the position of the vaginal apex or vault.
The vaginal apex is the site at which multiple vaginal support structures converge. If the cervix is present, it serves as a strong attachment point for the ligaments and fascia. A woman who has had a prior hysterectomy may not have a strong attachment point, leading to vault support weakness and potential prolapse.
DeLancey described the connective tissue support of the vagina as having 3 levels. Level I support is composed of the uterosacral/cardinal ligament complex that originates at the cervix and upper vagina and inserts at the pelvic sidewall and sacrum. This ligamentous complex suspends the uterus and upper vagina in its normal orientation. It helps maintain vaginal length and normal vaginal axis. Loss of level I support contributes to prolapse of the vaginal apex.
Level II support comprises the paravaginal attachments that run the length of the vagina and are suspended by the arcus tendineus fasciae pelvis (ATFP), or lateral pelvic white line. Loss of level II support contributes to cystocele (anterior vaginal prolapse).
Level III support is provided by the perineal membrane, perineal body, and superficial and deep perineal muscles. These structures support and maintain the normal anatomical position of the urethra and distal third of the vagina. Disruption of this level of support anteriorly can result in urethral hypermobility and stress incontinence and posteriorly may result in a rectocele or perineocele.
As stated above, it is the level I support, the uterosacral/cardinal ligament complex, that plays the most important role in maintaining vaginal vault support.
The endopelvic fascia is the fibromuscular tissue layer that underlies the vaginal epithelium. This layer envelopes the entire vaginal canal, extending from apex to perineum and arcus tendineus to arcus tendineus. The endopelvic fascia helps maintain the integrity of the vaginal walls. Therefore, a tear in this layer causes herniation of the underlying tissue. If a tear exists at the level of the vaginal apex, an enterocele can develop anteriorly or posteriorly, further leading to the breakdown of apical integrity. Reconstructive surgeons need to understand the importance of this layer and its reattachment to the vaginal apex in order to correct anterior or posterior vaginal wall prolapse. If the fascia is of poor quality, a graft may be required to reinforce the repair.
Contraindications to prolapse correction are based on the patient’s medical comorbidities and the risk they pose to surgery. Regional anesthesia can be used to lessen risk when surgery is performed vaginally. Appropriate surgical clearance, use of pulsatile anti-embolism stockings, prophylactic antibiotics, and diligent positioning using Allen stirrups help minimize perioperative complications. Atrophic, thinned, or ulcerated vaginal mucosa should be pretreated with local estrogen for an appropriate period of time.
Multiple components to vaginal vault support exist, including uterosacral and cardinal ligaments, endopelvic fascial envelopes, and lateral paravaginal attachments. The relationship between these components is both dynamic and static, and, when they are damaged, vaginal vault prolapse ensues. In a woman with intact uterine support, all of these structures attach to the uterus and provide appropriate support. If during a hysterectomy these structures are not firmly re-attached to the vaginal cuff, vault prolapse can occur.
Data from women enrolled in the Women’s Health Initiative reported that in women with an intact uterus, 41.1% had some form of prolapse and 14.2% had uterine prolapse. Of those women who had a prior hysterectomy, almost 38% had some form of prolapse.
In women who have had a prior hysterectomy, the incidence of prolapse requiring surgical correction is 1% at 3 years and 5% at 17 years following their hysterectomy.
The risk of prolapse increases with advancing age and the incidence of prolapse likely increases as life expectancy does.
Vaginal vault prolapse is a complex disorder not usually caused by one inciting incident. Rather, it usually results from a series of events that occur over a women’s lifetime. Collagen disorders and race can play a role in the development of vault prolapse, as can childbirth, menopause, and previous pelvic floor surgery that disrupted the apical support system. Any condition that chronically raises intra-abdominal pressure, such as chronic obstructive pulmonary disease (COPD), chronic constipation, and heavy lifting, can also contribute to the breakdown of vault support.
A woman’s symptoms are largely based on the severity of her prolapse. With minimal or stage 1 prolapse, a woman may be asymptomatic and not need any active intervention. As the prolapse progresses, women may experience vaginal fullness, lower back pain, urinary or defecatory dysfunction, dyspareunia, and pelvic pain. As prolapse worsens, the vault becomes exteriorized with a palpable and visible bulge which may bleed from mucosal ulcerations.
Accurate identification of vaginal vault support is critical for the correction of vaginal prolapse. Even to the experienced clinician, identifying apical prolapse (especially in the presence of a large cystocele or enterocele) is difficult (see image below). Most importantly, if the apical prolapse is not corrected at the time of the initial prolapse repair surgery, prompt recurrence of the prolapse may occur. It is also important to help guide the surgical approach.
The presence of an exposed cervix does not necessarily mean vaginal vault prolapse exists. Cervical hypertrophy can cause the cervix to protrude from the vaginal introitus while leaving the vault well supported. To evaluate, the posterior blade of a bivalved speculum is placed in the posterior fornix, and the patient is asked to Valsalva while the blade is slowly removed. If vault prolapse exists, the uterus descends further as the speculum is removed, and reinsertion of the speculum resuspends the uterus. If the vault is well supported, the uterus stays in place despite Valsalva efforts.
In a woman who has undergone hysterectomy, the primary goal during the vaginal examination is to identify the apical scar tissue resulting from the prior hysterectomy. Significant prolapse may have stretched the apical scar tissue band making it difficult to identify. A bivalve speculum helps in visualization of the apex, but redundant vaginal mucosa associated with substantial prolapse may make this challenging. In most cases, the site of the prior uterosacral cardinal ligament complex can usually be identified as dimples on the lateral edges of the apex.
Using 2 right-angle speculum blades, or one blade to retract the anterior wall and the examiners hand to retract the posterior wall, the patient is asked to Valsalva and the degree of vault prolapse is assessed. The tip of the speculum can then be placed between the dimples to elevate the vault and assess the degree of vault prolapse. This can also be done with the examiner’s hand by identifying the dimples and elevating them to their ipsilateral spines.
As stated above, the evaluation should guide the surgeon in planning the most appropriate surgical approach. Most reconstructive surgeons prefer a vaginal approach. However, the decision should be made based on what is best for the patient and her anatomic alterations.
The importance of sexual function should be assessed. If the patient reports vaginal sexual function is a key consideration, then a sacrocolpopexy should be the primary consideration, given it will avoid any vaginal incisions and potentially avoid any vaginal shortening or narrowing. The examiner should also assess vaginal length. A woman whose apex reaches the ischial spines without difficulty will likely be successful with a vaginal procedure. If the apex does not reach the spines or reaches well beyond them, she may be better served with either an obliterative procedure or abdominal colpopexy.
In today’s age of frequent graft use, the patient’s history of prior reconstructive surgery should be evaluated. This may lead to scarring or fibrosis around the sacral promontory or sacrospinous ligaments. The presence of a paravaginal defect should also be assessed, as this would be better repaired abdominally.
The quality of the patient’s tissue and the subsequent need for a graft at the time of the surgical procedure should also be assessed. Lastly, many women with pelvic organ prolapse also have coexistent colorectal problems that may require surgical correction. If this is the case, the surgical approach that would best accommodate both procedures should be considered.
Most clinicians grade prolapse based on either the Baden Walker halfway system or the Pelvic Organ Prolapse Quantification System (POP-Q) classification. The POP-Q classifications are as follows:
Stage 0 - No prolapse
Stage I - Descent of the most distal portion of the prolapse more than 1 cm above the hymen
Stage II - Descent of the most distal portion of the prolapse between 1 cm above and 1 cm below the hymen
Stage III - Descent of the most distal portion of the prolapse beyond 1 cm below the hymen but less than total vaginal length (TVL) -2 cm
Stage IV- Total or complete vaginal eversion
The goal of surgery is the restoration of vaginal vault support, as well as correction of all pelvic floor defects in order to have the most successful outcome.[6, 7] Therefore, bladder function, sexual function, and anterior and posterior support should all be assessed prior to surgery and corrected along with apical support.
Vaginal vault support procedures can be divided into abdominal and vaginal approaches. The decision is based on the preoperative physical examination and the patient’s sexual function.
This technique was introduced by McCall in 1957 and involves plication of the uterosacral ligaments in the midline while reefing the cul-de-sac peritoneum, including full thickness of the apical vaginal mucosa, in a posterior culdoplasty. It is typically done at the time of vaginal hysterectomy and uses nonabsorbable sutures, although delayed absorbable sutures may be used. As a general rule, the authors try to place the uppermost suture on the uterosacral ligament at a distance from the cuff equal to the amount of vault prolapse present (see image below).
The ureters lay approximately 1-2 cm lateral to the uterosacral ligaments at the level of the cervix, so being cautious to not kink or injure the ureters when placing the sutures is important. Cystoscopy with visualization of ureteral patency, usually with administration of intravenous indigo carmine, is recommended following the procedure.
Webb et al followed patients up to 8.8 years and reported 71% did not require any further prolapse operation. They also found 82% were "very satisfied" or "somewhat satisfied" with their results.
Uterosacral ligament suspension
Reattaching the uterosacral ligaments to the vaginal apex is likely the most physiologic approach to vault prolapse (see image below). The technique involves opening the vaginal wall over the apical defect into the peritoneal cavity and identifying the pubocervical fascia, rectovaginal fascia, and uterosacral ligaments.
A permanent 1-0 suture as well as one delayed absorbable 1-0 suture is placed in the posteromedial aspect of each uterosacral ligament 1-2 cm proximal and medial to each ischial spine. Next, one arm of the permanent and the delayed absorbable suture are placed through the pubocervical and rectovaginal fascia as well as the vaginal epithelium at the apex. After any additional vaginal repairs are completed, the sutures are tied, elevating the vaginal vault. If extensive vaginal prolapse exists, redundant peritoneal tissue can sometimes make identifying the uterosacral ligaments difficult.
Success rates for uterosacral ligament suspension are 87% to 90%, but ureteral injury has been reported to be as high as 11%, making it a limiting factor in the success of the technique.[9, 10] Given this reported high complication rate, cystoscopy following suspension is essential.
This technique involves elevating the apex to the iliococcygeus muscle overlying fascia along the lateral pelvic sidewall. It is a safe and simple procedure and can be done without any vaginal incision by placing a monofilament permanent suture into the muscle through the vaginal wall either unilaterally or bilaterally. It can be used when isolated unilateral vaginal vault prolapse occurs, which can develop following a unilateral sacrospinous fixation or as a result of a high unilateral paravaginal defect. The presence of a permanent suture at the vaginal apex can potentially cause dyspareunia, so this technique should be used with caution in women who are sexually active. It is most useful as a salvage procedure for unilateral apical prolapse.
The suspension can also be performed at the time of a posterior wall dissection in which the sutures are placed into the fascia overlying the iliococcygeus, anterior to the ischial spine along the arcus tendineus fascia pelvis, and incorporating the pubocervical fascia anteriorly and the rectovaginal fascia posteriorly.
Shull et al reported a 95% cure rate of vault prolapse following iliococcygeus suspension; however, he also found a 14% rate of prolapse at other sites during the follow-up period. A randomized controlled trial comparing iliococcygeus suspension with sacrospinous fixation demonstrated similar outcomes.
Suspension of the vaginal apex to the sacrospinous ligaments is one of the most commonly performed vault suspension procedures (see image below). It can be performed unilaterally or bilaterally, but bilateral fixation avoids vaginal axis deviation, giving a more physiologic correction of the vaginal vault prolapse.
Sacrospinous fixation is performed by entering the pararectal space through a posterior wall dissection. The sacrospinous ligaments are identified, running from the ischial spine to the sacrum. Next, 2 nonabsorbable sutures are placed through the ligament, not around it, as the pudendal nerve and vessels sit behind the ligament and damage to these structures can cause significant morbidity. The first suture is placed 2 cm medial to the ischial spine, and the second 1 cm medial to the first. Each suture is then passed through the vaginal apex so that when tied the apex is reapproximated to the ligament. Any additional reconstructive procedures are then performed.
The success rate of sacrospinous fixation is greater than 90% in multiple series. The concern lies in the exaggerated horizontal axis in which the procedure leaves the vagina, which increases force on the anterior compartment with increases in abdominal pressure. This is especially true if an anti-incontinence procedure is performed at the same time. The rate of cystocele formation following sacrospinous fixation is reported at 20%-30%. Other complications of the procedure include hemorrhage, vaginal shortening, sexual dysfunction, and buttock pain.
This is the simplest treatment for advanced prolapse in women who are not, and will not, be sexually active. A LeFort colpocleisis involves denuding rectangles of vaginal epithelium on the anterior and posterior vaginal wall and then approximating them front to back to one another. This is combined with a high perineoplasty. The success rate for LeFort is above 95% and postoperative pain is minimal.
Vaginal mesh kits can be divided into trocar-based kits that use a transobturator or transgluteal approach to suspend the vagina and nontrocar kits that use a transvaginal fixation method. The trocar guided kits include the Prolift (Ethicon, Somerville, NJ), Apogee and Perigee (American Medical Systems, Minnetonka, MN), and Avulta (CR Bard, Murray Hill, NJ).
Trocar guided kits use a precut sheet of graft material with arms that are used for fixation. Nontrocar kits include Elevate (American Medical Systems, Minnetonka, MN) and Pinnacle and Uphold (Boston Scientific, Natick, MA). With either type of kit some basic surgical principles apply; the vagina should be well estrogenized before surgery and any vaginal pessary should be removed for 2 weeks prior to surgery to avoid any vaginal epithelium irritation. Exposure of the correct vesicovaginal and rectovaginal planes can be accomplished through hydrodissection; lidocaine with epinephrine, dilute pitressin, or normal saline can be used. Correct hydrodissection should create a bubble in the avascular space. Mesh should be placed loosely because it can contract up to 20% after placement, which can compromise vaginal length and caliber.
On July 13, 2011, the FDA issued a statement that serious complications are not rare with the use of surgical mesh in transvaginal repair of pelvic organ prolapse. The FDA reviewed the literature from 1996-2011 to evaluate safety and effectiveness and found surgical mesh in the transvaginal repair of pelvic organ prolapse does not improve symptoms or quality of life more than nonmesh repair. The review found that the most common complication was erosion of the mesh through the vagina, which can take multiple surgeries to repair and can be debilitating in some women. Mesh contraction was also reported, which causes vaginal shortening, tightening, and pain.
The FDA’s update states, “Both mesh erosion and mesh contraction may lead to severe pelvic pain, painful sexual intercourse or an inability to engage in sexual intercourse. Also, men may experience irritation and pain to the penis during sexual intercourse when the mesh is exposed in mesh erosion.” The FDA is continuing to review the literature regarding surgical mesh in the treatment of stress urinary incontinence and will issue a report at a later date. See the full update regarding surgical mesh in pelvic organ prolapse here: FDA Safety Communication: Update on Serious Complications Associated with Transvaginal Placement of Surgical Mesh for Pelvic Organ Prolapse.
Apogee vaginal vault suspension
The Apogee system (American Medical Systems, Minnetonka, MN) creates neoligaments that are analogous to the Cardinal by anchoring graft arms at sites adjacent to the ischial spines, at the attachment of the arcus tendineus (see the image below).
The technique is performed by accessing the pararectal space and palpating the ischial spine and arcus tendineus. A modified SPARC needle is passed through a pararectal incision that is made 3 cm lateral and 3 cm posterior to the anus. The needle is then guided through the ipsilateral levators and then through the iliococcygeus muscle, ultimately anchoring into the arcus tendineus at the level of the ischial spine. The exact anchoring point for the Apogee is 0.5-1 cm anterior to the ischial spine through the white line.
The polypropylene mesh arms are attached to the needle and brought out through the para-anal incision. The graft is secured to the vaginal apex and the perineal body by interrupted delayed absorbable sutures. This re-creates apical support from ischial spine to ischial spine and gives a physiologic vaginal axis. Vaginal length averages 7-9 cm and success rate is 88% to 100% with minimal complications It is available in synthetic polypropylene mesh and biologic porcine dermis.
The Prolift system (Ethicon, Somerville, NJ) uses a slightly curved C-shaped trocar to anchor either into the arcus tendineus fascia pelvis (ATFP) or the sacrospinous ligament, depending on the approach taken (see the images below). The graft material is then laid down in a tension-free fashion.
Elmér et al found that the anatomic cure rate at one year for anterior repair was 79%, 82% for posterior repair and for combined anterior, and posterior repair cure rate was 81% and 86%, respectively. They also found that mesh erosions occurred in 11% of the cases. In another prospective trial, anatomic cure rate at 12 months was found to be 91% with a 15% mesh erosion rate.
The Avaulta System (CR Bard, Covington, GA) is another trocar-based vaginal mesh kit. It is similar to the above mentioned kits as trocars are used to fixate synthetic mesh (see the image below). Dissection is also similar and is done up to the level of the ischial spines. The Anterior kit fixation point is 1-2 cm lateral and 3 cm posterior to the ATFP near the ischial spine. The Posterior fixation point is the sacrospinous ligament at the ischial spine. The Avaulta comes as a posterior or an anterior kit. The posterior kit addresses both the vaginal vault and the posterior vaginal compartment while the anterior kit is used to treat cystoceles.
A recent trial that followed patients out for an average of 14 months found a surgical cure rate of 81% using a definition of any POP-Q point greater than 0 or any reports of vaginal bulge. They reported a mesh erosion rate of 11.7% and de novo pain in 3.3% of patients.
The Elevate apical prolapse repair system (American Medical Systems, Minnetonka, MN) is a single-incision procedure that uses small polypropylene fixation anchors to affix polypropylene mesh arms to the sacrospinous ligaments (see image below). The advantage is that the anchors are able to access the sacrospinous ligament without going through or behind it, avoiding potential neurovascular complications. Additionally, the Elevate does not use external needle passage avoiding the risk of long term postoperative pain from banding or tension.
The procedure is started with a midline vaginal incision along the anterior or posterior vaginal walls, which is used to access the sacrospinous ligaments and ischial spine through the paravaginal space. Next, using either a retractor or the operator’s hand, the rectum is swept medially for safety and the needle tip is positioned onto the ligament approximately 2 cm medial to the ischial spine to avoid neurovascular injury. The loose eyelets of the graft then slide over the fixation rods until they engage the mesh part of the fixating arms. The graft is then trimmed and the apical portion of the mesh is fixated to either the cervix or the vaginal apex. Final tensioning is then done and the fixating arms trimmed. It is important to ensure that the mesh is flat and the edges do not roll out.
A recent prospective multicenter trial demonstrated a cure rate of 92.5% at 12 months for the posterior wall and 89.2% apical cure rate. Extrusion was seen in 6.5% of subjects.
Pinnacle and Uphold
The advantage to nontrocar kits is the complete vaginal approach. These kits avoid the transobturator space so surgeons who are not familiar or comfortable with the area can still use a vaginal mesh kit for suspension of the vagina. With a total vaginal approach, no blind procedures exist; the mesh appendage placement can be done under direct visualization.
The dissection for both the Uphold and the Pinnacle (Boston Scientific, Natick, MA) are similar to that described for the Elevate system (American Medical Systems, Minnetonka, MN). Once the sacrospinous ligament is palpated and the insertion point has been cleaned off, the ligament is penetrated using the Capio transvaginal capturing device (Boston Scientific, Natick, MA) to suture the mesh arms to the sacrospinous ligament and the ATFP. The mesh arms are slowly and loosely tensioned and the mesh is sutured flat. The vagina is then minimally trimmed, if needed, keeping in mind that the epithelium will contract as it heals, and closed.
Abdominal sacral colpopexy
This is considered by most surgeons to be the criterion standard procedure for repair of vaginal vault prolapse (see image below). Although the procedure requires an abdominal incision and has a higher overall morbidity compared to vaginal procedures, its longevity and physiologic results as well as having the least risk of sexual dysfunction and dyspareunia make it very appealing.
The procedure is begun through an abdominal incision then exposing the sacral promontory by incising the peritoneum between the right ureter and the sigmoid colon. Sutures (2-0 polypropylene) or bone anchors are used to place 2-3 sacral suspensory sutures. Next, the vaginal apex is identified using either the operator’s hand or the obturator of an end-to-end anastomosis rectal tool. The bladder and peritoneum are dissected off the anterior vaginal wall and any fascial tears are identified and repaired.
The graft used for the procedure is synthetic polypropylene graft with a long arm (4-5 cm) that will extend down the posterior vagina, and a shorter end (2-3 cm) that is secured to the anterior vaginal wall. Typically, 3 rows of 2-0 polypropylene sutures are placed along the back wall, and 2 rows are placed along the anterior. Once secured to the graft the vault can be suspended to the sacral promontory with minimal tension. Prior to suspending the apex, a culdoplasty should be performed to obliterate the cul-de-sac and prevent future enterocele formation.
After the vault is suspended, the abdomen is copiously irrigated and the peritoneum closed.
The major complications related to the procedure are hemorrhage from the sacral promontory and postoperative ileus. The risk of bleeding can be minimized by using bone anchors on the sacral promontory.
Patients need to avoid any heavy lifting (over 5 pounds) for at least 6 weeks after surgery. At their 6-week postoperative visit, the surgical site is assessed, and, if the area is well healed, the patient is instructed to progressively return to their usual daily activities. Postmenopausal patients are instructed to use vaginal estrogen (we use 1 g twice weekly) to maintain integrity of the pelvic tissues.
Patients are instructed to follow-up 3 months after they return to normal activities to assess the repair. The authors also continually follow our patients to evaluate the integrity of the repair.
Bleeding is the most serious complication of sacral colpopexy through injury to the presacral venous plexus or the middle sacral artery. Other injuries includes ureteral injury and graft erosion. The erosion rate has been reported to be 3% for sacral colpopexy.
The complications associated with vaginal vault surgery are ureteral injury, injury to the lower urinary tract, fistula formation, pelvic infection, bowel injury, and graft exposure. Sacrospinous ligament fixation carries the additional risk of hemorrhage and nerve injury through the pudendal neurovascular bundle. Recurrence of vault prolapse is also a potential complication.
Mesh extrusion is always a potential complication with vaginal mesh kits at a rate of approximately 10% (7%-18%). Symptoms of mesh exposure or extrusion are vaginal discharge, persistent bleeding, pain, dyspareunia, partner pain, dysuria, and recurrent urinary tract infections. Examination reveals any exposed mesh. Management can be conservative with vaginal estrogen or trimming of the mesh in the office. If conservative measures fail or the exposure is too large to be managed in the office, excision with operative vaginal closure after excision of the exposed mesh may be required.
Pelvic reconstructive surgeons should be extremely familiar with the evaluation and treatment of vaginal vault prolapse. Multiple techniques are available for the restoration of vaginal vault support and most are very effective at suspending the vaginal apex. The primary challenge is identifying the vaginal vault in women with advanced degrees of vaginal prolapse. The surgical approach should be based on both patient’s needs and the surgeon’s evaluation.
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