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Vault prolapse follows on a previous hysterecto-

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									Vault Prolapse
Professor H S Cronjé
Department of Obstetrics and Gynaecology, University of the Free State, Bloemfontein
DEFINITION

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ault prolapse follows on a previous hysterectomy when the top of the vagina (vault) descends into the vagina. The bladder is usually pulled down as well, and posteriorly it is accompanied by an enterocoele. In fact, Nichols1 described vault prolapse as a variant of enterocoele, while Menefee and Wall2 described an enterocoele as “herniation of small bowel into the vaginal lumen”. This is actually what happens with vault prolapse as well, indicating the close relationship between these two entities.

all these factors into account, it is clear that vault prolapse is not a localised defect, but rather the tip of the iceberg, where the tip represents the prolapsed vault, and the iceberg a total defect in pelvic organ support. Incidence The incidence of vault prolapse requiring surgery is 36 per 10 000 person years. Posthysterectomy, 2 to 12 percent of women may experience significant vault prolapse.4 It seems as if the incidence is rising owing to increased life expectancy.5 In our unit, vault prolapse represents 19% of all cases with stage 3 and 4 pelvic organ prolapse. Presentation Vault prolapse in itself is not associated with prominent symptoms, which are rather attributed to concurrent enterocoele and cystocoele. Vault prolapse may cause a fullness in the pelvis, lower abdominal pain and coital difficulty. Enterocoele is associated with significant symptoms, which include heaviness, lower abdominal pain, dyspareunia, obstructive defaecation and overactive detrusor symptoms (with or without urinary incontinence). Cystocoele is often associated with difficulty in voiding and incomplete emptying of the bladder. Rarely, severe complications may occur, for example vault rupture with prolapse of small bowel, small bowel obstruction and ureteric obstruction with or without hydronephrosis.6,7

Diagnosis and Evaluation The clinical diagnosis is usually straightforward, where the prolapse is easily demonstrated with either a Cusco or a Sims speculum. More difficult, however, is separating vault from other forms of prolapse. A study using magnetic resonance imaging (MRI) demonstrated a poor correlation between clinical and MRI evaluation.8 Transperineal ultrasound, however, is more readily available and less expensive, and will clearly demonstrate associated anterior or posterior compartTable 1. Surgical procedures for the correction of ment prolapse.9 This should be recommended as a standard adjunct to clinical examination. vault prolapse Staging is done according to the POP-Q sysVaginal Procedures Abdominal Procedures tem.10 Point D will be the important denominator in 1. Sacrospinous ligament 1. Sacrocolpopexy, with vault prolapse.
fixation (SSLF) 2. Uterosacral complex fixation (McCall, uterosacal fixation, prespinous or iliococcygeal fixation 3. Posterior intravaginal slingplasty (IVS)/infracoccygeal sacropexy
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Aetiology and Pathophysiology Vault prolapse is caused by an absence of level 1 support of the vagina, and to some extent a lack of level 2 support as well.3 Level 1 support is provided mainly by the transverse cervical and uterosacral ligaments together with the endopelvic fascia.3 At hysterectomy, these ligaments and some of the endopelvic fascia are separated from the vaginal vault, leaving it without adequate support. This deficiency is compensated for by postoperative fibrosis around the vault, but where this process is either insufficient or broken down by some factor such as severe coughing, vault prolapse will occur. Absence of level 1 support is not the only factor in the pathophysiology of vault prolapse. Since enterocoeles are almost always present in the case of vault prolapse, its pathophysiology plays a concomitant role. Here level 2 and 3 support deficiencies are present, mainly featuring as a descent of the levator ani muscle and often also a perineal body defect. Paravaginal fascial defects are also not uncommon (level 2). These defects are all contributory to the development of vault prolapse, but the exact mechanism is not yet fully understood.3 The downward displacement of the bladder which is often associated with vault prolapse, can be explained by a paravaginal defect (level 2). It is promoted by a lack of posterior compartment support (level 2 and 3). Taking

or without concomitant defect site repair 2. Laparoscopical repair (mainly sacrocolpopexy)

Preoperative work-up A full blood count, urea and electrolytes, and a midstream urine specimen for microscopy, culture and sensitivity are required. Urodynamic investigation may be required in the presence of urinary symptoms, although its findings will rarely influence the treatment of the vault prolapse. Cystodefaecography is informative to a great
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extent, but rarely indicated in view of the value of transperineal ultrasound. Postmenopausal women not receiving hormone replacement therapy should preoperatively be treated with vaginal estrogen cream (two to three times per week), which will improve the integrity of the vaginal walls. Preoperatively a fleet enema is sufficient. Patients on low dose aspirin should discontinue it a week before surgery. Anticoagulation therapy is a contraindication for surgery. Physiotherapy is advised from the pre- to the postoperative phase, with the main emphasis on pelvic floor muscle exercises. Choice of operation Traditionally, abdominal surgery (sacrocolpopexy) yielded improved results compared to vaginal procedures (mainly sacrospinous colpofixation). According to recent studies,11,12 the difference has diminished and became insignificant making it difficult for the attending practitioner to decide on a specific operation. A classification of available procedures appears in Table 1, followed by a brief description of each procedure. 1. Sacrospinous ligament fixation (SSLF) SSLF was first described by Richter.13 Unilaterally or bilaterally, a stitch is placed from the vault to the sacrospinous ligament, usually 2-3 cm medial of the ischial spine. The advantages include its safety, simplicity, low morbidity and fairly good results. Disadvantages include de novo cystocoele formation on follow-up and urinary symptoms.4 This principle has been enhanced recently by “kits” where a mesh is placed between the vagina and rectum and fixed to the sacrospinous ligaments, for example the Posterior Prolift® system (Johnson & Johnson, Brussels, Belgium). Several other options are available. The advantages of such a system is the simplicity of application (with ready-made tools) and support of the posterior vaginal wall in addition to the vault. 2. Uterosacral complex: high McCall, high uterosacral fixation and prespinous/ iliococcygeal fixation These three procedures focus on structures around the sacrospinous ligament. The McCall culdoplasty was first described to treat an enterocoele, but gained popularity as a procedure for preventing vault prolapse.14 It consists of plication of the uterosacral ligaments, forming a firm structure to which the vault is fixed. In recent times, however, it has lost popularity in favour of sacrospinous fixation. The iliococcygeal fascia is just inferior and medial to the ischial spine. It was claimed that fixation to this structure was associated with less side-effects like pain, compared to sacrospinous fixation.15 However, no difference between these two procedures could be demonstrated.16
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3. Posterior intravaginal slingplasty (IVS)/ infracoccygeal sacropexy The IVS was described by Petros17 in an attempt to create an artificial uterosacral neo-ligament for the treatment of vaginal vault prolapse. A tunneller is passed through the ischiorectal fossa, penetrating the levator plate at the level of the ischial spines. This tunneller feeds a tension-free polypropylene tape through its tract. The tape is fixed to the vault in the midline and supported laterally on each side by the levator plate and surrounding fascia, as well as subsequent fibrosis. The IVS is a minimally invasive procedure effectively supporting the vaginal vault, but it lacks support of the vaginal walls. 4. Sacrocolpopexy Sacrocolpopexy involves a laparotomy, which is a much larger procedure compared to the abovementioned vaginal procedures. Many variations have been described over the past 100 years, but currently mesh is placed from the vagina to the sacrum at the level of S1.4. Our own work has shown that the longer the mesh extends along the vaginal walls, the lower the prolapse recurrence rate (any prolapse), but at a price of
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increased morbidity, mainly overactive detrusor symptoms (manuscript in preparation for publication). This principle is supported by others as well.4 Another approach is sacrocolpopexy with concomitant defect site repair.4 The mesh extends from the vaginal vault to the sacrum, but then other procedures are added to correct associated defects such as cystocoele and rectocoele. The bottomline is that more than suspension of the vault only is needed. Sacrocolpopexy can also be done laparoscopically, reducing morbidity but probably at an increased cost.18 Comparison of abdominal and vaginal approaches Maher et al.12 demonstrated in a prospective randomized study with a two-year follow-up, that abdominal sacrocolpopexy and vaginal sacrospinous fixation of the vault were equally effective in the treatment of vaginal vault prolapse. Similar results have been reported in retrospective studies.19 In our experience, vault prolapse is a high-risk form of recurrent prolapse due to the complete absence of any support of the upper third of the vagina.20 This, in addition to the associated defects (enterocoele, cystocoele), prompted us to opt for a comprehensive repair approach, namely sacrocolpopexy with mesh on both sides of the vagina (full length). Rectopexy is performed in combination to eliminate the enterocoele.21 Concomitant stress incontinence Stress urinary incontinence is a common condition associated with vault prolapse.4 Although most women with moderate to severe uterovaginal prolapse will not complain of stress incontinence, and might even present with voiding difficulties, it is well-known that 3680% of these women have associated stress incontinence.22 Therefore, it is recommended to evaluate women with uterovaginal prolapse preoperatively with urodynamic tests. If stress incontinence is demonstrated, a midurethral tape should be applied at the time of surgery (vaginally or abdominally). Without such an

approach, 10-15% of women will present with stress incontinence postoperatively.20,21 Prevention of vault prolapse at the time of hysterectomy The mainstay in preventing posthysterectomy vault prolapse is accurate prehysterectomy identification of any form of prolapse. Transperineal/labial ultrasound is invaluable in the preoperative assessment. With a clear understanding of the situation, a strategy can be determined to prevent subsequent vault prolapse.4 Without any prolapse, a hysterectomy can be done without additional measures for preventing subsequent vault prolapse. Any kind of mild to moderate prolapse is an indication for fixing the vault to the uterosacral ligaments, either by simple plication of the ligaments and fixation of the vault, or by a McCall’s culdoplasty. Severe prolapse, however, is usually associated with marked stretching and thinning of these ligaments, making them not suitable for use. The sacrospinous ligament should then be used for fixation in vaginal procedures and the anterior longitudinal ligament of the sacrum in abdominal procedures (sacrocolpopexy).4 Conclusions Vault prolapse is a difficult form of prolapse to treat because of the complete absence of support of the upper vagina. In addition, vault prolapse is always associated with other forms of prolapse (mainly enterocoele) and often with clinical or subclinical urinary stress incontinence. Careful and complete evaluation of these patients is therefore crucial. Although the vaginal procedures for the treatment of vault prolapse have gained in popularity, abdominal sacrocolpopexy must still be regarded as the golden standard. It is, however, important that at sacrocolpopexy, the mesh adequately covers both sides of the vagina. This is important for not only support of the vault, but also of the anterior and posterior vaginal walls. References on request

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