Post-Hysterectomy Vaginal Vault Prolapse GTG 2015 Flashcards
What proportion of hysterectomies have vault prolapse?
11% Hysterectomy for prolapse
1.8% hysterectomy for other bengin causes
How many points are measured in POP-Q in relation to the Hymen?
6 points
When are the points measured
All except TVL are measured in maximum valsalva
Describe point Aa and Ap
Aa Anterior vaginal wall 3cm proximal to hymen
Ap posterior vaginal wall 3cm proximal to hymen
-3cm to +3cm
Describe point Ba and Bp
Ba Most distal portion of remaining anterior vaginal wall
Bp Most distal portion of remaining posterior vaginal wall
-3cm to +tvl
How to measure total vaginal length?
Depth of vagina when point D or C is reduced to normal position
Describe point C
Most distal edge of cervix or vaginal cuff scar
Describe point D
Posterior fornix (N/A if post hysterectomy)
What is the genital hiatus (gH)
Middle of external urethral meatus to posterior nudkube hymen
What is the perineal body
Measure from posterior margin of gH to middle of anal opening
POP-Q staging Stage 0
Stage 0 No descent
(Aa, Ap, Ba, Bp -3cm
C or D < TVL-2cm)
POP-Q staging 1
Stage 0 not met, leading edge > 1cm above hymnal ring
POP-Q staging 2
Leading edge from 1cm above to 1cm below hymnal ring
POP-Q Staging 3
Leading edge more than 1 cm but less than (TVL-2cm)
ie not complete eversion
POP-Q staging 4
Leading edge over TVL-2cm
Complete eversion
What does this show
Anterior wall defect
What does this show
Posterior wall defect
What Q to assess vault prolapse
- 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
What procedure can be offered at time of vaginal hysterectomy to prevent vault prolapse?
McCall Culdoplasty
What is McCall Culdoplasty
Approximating the uterosacral ligaments with continuous suture to obliterate peritoneum of the sister cut-de-sac as high as possible
What other procedure can be offered in both abdominal and vaginal hysterectomy to prevent vault prolapse?
Suturing cardinal or uterosacral ligament to the vaginal cuff at time of hysterectomy
What procedure can be offered when the vault descent to introits during closure
Sacrospinous fixation
Should subtotal hysterectomy be recommended to prevent PHVP
No
What conservative management can be offered to manage PHVP?
Pelvic floor training stage 1-2
Vaginal pessary stage 2-4
What 2 main surgical procedures are offered for the treatment of PHVP?
Open abdominal sacrocolpopexy (ASC) or vaginal sacrospinous fixation
Describe open abdominal sacrocolpopexy
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
Describe Sacrospinous fixation
SSF involves unilateral anchoring of the vaginal vault to the sacrospinous ligament (usually the right side) using either absorbable or non-absorbable sutures.
Benefits of ASC over SSF
- Lower recurrence vault prolapse
- Low rates dyspareunia and stress urinary incontinece
Any difference in re-operations rate and patient satisfaction between SSF and ASC
No
Benefits of SSF over ASC
- Earlier recovery
- Reduced operating time
- Less expensive
When is SSF not appropriate
If short vaginal length or pre-existing dyspareunia
Following SSF rate postoperative anterior compartment prolapse SUI and buttock pain
SUI 8-30%
Buttock pain 18% (usually resolves in 2-3 months)
ACS incidence bowel injury, sacral myelitis and severe bleeding?
2%
What other routes can be considered for sacrocolpopexy?
Laparoscopic and robotic
When should colpoclesis be offered?
Too frail for surgery
Do not wish to retain sexual function.
What other procedure can be offered at time of sacroplexy to reduce the rates of post symptomatic SUI in previously continent women?
Colposuspension
Not effective in treatment for SUUI.
What other procedure can be offered at time of vaginal route to reduce the rates of post symptomatic SUI in previously continent women?
Mid-urethral sling
