13.12: Prolapse And Concomitant Hysterectomy

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Apical (Vault) Prolapse Procedures

A well supported vaginal apex is the cornerstone of pelvic organ support, and recognition of apical defects is critical prior to prolapse correction.

Apical Support Procedures With The Uterus Present

Establishment of vaginal support at the time of vaginal hysterectomy is recommended and may be achieved by a “prophylactic” attachment of the vaginal cuff to the uterosacral or sacrospinous ligaments (level 4 evidence).
When women with a uterus have apical vaginal prolapse and wish to conserve the uterus, options are restricted and evidence to support specific procedures is very limited.

Recently a number of novel techniques have been described involving Type 1 Prolene mesh placement vaginally, with fixation through the obturator foramen and sacrospinous ligament. (ProliftR: Johnson & Johnson Womens Health Urology, PerigeeR, ApogeeR, American Medical Systems). There is no specific need for vaginal hysterectomy when these mesh kits are used. Lateral prolene straps pass through ligamentous structures to provide support for central mesh hammocks placed without tension vaginally. The mesh systems are safe and minimally invasive but at present long term data are not available. Efficacy in the short term appears to be promising with few side – effects being encountered, but review of larger studies is desirable. Although these procedures using propriety kits are easily mastered by proficient prolapse surgeons, proper training and expert instruction is mandatory.

If the surgeon does not wish to use a propriety mesh kit, there are a few reports of uterine preservation with apical support procedures, being small retrospective case series involving fewer than 50 cases with short follow – up and poorly defined outcomes. (Level 3 evidence)

Vaginal obliterative procedures (colpocleisis) have a role to play in stage III – IV POP in cases where women no longer wish to preserve coital function, and surgery is balanced by a positive impact on daily activities. The vagina is obliterated, the enterocoele is not addressed and the uterus is left in – situ unless there is separate pathology. The procedures are gentle with a speedy return to normal activity, with good success rates described (level 3 evidence). The distal anterior vaginal wall should be spared and not drawn into the operation, to reduce the risk of stress urinary incontinence.