GTG 46 PVHP Flashcards
What is the incidence of vault prolapse following hysterectomy for pelvic organ prolapse?
11.6%
What is the incidence of vault prolapse following hysterectomy for benign conditions?
1.8%
What proportion of post hysterectomy vault prolapses require surgery?
6-8%
For PHVP, when is urodynamics required?
Not routinely pre-operatively as it has not been shown to predict stress urinary incontinence rates postop
Which procedures have been shown to reduce rates of PHVP at the time of hysterectomy?
At abdominal and vaginal hysterectomy – McCalls culdoplasty or suturing cardinal and uterosacral ligaments to vaginal vault
At vaginal hysterectomy – sacrospinous fixation
Describe McCalls culdoplasty
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
Following hysterectomy with McCalls culdoplasty, what proportion have PHVP at 2 years follow up?
10% have stage 1 prolapse, 89.2% have stage 0 prolapse
When might you consider performing sacrospinous fixation?
At vaginal hysterectomy, if the vault descends to the introitus on pulling to try to prevent PHVP
How does subtotal hysterectomy compare to total hysterectomy in terms of PHVP incidence?
Subtotal does not prevent PHVP, more woman experience prolapse and urinary incontinence following subtotal
What is the role of pelvic floor muscle training for treatment of PHVP?
It is an effective non-surgical treatment option for patients with stage 1 and 2 vault prolapse
Which non-surgical options can be considered for treatment of PHVP?
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
What are the potential complications of vaginal pessaries?
Ulceration, bleeding, small risk of fistula formation
N.B. Need to be changed 6 monthly and impact on sexual function
What are the surgical options for PHVP?
Sacrospinous fixation Open abdominal sacrocolpopexy Laparoscopic sacrocolpopexy Robotic sacrocolpopexy (research only) High uterosacral suspension (only in the context of research) Transvaginal mesh Colpocleisis
Describe abdominal sacrocolpopexy
Procedure performed for treatment of PHVP
Apical attachment of the vaginal vault using permanent mesh to the longitudinal ligament of the sacrum
What are the longterm success rates with abdominal sacrocolpopexy?
78-100%
What are the rates of complications with abdominal sacrocolpopexy?
Mesh erosion = 2-11%
Bowel injury, sacral myelitis, severe bleeding = 2% (0-8%)
Describe sacrospinous fixation
Absorbable or non absorbable suture anchoring vaginal vault to sacrospinous ligament (usually unilaterally to right side)
Describe the difference in terms of risks and benefits of SSF and sacrocolpopexy?
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
What are the rates of complications with sacrospinous fixation?
Anterior prolapse and stress incontinence – 8-30%
16% prolapse symptoms at 2 years
18% buttock pain (but resolves with analgesia)
Who might colpocleisis be appropriate for and what are the success rates?
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
What is the evidence for performing colposuspension at the time of sacrocolpopexy to prevent post operative stress urinary incontinence
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
