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Enterocele and Massive Vaginal Eversion Treatment & Management

  • Author: Rony A Adam, MD; Chief Editor: Kris Strohbehn, MD  more...
 
Updated: May 11, 2016
 

Medical Therapy

Supporting 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. The primary indication for fitting a pessary is the nonsurgical relief of symptoms associated with pelvic organ prolapse. In a long-term assessment of quality of life, Tenfelde et al report improved quality of life with the use of pessaries over a mean of 4½ years (range of 1-15).[27]

A prospective study conducted by Wu et al identified younger age, higher parity, a history of pelvic surgery, and stress urinary incontinence as characteristics associated with initial failure of pessary fitting. Interestingly, the degree of pelvic organ prolapse, hormone replacement therapy, and adequacy of perineal body did not predict failure of initial fitting.[28, 29] Maintaining pessary rates varies from 41 to 64% and the reasons for discontinuation usually associated with inconvenience or inadequate relief of symptoms (40%), difficulty in removal (23%), pessary fell out (6%), and inability to urinate (5%).[30]

Longitudinal data from the US Centers for Medicare and Medicaid Service over a 9 year period on 4,019 women with diagnosed pelvic organ prolapse, demonstrated a pessary continuation rate of 69% with 3% developed vesicovaginal or rectovaginal fistulas and 5% had a mechanical genitourinary device complication. Twelve percent of women underwent surgery for prolapse repair by 1 year, with 24% by 9 years.[31]

Evaluation of vaginal epithelium to assess estrogen status is necessary and vital in order to prevent pessary-associated erosion and ulceration in atrophic vagina. Thus, the use of concurrent vaginal estrogen therapy is recommended in the absence of contraindications.[32]

At present, fewer than twenty pessary types are available and used for prolapse. In a survey among AUGS members 78% of providers tailored their choice of pessary to the specific pelvic support defect. Most respondents generally favored a space-occupying rather than supportive pessary.[32] Supportive pessaries are defined as those that involve a spring mechanism (ring, Gehrung, lever-type pessary) and thought to be supported by symphysis pubis.  Space-occupying pessaries are defined as supported by the creation of suction between the pessary and vaginal wall (e.g. cube) or by providing a diameter larger than the genital hiatus (donut, InflatoBall, Shaatz) or by both mechanisms (Gellhorn).

Patients who choose pessary as treatment of their prolapse should be followed closely and should be examined at regular intervals. Common complications of long-term pessary use include vaginal discharge and bleeding, and mucosal erosion/abrasion. Serious complications of pessary use are usually seen in neglected patients and can include infections, fistulas, complete erosions, or incarcerations.

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Surgical Therapy

Surgery 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. There are several options for the treatment of vaginal eversion. Changes and modifications have been made to original procedures, however, the paramount principles are still present and include the attachment of vaginal apex to level I support. Therefore this manuscript 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, robot-assisted or a combination of these. Surgical techniques can be reconstructive, with the aim of restoring anatomy and maintaining the potential for coitus, or can be obliterative that by definition eliminate prolapse at the expense of future coital function.

The goals of surgical treatment of vaginal eversion include but are not limited to improvement of quality of life, restoration of anatomy (with the exception of colpocleisis), and prevention of reoccurrence pf prolapse.

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Preoperative Details

Preoperative bowel preparation was historically employed.  However, a single-blind, randomized control trial of mechanical bowel preparation, conferred no benefit regarding surgeons' intraoperative assessment of the operative field.  Furthermore, it noted decreased patient satisfaction, and increased abdominal symptoms in the postoperative period in patients who underwent bowel preparation before reconstructive vaginal prolapse surgery.[33]

A first-generation cephalosporin is administered as a preoperative antibiotic 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 ml balloons for better palpation of the bladder neck, although 10 ml balloons also seem to work well.

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Intraoperative Details

When including hysterectomy as a treatment modality for uterovaginal prolapse, preservation, restoration, and strengthening of pelvic support is of primary importance.[34] Pay particular attention to reattachment of the cardinal-uterosacral ligament complex to the posterolateral vaginal apex, with a high uterosacral ligament attachment thus reestablishing its continuity with the rectovaginal fascia. The use of permanent sutures for the uterosacral ligament colpopexy has been traditionally advocated.  Another option is to use prolonged delayed absorbable suture. If the uterosacral ligaments are of insignificant strength, one may consider a sacrospinous ligament fixation or abdominal sacral colpopexy instead.

Culdoplasty

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 and therefore have been abandoned by some.

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, rectovaginal septal reconstruction and/or perineorrhaphy as needed.

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 high 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 considered obliterative procedures.

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 image below), and the EndoStitch (U.S. Surgical, Norwalk, Conn).

Enterocele and massive vaginal eversion. Sacrospin Enterocele and massive vaginal eversion. Sacrospinous ligament fixation. The right sacrospinous ligament is being penetrated using the Nichols-Veronikis ligature carrier.

Take care to avoid injury to the inferior gluteal artery, pudendal neurovascular bundle, and the sciatic nerve (see image below).

Enterocele and massive vaginal eversion. The anato Enterocele and massive vaginal eversion. The anatomy surrounding the right ischial spine.

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 image below).

Enterocele and massive vaginal eversion. Note the Enterocele and massive vaginal eversion. Note the pudendal neurovascular bundle at the lateral aspect of the sacrospinous ligament. Also note the proper penetration of the suture into the body of the coccygeus muscle.

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 with both arms brought out through the vaginal epithelium (see image below). Avoid suture bridging when tying down these sutures.

Enterocele and massive vaginal eversion. Following Enterocele and massive vaginal eversion. Following penetration of the sacrospinous ligament, the permanent suture (on the left) is attached to the posterior vagina by a figure-eight stitch, incorporating rectovaginal fascia but not penetrating the mucosa. Once this stitch is tied, a pulley has been created whereby the vagina can be drawn up to the ligament by pulling on the free suture and then tied down. The delayed absorbable suture is driven through-and-through and is tied on the vagina.

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 and is almost always done bilaterally (see image below).

Enterocele and massive vaginal eversion. Depiction Enterocele and massive vaginal eversion. Depiction of completed fascial reconstruction with uterosacral reattachment in the sagittal view. Note that the vaginal apex has been restored to its normal anatomic location and is directed to the hollow of the sacrum.

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. It may be used immediately following a vaginal hysterectomy or for posthysterectomy vaginal prolapse.  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; 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 and verifying adequate urine efflux.

Le Fort colpocleisis

Le Fort partial colpocleisis involves retention of the uterus, and, therefore, should be preceded by dilatation and curettage (D&C) or preoperative endometrial biopsy and is contraindicated in patients with postmenopausal bleeding. 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 image below).

Enterocele and massive vaginal eversion. Le Fort c Enterocele and massive vaginal eversion. Le Fort colpocleisis begins with dissection and excision of a rectangular patch of mucosa on both the anterior and posterior vagina. Gradual inversion of the vaginal tube is accomplished by interrupted sutures that approximate anterior to posterior. Reapproximation of the lateral vaginal mucosal edges serves to maintain the tunnels on either side of the repair. From Thompson JD. Surgical correction of defects in pelvic support. In: Rock JR, Thompson JD, eds. TeLinde's Operative Gynecology. 8th ed. Philadelphia, Pa: Lippincott-Raven; 1997.

Dissection should leave adequate endopelvic fascia anteriorly and posteriorly to retain strong tissue for reapproximation. Excellent hemostasis is required and achieved by electrocautery.

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 epithelium-lined tunnels are created. The entire vaginal epithelium 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. 

Whether performing a LeForte or a total colpocleisis, care must be exercised to not carry the anterior epithelial excision too far distal for fear of opening the bladder neck and urethra by the posterior displacement the anterior segment will undergo when the colpocleisis is complete.  Severe postoperative urinary incontinence may result if this occurs.

Mesh-based kits

Trocar-based vaginal kits have become popular in the management of vaginal vault prolapse in the beginning of this century and were advocated as safe and durable treatment option for vaginal prolapse. With the increase in adverse event reports related to these devices over the past several years, the FDA has reclassified transvaginal mesh used for treating pelvic organ prolapse or POP to indicate the risks associated with the product. The new requirements currently only pertain to transvaginal mesh used for transvaginal prolapse repair and does not include mesh used to treat stress urinary incontinence (SUI) and abdominal repair of POP.  Thus, well-designed comparison studies need to determine their place and safety in the management of pelvic organ prolapse.

Abdominal approaches

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 image below). Conversely, a traditional Moschcowitz or Halban procedure is recommended by some urogynecologists.

Enterocele and massive vaginal eversion. Transabdo Enterocele and massive vaginal eversion. Transabdominal repair of the large enterocele noted in Image 2. Note interrupted permanent sutures used for repair.

Abdominal sacral colpopexy may be performed with fascia but is most often performed with a permanent light polypropylene mesh. 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 image below). This potentially decreases the amount of mesh in contact with the vagina, which may be important in the prevention of subsequent erosion.

Enterocele and massive vaginal eversion. Mesh conf Enterocele and massive vaginal eversion. Mesh configuration for abdominal sacral colpopexy. The crux of the Y is formed by permanent sutures with the knots tied down on the side that faces the sacrum, not the vagina.

Each arm of the mesh is attached to the vagina with 4-5 interrupted stitches of permanent suture, taking care to incorporate endopelvic fascia in each bite. The proximal aspect of the mesh is attached to the anterior sacral fascia at the level of S2 with permanent suture (see images below).

Enterocele and massive vaginal eversion. Note the Enterocele and massive vaginal eversion. Note the anatomy of the lower presacral space. Take care to adequately mobilize the sigmoid colon and ensure the safety of the right ureter. Identification of the middle sacral vessels is important to avoid hemorrhage.
Enterocele and massive vaginal eversion. Note adeq Enterocele and massive vaginal eversion. Note adequate bites taken into the anterior sacral fascia at sacral level 3 (S3). Take care not to attach the mesh too high (towards the sacral promontory) so that the normal vaginal axis is maintained. Also, take care to avoid excess tension on the vagina.
Enterocele and massive vaginal eversion. Note the Enterocele and massive vaginal eversion. Note the axis of the vagina and the attachment of the mesh to the sacrum at sacral level 3 (S3).

Attachment of the mesh to the sacral promontory may minimize vascular and/or neurologic injuries, but it also results in an unnatural anteflexion of the vaginal apex. Some have felt that this predisposes the posterior compartment to development or recurrence of enteroceles. There is also concern of increased risk of spondylodiscitis if the promontory is chosen as the attachment site.

Reperitonealization is used 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 middle sacral vessels. Assure that there is no undue tension on the vagina with the mesh in place.

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.[35]

High uterosacral reattachment is performed using the same principles discussed previously. 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 sacrum and vagina after the sutures are tied by allowing 2 finger breadths to leave sufficient space for the sigmoid colon. 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 image below).

Enterocele and massive vaginal eversion. Bilateral Enterocele and massive vaginal eversion. Bilateral uterosacral reattachment has been performed laparoscopically with a permanent suture in a patient who desired retention of the uterus.

Similarly, sacral colpopexy has been reported via the laparoscopic approach with or without robotic assistance. 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.

Purported advantages of robotic surgery include improved (3-dimensional) visualization of the operative field with increased dexterity allowing more precise movements.[36] The surgical technique consists with placement of four laparoscopic ports, three for the surgical robot and one for the assistant in addition to a port for the camera. A prolene mesh is then attached to the sacrum and to the vaginal apex or cervical stump using nonabsorbable sutures. Peritonealization of the mesh desirable, but not always performed. Data suggests that this approach combines the advantages of open sacrocolpopexy with decreased hospital stay, less blood loss, low complication and conversion rates, and high rates of patient satisfaction.[37, 38]

When the robotic approach is compared to traditional (“straight stick”) laparoscopy, although it has similar outcomes, is noted to take longer and to be associated with significantly increased cost.[39]

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Postoperative Details

The authors strongly recommend following all reconstructive surgical procedures with evaluation of bilateral ureteral patency with 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.

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Follow-up

Patients are usually seen in 4 weeks for vaginal reconstructive surgery or in 1 week and then 4-6 weeks following abdominal (or laparoscopic) surgery. For long-term follow-up, they are observed every 6-12 months, as needed.

For excellent patient education resources, visit eMedicineHealth's Women's Health Center. Also, see eMedicineHealth's patient education article Prolapsed Uterus.

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Complications

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.  Reported complications from the vaginal kits include infection, bleeding, and rectal lacerations. In addition, dyspareunia and mesh erosions may also occur. Long-term follow-up is still lacking for these kits.

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.

An emerging, significant but rare complication of sacral colpopexy is spondylodiscitis.  This is thought to be due to infection of the disc, bone, periosteum or other surrounding spinal structures near the proximal attachment of the graft following sacral colpopexy.  It has been postulated that placement of suture at the promontory corresponds to the L5-S1 disc.[40] For that and other anatomical reasons, the authors suggest placing these proximal sutures lower down at around S2.

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Outcome and Prognosis

Sacrospinous ligament fixation was reviewed by Sze and Karram.[41] 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 10-24% depending on the criteria used and length of follow-up.  Indeed based on extended follow-up of the CARE trial 2-year cure rates may range from 19% if perfect anatomic support is the criteria, to 97% if the criteria is absence of subsequent treatment for POP.  Similarly failure rates increased from years 2 to 7 following surgery.[42] Destructive operations, such as the Le Fort procedure, tend to have a success rate of over 90%.

Benson et al reported the first randomized comparison between abdominal and vaginal approaches to pelvic floor defects.[43] 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.[44] 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.

The most recent Cochrane review to date (2013) determined effects of different surgeries used in the management of pelvic organ prolapse from fifty six randomized controlled trials (5954 women). They concluded that for upper vaginal prolapse (uterine or vault), abdominal sacral colpopexy was associated with a lower rate of (1) recurrent vault prolapse on examination and (2) painful intercourse than with vaginal sacrospinous colpopexy. These benefits must be balanced against a longer operating time, longer time to return to activities of daily living and increased cost of the abdominal approach. In single studies the sacral colpopexy had a higher success rate on examination and lower reoperation rates than high vaginal uterosacral suspension and transvaginal polypropylene mesh.[45]

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Future and Controversies

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.

The implications of minimally invasive approaches in the treatment of apical prolapse, specifically laparoscopic and robotic-assisted sacrocolpopexy, present potential improvements in correction of impaired native tissue. Recent systemic review and meta- analysis yielded estimated success rate for robotic sacrocolpopexy of 98.6% ( 95% CI, 97.0%-100%) with mesh exposure rate of only 4.1% (95%CI, 1.4%-6.9%), and rate of reoperation for mesh revision 1.7%.  The rates of reoperation for recurrent apical and nonapical prolapse were 0.8% and 2.5% respectively.[46]

There remains a debate if the uterus is a bystander in surgical management of prolapse in perimenopausal women, specifically in women of certain cultural beliefs. Some authors propose uterine preservation as another option for the surgical correction of uterovaginal prolapse.  A contemporary randomized trial comparing mesh-based laparoscopic sacral hysteropexy with standard TVH with 1 year follow-up had 20% loss to follow-up and admittedly large technical differences between the operations.  It showed no improvement in apical failures from uterine sparing surgery and revealed more reoperations for failures of non-apical compartments.[47]

Practice patterns with respect to hysterectomy for prolapse are complex when the use of colpopexy and cystoscopy and rates of intraoperative complications are analyzed by surgeon volume. High volume surgeons had the lowest complication rates, were most likely to perform an apical suspension procedure as well as address the anterior and/or posterior compartments and to use intraoperative cystoscopy.  This was noted despite noting that the high volume surgeons operated on patients with higher degrees of prolapse and those who had prior prolapse or anti-incontinence surgery. The finding that intermediate-volume surgeons have the highest rates of intraoperative complications suggests a nonlinear relationship between surgeon volume and complications and may be reflective of the likelihood of requesting further assistance.[48] Moreover, High-volume surgeons were more likely than low-volume surgeons to perform a standardized preoperative pelvic examination, offer a pessary, and preoperatively evaluate for stress urinary incontinence.[49]

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Contributor Information and Disclosures
Author

Rony A Adam, MD Professor of Clinical Obstetrics and Gynecology, Vanderbilt University School of Medicine

Rony A Adam, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists

Disclosure: Nothing to disclose.

Coauthor(s)

Raisa O Platte, MD, PhD Urogynecology Associate, Department of Obstetrics and Gynecology, Geisinger Health System

Raisa O Platte, MD, PhD is a member of the following medical societies: American Medical Association, AAGL, American Urogynecologic Society, International Continence Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Michel E Rivlin, MD Former Professor, Department of Obstetrics and Gynecology, University of Mississippi School of Medicine

Michel E Rivlin, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Medical Association, Mississippi State Medical Association, Royal College of Surgeons of Edinburgh, Royal College of Obstetricians and Gynaecologists

Disclosure: Nothing to disclose.

Chief Editor

Kris Strohbehn, MD Professor of Obstetrics and Gynecology, Geisel School of Medicine at Dartmouth; Director, Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, Dartmouth-Hitchcock Medical Center

Kris Strohbehn, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American College of Surgeons, American Urogynecologic Society, Society of Gynecologic Surgeons

Disclosure: Nothing to disclose.

Additional Contributors

Robert K Zurawin, MD Associate Professor, Chief, Section of Minimally Invasive Gynecologic Surgery, Department of Obstetrics and Gynecology, Baylor College of Medicine

Robert K Zurawin, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Society for Reproductive Medicine, Association of Professors of Gynecology and Obstetrics, Central Association of Obstetricians and Gynecologists, Society of Laparoendoscopic Surgeons, Texas Medical Association, AAGL, Harris County Medical Society, North American Society for Pediatric and Adolescent Gynecology

Disclosure: Received consulting fee from Ethicon for consulting; Received consulting fee from Bayer for consulting; Received consulting fee from Hologic for consulting.

Acknowledgements

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous author Thinh H Duong, MD, FACOG to the development and writing of this article.

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Enterocele and massive vaginal eversion. Posthysterectomy vaginal vault prolapse.
Enterocele and massive vaginal eversion. Large apical endopelvic fascial defect representing an enterocele demonstrated by the transabdominal route. Note the proximal cervicovaginal and rectovaginal fascia separate from the peritoneum.
Enterocele and massive vaginal eversion. Levels of support as described by DeLancey (1992). Note that level I refers to apical (or uterovaginal) support.
Enterocele and massive vaginal eversion. Normal posthysterectomy vaginal vault. Note the presence of continuity of the endopelvic fascia at the vaginal apex, resulting from the fusion of cervicovaginal and rectovaginal fascia, and their fusion with the uterosacral ligament portion of endopelvic fascia.
Enterocele and massive vaginal eversion. Early enterocele with no vault prolapse. Note contact of peritoneal contents with vaginal mucosa, with no intervening endopelvic fascia.
Enterocele and massive vaginal eversion. Progressive enterocele now demonstrating true vaginal vault prolapse.
Enterocele and massive vaginal eversion. Massive enterocele with total vaginal vault prolapse.
Enterocele and massive vaginal eversion. Posterior enterocele in a patient with a uterus. Note that peritoneal contents have dissected between the vaginal mucosa and rectovaginal fascia through a proximal defect.
Enterocele and massive vaginal eversion. Sacrospinous ligament fixation. The right sacrospinous ligament is being penetrated using the Nichols-Veronikis ligature carrier.
Enterocele and massive vaginal eversion. The anatomy surrounding the right ischial spine.
Enterocele and massive vaginal eversion. Note the pudendal neurovascular bundle at the lateral aspect of the sacrospinous ligament. Also note the proper penetration of the suture into the body of the coccygeus muscle.
Enterocele and massive vaginal eversion. Following penetration of the sacrospinous ligament, the permanent suture (on the left) is attached to the posterior vagina by a figure-eight stitch, incorporating rectovaginal fascia but not penetrating the mucosa. Once this stitch is tied, a pulley has been created whereby the vagina can be drawn up to the ligament by pulling on the free suture and then tied down. The delayed absorbable suture is driven through-and-through and is tied on the vagina.
Enterocele and massive vaginal eversion. Depiction of completed fascial reconstruction with uterosacral reattachment in the sagittal view. Note that the vaginal apex has been restored to its normal anatomic location and is directed to the hollow of the sacrum.
Enterocele and massive vaginal eversion. Le Fort colpocleisis begins with dissection and excision of a rectangular patch of mucosa on both the anterior and posterior vagina. Gradual inversion of the vaginal tube is accomplished by interrupted sutures that approximate anterior to posterior. Reapproximation of the lateral vaginal mucosal edges serves to maintain the tunnels on either side of the repair. From Thompson JD. Surgical correction of defects in pelvic support. In: Rock JR, Thompson JD, eds. TeLinde's Operative Gynecology. 8th ed. Philadelphia, Pa: Lippincott-Raven; 1997.
Enterocele and massive vaginal eversion. Transabdominal repair of the large enterocele noted in Image 2. Note interrupted permanent sutures used for repair.
Enterocele and massive vaginal eversion. Mesh configuration for abdominal sacral colpopexy. The crux of the Y is formed by permanent sutures with the knots tied down on the side that faces the sacrum, not the vagina.
Enterocele and massive vaginal eversion. Note the anatomy of the lower presacral space. Take care to adequately mobilize the sigmoid colon and ensure the safety of the right ureter. Identification of the middle sacral vessels is important to avoid hemorrhage.
Enterocele and massive vaginal eversion. Note adequate bites taken into the anterior sacral fascia at sacral level 3 (S3). Take care not to attach the mesh too high (towards the sacral promontory) so that the normal vaginal axis is maintained. Also, take care to avoid excess tension on the vagina.
Enterocele and massive vaginal eversion. Note the axis of the vagina and the attachment of the mesh to the sacrum at sacral level 3 (S3).
Enterocele and massive vaginal eversion. Bilateral uterosacral reattachment has been performed laparoscopically with a permanent suture in a patient who desired retention of the uterus.
 
 
 
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