Post-Hysterectomy Vaginal Vault Prolapse

Question 1

What is the preferred classification for vault/pelvic organ prolapse?

Answer 1

• Standardised classification systems should be used for assessment and documentation of POP, including vault prolapse.

Question 2

When is urodynamic testing required?

Answer 2

• Routine urodynamic assessment is not recommended in women with PHVP.

Question 3

In what setting should a patient with PHVP be assessed?

Answer 3

• Clinicians should work as part of a pelvic floor MDT.

Question 4

Are quality of life (QoL) measures of value?

Answer 4

• Patient assessment should address QoL issues using standardised tools.

Question 5

What preventive techniques are of value at hysterectomy?

Answer 5

• McCall culdoplasty at time of vaginal hysterectomy is effective in preventing subsequent PHVP.
• Suturing the cardinal and uterosacral ligaments to the vaginal cuff at the time of hysterectomy is effective in preventing PHVP following both abdominal and vaginal hysterectomies.
• Sacrospinous fixation (SSF) at time of vaginal hysterectomy should be considered when vault descends to the introitus during closure.

Question 6

Does subtotal hysterectomy have a place in prevention of PHVP?

Answer 6

• Subtotal hysterectomy is not recommended for the prevention of PHVP.

Question 7

Are there preferred suture materials for vault support at the time of hysterectomy?

Answer 7

• There is inadequate and conflicting evidence over use of permanent sutures in the short term and no evidence of benefit in the long term; they can be associated with high suture exposure rates.

Question 8

Is pelvic floor therapy of value in management of PHVP?

Answer 8

• Pelvic floor muscle training (PFMT) is an effective treatment option for women with stage I–II vaginal prolapse, including PHVP

Question 9

What is the place of vaginal devices?

Answer 9

• Vaginal pessaries are an alternative treatment option for women with stage II–IV PHVP.

Question 10

What are the indications for surgery?

Answer 10

• Surgical treatment should be offered to women with symptomatic PHVP after appropriate counselling.

Question 11

Who should undertake surgery?

Answer 11

• PHVP surgery should be performed by RCOG-accredited subspecialist urogynaecologist, or
  gynaecologists who can demonstrate an equivalent level of training or experience.

Question 12

What is an acceptable successful result after surgical treatment?

Answer 12

• Patient-reported outcomes, including patient-reported success rates and relief of presenting
  symptoms, should be the primary assessment outcomes. [New 2015]
• Objective cure: important as it correlates to symptoms of vaginal bulge; a Pelvic Organ Prolapse Quantification (POP-Q) stage of I or O in the apical compartment seems to be acceptable and widely used as optimum postoperative result.

Question 13

What surgical procedures are available for treatment of PHVP?

Answer 13

• The type of operation performed should be tailored to the individual patient’s circumstances

Question 14

A comparison of surgical procedures

Open abdominal sacrocolpopexy (ASC) versus vaginal SSF

Answer 14

• Women should be aware that both ASC and SSF are effective treatments for primary PHVP.
• ASC is associated with significantly lower rates of recurrent vault prolapse, dyspareunia and postoperative stress urinary incontinence (SUI) when compared with SSF. However, this is not reflected in significantly lower reoperation rates or higher patient satisfaction.
• SSF: associated with earlier recovery compared with ASC.
• SSF may not be appropriate in women with short vaginal length and should be carefully considered
  in women with pre-existing dyspareunia.

Question 15

A comparison of surgical procedures

Laparoscopic and robotic sacrocolpopexy (LSC and RSC)

Answer 15

• LSC can be equally effective as ASC in selected women with primary PHVP. LSC can include mesh
  extension or be combined with other vaginal procedures to correct other compartment prolapse.
• Limited evidence on effectiveness of RSC; therefore, it should only be performed in context of research or prospective audit following local governance procedures.

Question 16

A comparison of surgical procedures

High uterosacral ligament suspension (HUSLS)

Answer 16

• HUSLS should only be offered as first-line MX in women with PHVP within context of research or prospective audit following local governance procedures.
• Clinicians should be aware of risk of ureteric injury, especially in laparoscopic approach.

Question 17

Under what circumstances would transvaginal mesh (TVM) kits/grafts be considered?

Answer 17

• Limited evidence on TVM kits does not support their use as first-line treatment of PHVP.
• If TVM is considered, women should be fully informed of permanent nature of the mesh and potential mesh complications, some of which are serious and have long-term effects that can be difficult to treat.
• If TVM is considered, women should be fully informed of alternative surgical and nonsurgical options and referral to other surgeons/units arranged as appropriate.
• TVM should only be performed by an appropriately trained urogynaecologist, after discussion of each individual case in an MDT meeting.
• Results of all surgical procedures involving mesh should be prospectively audited and submitted to a national surgical database (e.g. British Society of Urogynaecology [BSUG]) and any mesh complications reported to the Medicines and Healthcare Products Regulatory Agency (MHRA).

Question 18

When should colpocleisis be used?

Answer 18

• Colpocleisis is a safe and effective procedure that can be considered for frail women and/or women who do not wish to retain sexual function.

Question 19

Is there an indication for concomitant surgery for occult SUI?

Answer 19

• Colposuspension performed at time of sacrocolpopexy is an effective measure to reduce postoperative symptomatic SUI in previously continent women.

Question 20

Is there an indication for concomitant surgery for PHVP and overt SUI?

Answer 20

• Colposuspension at time of ASC does not appear to be effective treatment for SUI.
• Concomitant mid-urethral sling surgery may be considered when vaginal surgical approaches are used for treatment of PHVP.

Question 21

What is the optimal treatment of recurrent vault prolapse?

Answer 21

• management of recurrent vault prolapse should be through a specialist MDT with experience and training in this field.

Question 22

Clinical governance & PHVP

Answer 22

• National databases, such as the BSUG surgical database, should be used to document surgical
  outcomes and complications. [New 2015]
• International Urogynecological Association (IUGA) /International Continence Society (ICS) terminology and classification of complications should be used for the documentation of graftrelated complications.
• All complications related to use of devices and mesh should be reported to the MHRA.

Question 23

POP-Q exam – reference guide

Answer 23

pelvic organ prolapse quantification (POP-Q) exam is used to quantify, describe and stage pelvic support.

• There are 6 points measured at the vagina with respect to the hymen.
• Points above the hymen are negative numbers; points below the hymen are positive numbers.
• All measurements except tvl are measured at maximum valsalva.

Question 24

Point,  Description,  Range of values
Aa 
Ba 
C 
D 
Ap 
Bp 
Genital hiatus (gh) –
Perineal body (pb) – 
Total vaginal length (tvl) – n

Answer 24

• Aa: Anterior vaginal wall 3 cm proximal to hymen –(3 cm to +3 cm)

Ba: Most distal position of remaining upper anterior vaginal wall (–3 cm to +tvl)

C: Most distal edge of cervix or vaginal cuff scar

D: Posterior fornix (N/A if post hysterectomy)

Ap: Posterior vaginal wall 3 cm proximal to the hymen –(3 cm to +3 cm)

Bp: Most distal position of the remaining upper posterior vaginal wall – (3 cm to +tvl)

Genital hiatus (gh) – measured from middle of external urethral meatus to posterior midline hymen

Perineal body (pb) – measured from posterior margin of gh to middle of anal opening

Total vaginal length (tvl) – depth of vagina when point D or C is reduced to normal position

Question 25

POP-Q staging criteria
Stage O 
Stage I 
Stage II 
Stage III 
Stage IV

Answer 25

• Stage O: Aa, Ap, Ba, Bp = –3 cm and C or D ≤ – (tvl – 2) cm
• Stage I: Stage O criteria not met and leading edge < –1 cm
• Stage II: Leading edge ≥ –1 but ≤ +1 cm
• Stage III: Leading edge > +1 cm but < + (tvl – 2) cm
• Stage IV: Leading edge ≥ + (tvl – 2) cm