Post-Hysterectomy Vaginal Vault Prolapse GTG 2015

Question 1

What proportion of hysterectomies have vault prolapse?

Answer 1

11% Hysterectomy for prolapse
1.8% hysterectomy for other bengin causes

Question 2

How many points are measured in POP-Q in relation to the Hymen?

Answer 2

6 points

Question 3

When are the points measured

Answer 3

All except TVL are measured in maximum valsalva

Question 4

Describe point Aa and Ap

Answer 4

Aa Anterior vaginal wall 3cm proximal to hymen
Ap posterior vaginal wall 3cm proximal to hymen

-3cm to +3cm

Question 5

Describe point Ba and Bp

Answer 5

Ba Most distal portion of remaining anterior vaginal wall
Bp Most distal portion of remaining posterior vaginal wall

-3cm to +tvl

Question 6

How to measure total vaginal length?

Answer 6

Depth of vagina when point D or C is reduced to normal position

Question 7

Describe point C

Answer 7

Most distal edge of cervix or vaginal cuff scar

Question 8

Describe point D

Answer 8

Posterior fornix (N/A if post hysterectomy)

Question 9

What is the genital hiatus (gH)

Answer 9

Middle of external urethral meatus to posterior nudkube hymen

Question 10

What is the perineal body

Answer 10

Measure from posterior margin of gH to middle of anal opening

Question 11

POP-Q staging Stage 0

Answer 11

Stage 0 No descent
(Aa, Ap, Ba, Bp -3cm
C or D < TVL-2cm)

Question 12

POP-Q staging 1

Answer 12

Stage 0 not met, leading edge > 1cm above hymnal ring

Question 13

POP-Q staging 2

Answer 13

Leading edge from 1cm above to 1cm below hymnal ring

Question 14

POP-Q Staging 3

Answer 14

Leading edge more than 1 cm but less than (TVL-2cm)

ie not complete eversion

Question 15

POP-Q staging 4

Answer 15

Leading edge over TVL-2cm

Complete eversion

Question 16

What does this show

Answer 16

Anterior wall defect

Question 17

What does this show

Answer 17

Posterior wall defect

Question 18

What Q to assess vault prolapse

Answer 18

• Subjective severity
• Effects on QoL - use disease-specific validated QoL questionnaires
• Medical / surgical / drug history
• Urinary & bowel symptoms including incontinence
• Sexual function and desire to retain sexual function

Question 19

What procedure can be offered at time of vaginal hysterectomy to prevent vault prolapse?

Answer 19

McCall Culdoplasty

Question 20

What is McCall Culdoplasty

Answer 20

Approximating the uterosacral ligaments with continuous suture to obliterate peritoneum of the sister cut-de-sac as high as possible

Question 21

What other procedure can be offered in both abdominal and vaginal hysterectomy to prevent vault prolapse?

Answer 21

Suturing cardinal or uterosacral ligament to the vaginal cuff at time of hysterectomy

Question 22

What procedure can be offered when the vault descent to introits during closure

Answer 22

Sacrospinous fixation

Question 23

Should subtotal hysterectomy be recommended to prevent PHVP

Answer 23

No

Question 24

What conservative management can be offered to manage PHVP?

Answer 24

Pelvic floor training stage 1-2
Vaginal pessary stage 2-4

Question 25

What 2 main surgical procedures are offered for the treatment of PHVP?

Answer 25

Open abdominal sacrocolpopexy (ASC) or vaginal sacrospinous fixation

Question 26

Describe open abdominal sacrocolpopexy

Answer 26

ASC involves apical suspension of the vault with a permanent mesh fixed to the longitudinal ligament of the sacrum. Mesh is typically attached to the anterior and posterior aspects of the vault with possible ‘mesh extension’ to correct prolapse in other compartments

Question 27

Describe Sacrospinous fixation

Answer 27

SSF involves unilateral anchoring of the vaginal vault to the sacrospinous ligament (usually the right side) using either absorbable or non-absorbable sutures.

Question 28

Benefits of ASC over SSF

Answer 28

- Lower recurrence vault prolapse - Low rates dyspareunia and stress urinary incontinece

Question 29

Any difference in re-operations rate and patient satisfaction between SSF and ASC

Answer 29

No

Question 30

Benefits of SSF over ASC

Answer 30

- Earlier recovery - Reduced operating time - Less expensive

Question 31

When is SSF not appropriate

Answer 31

If short vaginal length or pre-existing dyspareunia

Question 32

Following SSF rate postoperative anterior compartment prolapse SUI and buttock pain

Answer 32

SUI 8-30% Buttock pain 18% (usually resolves in 2-3 months)

Question 33

ACS incidence bowel injury, sacral myelitis and severe bleeding?

Answer 33

2%

Question 34

What other routes can be considered for sacrocolpopexy?

Answer 34

Laparoscopic and robotic

Question 35

When should colpoclesis be offered?

Answer 35

Too frail for surgery Do not wish to retain sexual function.

Question 36

What other procedure can be offered at time of sacroplexy to reduce the rates of post symptomatic SUI in previously continent women?

Answer 36

Colposuspension Not effective in treatment for SUUI.

Question 37

What other procedure can be offered at time of vaginal route to reduce the rates of post symptomatic SUI in previously continent women?

Answer 37

Mid-urethral sling