GTG 46 PVHP

Question 1

What is the incidence of vault prolapse following hysterectomy for pelvic organ prolapse?

Answer 1

11.6%

Question 2

What is the incidence of vault prolapse following hysterectomy for benign conditions?

Answer 2

1.8%

Question 3

What proportion of post hysterectomy vault prolapses require surgery?

Answer 3

6-8%

Question 4

For PHVP, when is urodynamics required?

Answer 4

Not routinely pre-operatively as it has not been shown to predict stress urinary incontinence rates postop

Question 5

Which procedures have been shown to reduce rates of PHVP at the time of hysterectomy?

Answer 5

At abdominal and vaginal hysterectomy – McCalls culdoplasty or suturing cardinal and uterosacral ligaments to vaginal vault
At vaginal hysterectomy – sacrospinous fixation

Question 6

Describe McCalls culdoplasty

Answer 6

A procedure performed at vaginal or abdominal hysterectomy to prevent PHVP
The uterosacral ligaments are approximated to obliterate the peritoneum of the posterior cul de sac

Question 7

Following hysterectomy with McCalls culdoplasty, what proportion have PHVP at 2 years follow up?

Answer 7

10% have stage 1 prolapse, 89.2% have stage 0 prolapse

Question 8

When might you consider performing sacrospinous fixation?

Answer 8

At vaginal hysterectomy, if the vault descends to the introitus on pulling to try to prevent PHVP

Question 9

How does subtotal hysterectomy compare to total hysterectomy in terms of PHVP incidence?

Answer 9

Subtotal does not prevent PHVP, more woman experience prolapse and urinary incontinence following subtotal

Question 10

What is the role of pelvic floor muscle training for treatment of PHVP?

Answer 10

It is an effective non-surgical treatment option for patients with stage 1 and 2 vault prolapse

Question 11

Which non-surgical options can be considered for treatment of PHVP?

Answer 11

Pelvic floor muscle training – shown to be effective for stage 1 and 2 vault prolapses, but can be offered to all prolapses as per NICE
Vaginal pessaries are suitable for stage 1-4 vault prolapses

Question 12

What are the potential complications of vaginal pessaries?

Answer 12

Ulceration, bleeding, small risk of fistula formation

N.B. Need to be changed 6 monthly and impact on sexual function

Question 13

What are the surgical options for PHVP?

Answer 13

Sacrospinous fixation 
Open abdominal sacrocolpopexy 
Laparoscopic sacrocolpopexy 
Robotic sacrocolpopexy (research only)
High uterosacral suspension (only in the context of research) 
Transvaginal mesh 
Colpocleisis

Question 14

Describe abdominal sacrocolpopexy

Answer 14

Procedure performed for treatment of PHVP

Apical attachment of the vaginal vault using permanent mesh to the longitudinal ligament of the sacrum

Question 15

What are the longterm success rates with abdominal sacrocolpopexy?

Answer 15

78-100%

Question 16

What are the rates of complications with abdominal sacrocolpopexy?

Answer 16

Mesh erosion = 2-11%

Bowel injury, sacral myelitis, severe bleeding = 2% (0-8%)

Question 17

Describe sacrospinous fixation

Answer 17

Absorbable or non absorbable suture anchoring vaginal vault to sacrospinous ligament (usually unilaterally to right side)

Question 18

Describe the difference in terms of risks and benefits of SSF and sacrocolpopexy?

Answer 18

SSF – shorter procedure, day case, but higher rates of stress urinary incontinence, prolapse recurrence and dyspareunia
Sacrocolpopexy – longer procedure, longer recovery, involves mesh 2-11% risk of mesh erosion but lower rates of prolapse recurrence, stress urinary incontinence and dyspareunia

Question 19

What are the rates of complications with sacrospinous fixation?

Answer 19

Anterior prolapse and stress incontinence – 8-30%
16% prolapse symptoms at 2 years
18% buttock pain (but resolves with analgesia)

Question 20

Who might colpocleisis be appropriate for and what are the success rates?

Answer 20

Colpocleisis can be used as a surgical treatment for PHVP for frail elderly women who do not wish to retain their sexual function and is associated with 97% success rates

Question 21

What is the evidence for performing colposuspension at the time of sacrocolpopexy to prevent post operative stress urinary incontinence

Answer 21

In previously continent women it reduces the incidence of SUI (23% had de novo SUI vs. 43% in patients with no colposuspension)
In women with pre-existing stress incontinence there is no evidence that reduces the incidence of postoperative SUI