Post-Hysterectomy Vaginal Vault Prolapse GTG 2015 Flashcards

1
Q

What proportion of hysterectomies have vault prolapse?

A

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

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2
Q

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

A

6 points

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3
Q

When are the points measured

A

All except TVL are measured in maximum valsalva

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4
Q

Describe point Aa and Ap

A

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

-3cm to +3cm

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5
Q

Describe point Ba and Bp

A

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

-3cm to +tvl

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6
Q

How to measure total vaginal length?

A

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

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7
Q

Describe point C

A

Most distal edge of cervix or vaginal cuff scar

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8
Q

Describe point D

A

Posterior fornix (N/A if post hysterectomy)

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9
Q

What is the genital hiatus (gH)

A

Middle of external urethral meatus to posterior nudkube hymen

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10
Q

What is the perineal body

A

Measure from posterior margin of gH to middle of anal opening

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11
Q

POP-Q staging Stage 0

A

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

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12
Q

POP-Q staging 1

A

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

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13
Q

POP-Q staging 2

A

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

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14
Q

POP-Q Staging 3

A

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

ie not complete eversion

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15
Q

POP-Q staging 4

A

Leading edge over TVL-2cm

Complete eversion

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16
Q

What does this show

A

Anterior wall defect

17
Q

What does this show

A

Posterior wall defect

18
Q

What Q to assess vault prolapse

A
  • 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
19
Q

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

A

McCall Culdoplasty

20
Q

What is McCall Culdoplasty

A

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

21
Q

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

A

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

22
Q

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

A

Sacrospinous fixation

23
Q

Should subtotal hysterectomy be recommended to prevent PHVP

A

No

24
Q

What conservative management can be offered to manage PHVP?

A

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

25
Q

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

A

Open abdominal sacrocolpopexy (ASC) or vaginal sacrospinous fixation

26
Q

Describe open abdominal sacrocolpopexy

A

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

27
Q

Describe Sacrospinous fixation

A

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

28
Q

Benefits of ASC over SSF

A
  • Lower recurrence vault prolapse
  • Low rates dyspareunia and stress urinary incontinece
29
Q

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

A

No

30
Q

Benefits of SSF over ASC

A
  • Earlier recovery
  • Reduced operating time
  • Less expensive
31
Q

When is SSF not appropriate

A

If short vaginal length or pre-existing dyspareunia

32
Q

Following SSF rate postoperative anterior compartment prolapse SUI and buttock pain

A

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

33
Q

ACS incidence bowel injury, sacral myelitis and severe bleeding?

A

2%

34
Q

What other routes can be considered for sacrocolpopexy?

A

Laparoscopic and robotic

35
Q

When should colpoclesis be offered?

A

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

36
Q

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

A

Colposuspension
Not effective in treatment for SUUI.

37
Q

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

A

Mid-urethral sling