Enterocele and Massive Vaginal Eversion |
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INTRODUCTION |
Massive vaginal vault prolapse (uterovaginal prolapse) is a devastating condition with discomfort, and genitourinary and defecatory abnormalities as the primary consequences. References to prolapse of the womb were first made in ancient Egypt, dating back to 1550 BC. Vaginal vault prolapse refers to significant descent of the vaginal apex following a hysterectomy (see Figure 1). Apical prolapse is used to denote prolapse of the vaginal apex with or without the presence of a uterus. Although this obviously is not a new condition, apical prolapse is thought to be increasingly common as life expectancy increases.
Prolapse of the vaginal apex may or may not be accompanied by enterocele. Whereas complete vaginal eversion is obvious, lesser degrees of prolapse and the presence of enterocele are more difficult to discern and require careful evaluation of anterior, posterior, and apical compartment defects. Also, associated functional abnormalities, whether concurrent or potential, need to be properly explored, evaluated, and discussed with the patient.
Problem: A uniform definition of what constitutes apical prolapse or any pelvic organ prolapse does not exist. Indeed, a degree of uterine descensus is present in many, if not most, women who are multiparous. Not all patients with prolapse are symptomatic, and the degree of prolapse often does not correlate with the degree of patient complaint.
The pelvic organ prolapse quantification (POP-Q) has been instituted to address this deficiency in defining the extent of prolapse. Specific sites are defined separately on the anterior, posterior, and apical vaginal compartments and are measured with respect to a fixed reference point, the hymen. These measurements can then be categorized into an ordinal staging system ranging from 0-4.
The POP-Q staging system has been validated and demonstrates good interobserver and intraobserver reliability. Although POP-Q staging adequately addresses the extent of prolapse, assumptions about which organ is behind each bulge should be made with caution and should be made only after a complete evaluation.
Regarding enterocele, the definition is somewhat more difficult. Previous texts have defined enterocele as any intraperitoneal contents (bowel or mesentery) palpable within the cul-de-sac, as evaluated during an examination in the erect position. A more anatomic definition was made by Richardson, who suggested that enterocele occurs when contact between the peritoneum and vagina occurs without intervening endopelvic fascia (see Figure 2). A careful preoperative and intraoperative search for these defects is necessary for proper diagnosis.
Frequency: Swift recently reported on the frequency of different stages of pelvic organ prolapse based upon the POP-Q staging system. In a routine gynecologic clinic population, most women had stage 1 or stage 2 prolapse (43.3% and 47.7%, respectively). Few women had stage 0 or stage 3 prolapse (6.4% and 2.6%, respectively), and no women had stage 4 pelvic organ prolapse. Samuelsson et al report a prevalence of 30.8% for any prolapse, using the Baden halfway system, in a study of the general population in Sweden. Vaginal vault prolapse is thought to occur postoperatively in 0.5% of hysterectomy cases, whether they are performed vaginally or abdominally.
Etiology: Swift reported that significant trends for increasing prolapse were found with advancing age, parity, postmenopausal status, previous hysterectomy, and prior corrective surgery for prolapse. Multivariate analysis in a study performed by Samuelsson et al revealed independent statistical associations with age, parity, maximal birth weight, and pelvic floor muscle strength. Such associations were not found regarding the woman's weight or prior hysterectomy.
Precise etiology regarding pelvic organ prolapse remains elusive. Theories include diminished sacral nerve function and/or defects in collagen.
Pathophysiology: DeLancey describes the anatomy of vaginal vault prolapse in terms of 3 levels of support (see Figure 3).
The conditions of enterocele and vaginal eversion represent failures of level I support. Uterovaginal prolapse does not denote intrinsic uterine disease and, therefore, may not necessarily require a hysterectomy in all cases.
Apical prolapse occurs because of tearing or attenuation of the cardinal-uterosacral ligament complex. This results in failure to support the upper vagina and/or uterus over the pelvic diaphragm, which should be in a near-horizontal plane in a woman in the erect position. Level I support is considered most important in maintaining adequate overall pelvic support.
Richardson describes an enterocele in anatomic terms, as a break in the integrity of endopelvic fascia at the vaginal apex (see Figure 4). Normally, posthysterectomy enterocele is precluded by the apposition of pubocervical and rectovaginal fascia (collectively termed endopelvic fascia) at the apex. Anterior, apical, and posterior enteroceles have been described based upon the location of the fascial defect and the location of the ensuing herniation of bowel.
Apical enterocele is the most common enterocele and, by definition, can develop only after a hysterectomy. Apical enterocele may present with or without vaginal vault prolapse (see Figures 5, Figure 6, Figure 7).
Anterior enteroceles are rare and may occur following sacrospinous ligament fixation, when the proximal vaginal tube is pulled somewhat posteriorly creating a potential space in the anterior compartment. Because they present as a protrusion of the anterior vaginal wall, they may be confused with cystoceles. In women with an intact uterus, posterior enteroceles have been described. These are due totearing of the proximal rectovaginal fascia, often involving its attachment to the cardinal-uterosacral ligament complex, which results in descent of the peritoneal contents down the posterior aspect of the vagina (see Figure 8).
Posterior enterocele usually is accompanied by significant uterovaginal prolapse and prolapse of other compartments as well.
Clinical: Patients may present with an obvious vaginal bulge that is seen or felt by the patient. Conversely, the patient may complain of a vague sense of pelvic heaviness or a sensation that something is about to fall out. The bulging often is noted to be worse toward the end of the day, as compared to when the patient first wakes or when straining at defecation or urination. When vaginal epithelium remains exteriorized, it undergoes cornification and, often, ulceration, which can result in infection.
Functional difficulties may be encountered during coitus. Defecation may be difficult, with associated constipation being very common. Incomplete bladder emptying also is common, and in severe cases, complete obstruction may be seen. Voiding dysfunction may result in frequent urinary tract infections and, occasionally, overflow incontinence. Due to kinking of the urethra, occult (potential) stress incontinence and even intrinsic sphincter deficiency may be present. A history of stress incontinence that spontaneously improved and/or resolved as the prolapse progressively worsened is especially concerning for the presence of occult stress incontinence. Although rare, severe pelvic prolapse may result in ureteral kinking with the potential for renal damage.
A detailed history is required to evaluate the patient. Ascertain information regarding any functional problems that may be caused by prolapse. Essential to the preoperative evaluation and surgical decision making is the review of any prior pelvic surgery, including obtaining operative reports, especially if surgery was performed for prior pelvic floor dysfunction.
A commitment to treat all associated pelvic floor defects requires a careful and comprehensive urogynecologic examination. A diligent search for all pelvic support defects and repairs of these defects increases the likelihood of surgical success. The apical, anterior, and posterior compartments are evaluated separately, with and without straining and/or coughing in the supine position and again in the erect position. POP-Q is helpful for categorization and accurate follow-up. Carefully evaluate the rectovaginal septum for integrity, strength, and thickness along its entire length. Look for any signs of enterocele, such as bowel peristalsis, along the upper vagina or near the apex. Look for any obvious pubocervical/rectovaginal detachments at the periphery of an apical bulge. Evaluate the cul-de-sac in the supine and standing positions, with and without Valsalva maneuvers.
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INDICATIONS |
Treatment of pelvic organ prolapse is indicated if it is symptomatic or is causing associated morbidity. Asymptomatic prolapse, with minor degrees of protrusion that cause no other problems, needs to be discussed with the patient but does not necessarily need to be treated.
In the older population, even extensive prolapse may be asymptomatic from the patient's point of view, but questioning her family or caregiver may reveal troublesome symptoms, and further evaluation may reveal significant resultant morbidity.
Offer conservative management to these patients as the initial management option. Conservative management may include observation with mild degrees of asymptomatic prolapse or a pessary fitting. Surgical management may be considered in appropriate candidates if conservative therapies fail or are declined by the patient.
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RELEVANT ANATOMY AND CONTRAINDICATIONS |
Relevant Anatomy: The cardinal-uterosacral ligaments are localized thickenings of the endopelvic fascia that invest the pelvic organs. The same endopelvic fascia that is anterior to the vagina is called pubocervical; posteriorly, it is termed rectovaginal fascia or the fascia of Denonvilliers. Laterally, the endopelvic fascia attaches the lateral vagina to the arcus tendineus fascia pelvis to provide paravaginal support.
The integrity of the vaginal apex following hysterectomy depends upon the fusion of the pubocervical fascia with the rectovaginal fascia. Surgically, the uterosacral ligaments lay medial to the ureters in the pelvis. The proximal uterosacral ligament fans out and attaches to the lateral aspect of the sacrum. The proximal vagina normally points into the hollow of the sacrum towards sacral levels 3 and 4 (S3, S4) and maintains a near-horizontal plane when the woman stands erect.
Although the term fascia is used frequently to denote the surgically significant layer used for pelvic reconstruction, histologically, it is a fibromuscular layer with varying amounts of smooth muscle, collagen, and elastin that is located just below the epithelium.
Contraindications: Pessary use is contraindicated in the presence of vaginal ulceration and breakdown or in the presence of an active vaginal infection. Severe vaginal atrophy is best treated prior to starting pessary use, in the absence of contraindications for estrogen use.
The evaluation of a patient for surgical repair is a topic that is too broad for this chapter and may be found elsewhere. However, it is very important to tailor the proposed operation to the specific defects noted preoperatively, taking into consideration the patient's overall health, and prior surgical history. The chosen approach, be it vaginal, abdominal, or laparoscopic, should take these patient-related points, in addition to the surgeon𠏋 level of skill and available local resources, into careful consideration. Appropriate consultations and referrals during the preoperative evaluation can ensure the highest degree of success and safety.
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WORKUP |
Lab Studies:
Imaging Studies:
Diagnostic Procedures:
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TREATMENT |
Medical therapy: Supporting the epithelial environment in the vagina with estrogen, if no contraindication otherwise exists, helps minor symptoms of vaginal irritation and discomfort. Estrogen assists the healing process if ulceration is present and prepares the vagina for subsequent pessary use. Short-term topical preparations are preferred because of their rapid effect and limited systemic absorption. The author uses conjugated equine estrogens or estradiol cream 2-3 times a week for at least 4-6 weeks until an effect can be noted.
Subsequent to or in conjunction with estrogen therapy (depending upon the severity of the prolapse), a pessary may be offered. A tampon can occasionally be used, but only in mild cases. Because of the variety of shapes and sizes of pessaries, the variability in the extent and type of prolapse being treated, and the patient's anatomy, inform the patient that fitting a pessary may necessitate an adjustment in the initial fitting.
A complete discussion of all available pessaries and their fitting is beyond the scope of this chapter, but a few observations may be helpful. (1) For total uterovaginal or vault prolapse, the most effective pessary is the cube because of its suction action upon the vaginal walls. The use of the cube is severely limited by the need to remove it nightly and reinsert it in the morning, a task the patient must learn to do herself. (2) The donut-shaped pessary may be retained for 3 months at a time after the initial fitting period but requires an intact levator plate upon which it rests. The Inflato Ball is useful if a donut configuration is desired, but the introitus is too narrow to insert the appropriate size. (3) A Gelhorn pessary is useful for vault prolapse in the presence of an intact perineal body. Follow-up is necessary to prevent and treat mucosal damage in the vagina, especially early after the initial fitting.
Surgical therapy: Surgery to repair enterocele and apical prolapse should address the underlying defect-specific pathophysiology of the patient's condition and should restore normal anatomy. This includes addressing attention to all 3 levels of vaginal support as discussed previously (see Pathophysiology), with restoration of the normal vaginal axis and the integrity of the endopelvic fascia in all of its compartments. This chapter is limited to discussing these surgical principles as they relate to management of the failure of level I (apical) support.
Pelvic reconstructive procedures can be vaginal, abdominal, laparoscopic, or a combination of these. Surgical techniques can be reconstructive, with the aim of restoring anatomy and maintaining the potential for coitus, or surgical techniques can be destructive procedures that eliminate prolapse at the expense of potential coital function.
Intraoperative details: When including hysterectomy as a treatment modality for uterovaginal prolapse, preservation, restoration, and strengthening of pelvic support is of primary importance. Pay particular attention to reattachment of the cardinal-uterosacral ligament complex to the posterolateral vaginal apex (reestablishing its continuity with the rectovaginal fascia), with appropriate shortening of the ligament for adequate support. Specifically in cases of uterovaginal prolapse, the use of permanent sutures is preferable.
Culdoplasty is performed per surgeon preference. The two most commonly performed techniques for culdoplasty are the McCall and Halban methods. Although not described in this chapter, the McCall culdoplasty approximates the uterosacral ligaments in the midline, incorporating posterior vaginal fornix in the stitch. The Halban culdoplasty shortens each uterosacral ligament using a reefing stitch, with vertical purse-string sutures interposed between the uterosacral sutures. Culdoplasty serves to close the posterior cul-de-sac and further direct the vaginal apex towards the hollow of the sacrum.
Adequate closure of the cuff serves to reestablish continuity of the endopelvic fascia at the apex by reapproximating pubocervical fascia with rectovaginal fascia at the most proximal end. The combined effect of proper orientation of the upper vagina in a near-horizontal plane (in the erect position) and the reestablishment of endopelvic fascial integrity as described, constitutes both the treatment and prevention of enterocele. All pelvic floor defects need to be addressed during this surgery to decrease the likelihood of recurrence. Repair of pelvic floor defects may be performed vaginally and may include anterior colporrhaphy, paravaginal repair, posterior colporrhaphy, and/or perineorrhaphy as required.
Vaginal approaches
Vaginal approaches to reconstruction of the vaginal vault (following prior hysterectomy) includes sacrospinous ligament fixation (unilateral or bilateral), bilateral iliococcygeus fascia suspension, or uterosacral reattachment. Each of these reconstructive procedures addresses level I (apical) support. Procedures such as the LeFort partial colpocleisis or colpectomy with colpocleisis are useful in particular situations.
Sacrospinous ligament fixation begins with incision of
the posterior vagina in the midline to the level of the vaginal apex. If an
enterocele is encountered, it is completely dissected and opened. The bowel
contents are reduced, the redundant peritoneum is excised. The most important
part of the repair, however, is the proper identification and reapproximation of
the endopelvic fascial defect, preferably with permanent sutures. The
rectovaginal space is then dissected laterally, and the rectal pillar is
perforated to gain access to the pararectal space in a position overlying the
ischial spine. The space is developed, the sacrospinous ligament within the
coccygeus muscle is palpated, and the surrounding area gently is cleared off.
Several instruments are available to penetrate the ligament for adequate
suspension, including the Deschamps ligature carrier, the Miya hook, the
Nichols-Veronikis ligature carrier (BEI Medical Systems, CA), and the Laurus
needle driver (MicrovasiveBoston Scientific Corp, MA) (see
Figure 9) and
the EndoStitch (USS Surgical). Take care to avoid injury to the inferior gluteal
artery, pudendal neurovascular bundle, and the sciatic nerve (see
Figure 10).
Avoid dissection superior to the coccygeus muscle and lateral to the ischial
spine. Do not place retractors beyond the sacrospinous ligament, and never pass
the ligature carrier/needle posterior to the ligament because of risk of
vascular injury of the inferior gluteal artery. The ligature carrier should
pierce the ligament 1.5-2 fingerbreadths medial to the ischial spine, without
encircling the coccygeus muscle (see
Figure 11).
Two sutures are used, with at least one that is permanent. They are sutured to
the muscularis of the vagina, incorporating rectovaginal fascia but excluding
vaginal mucosa because of the high incidence of granulation tissue at the site
of the surgical knots of permanent suture. A second stitch can be delayed
absorbable and brought out through the vaginal epithelium (see
Figure 12).
Avoid suture bridging when tying these sutures down. Some physicians have
advocated bilateral sacrospinous ligament fixation for a more durable repair.
Exercise clinical judgment intraoperatively to determine whether this can be
accomplished without undue tension. Consider the potential benefits in view of
the potential increase in risk, both from intraoperative injury and the
long-term effect on vaginal anatomy.
Uterosacral reattachment with fascial reconstruction aims to restore normal level I anatomy (see Figure 13). This does not result in lateral deviation of the proximal vagina or in the posterior displacement seen with sacrospinous ligament fixation.
Once the posterior vagina is opened, the enterocele sac is identified and excised, the peritoneal cavity is entered, and the uterosacral ligaments are identified distally and are gradually "walked up" toward the sacrum using Allis clamps. Identification may be aided by inserting a finger rectally and palpating the proximal rectovaginal fascia. The proximal aspect of the ligament, at the level of the ischial spine, is used for resuspension to exclude the defect that is responsible for the prolapse. Permanent sutures are used to grasp and hold each ligament separately in a helical bite; anterior compartment defects can be addressed at this stage. The proximal ligaments are sutured to the rectovaginal fascia laterally near the apex, with no need for midline plication. This lateral stitch may be fashioned to incorporate rectovaginal and pubocervical fascia together, if this is preferred.
The pubocervical and rectovaginal fasciae are reapproximated across the vaginal apex to correct and prevent enterocele. Posterior colpoperineorrhaphy may be performed as needed. Take care to ensure the integrity of the ureters by carefully palpating the uterosacral ligament, staying well medial to the ureter, and liberally using cystoscopy with intravenous indigo-carmine dye.
LeFort partial colpocleisis involves retention of the uterus, and therefore, should be preceded by dilatation and curettage (D&C). This procedure may be performed under local or regional anesthesia to accommodate a patient who is frail.
Rectangular strips of both anterior and posterior vagina are obtained, extending from 2 cm distal to the cervix to the level of the bladder neck anteriorly and similarly on the posterior vaginal wall. Enough vagina is left laterally to fashion bilateral canals for drainage (see Figure 14). Dissection should leave adequate endopelvic fascia anteriorly and posteriorly to retain strong tissue for reapproximation. Excellent hemostasis is required and achieved by electrocautery. Some authors prefer plication of the bladder neck (eg, Kelly plication) at this stage if no demonstrable or occult stress incontinence has been demonstrated preoperatively.
The anterior and posterior denuded vaginal walls are sutured with an interrupted delayed-absorbable suture in a progressive manner to invert the prolapsed vagina. The lateral mucosal edges are reapproximated so that lateral tunnels are formed throughout the length of the vagina on either side. If actual or occult incontinence has been demonstrated preoperatively, a tension-free vaginal tape (TVT) may be performed by adding a midline vaginal incision at this time and continuing as per routine for TVT.
For posthysterectomy vault prolapse, a colpectomy with colpocleisis is performed in a similar fashion, except that no mucosa-lined tunnels are created. The entire vaginal mucosa is dissected off in strips, and the vaginal endopelvic fascia is progressively inverted by concentric purse string sutures of delayed-absorbable material once meticulous hemostasis is achieved. Manage the urethra and bladder neck in the same manner that is described for a LeFort procedure.
Abdominal approaches
Abdominal approaches to vaginal vault suspension include sacral colpopexy or uterosacral reattachment with fascial reconstruction. The abdominal approach allows concomitant abdominal procedures to be performed, including paravaginal repair, Burch colposuspension, or suburethral sling (depending upon associated pelvic floor defects, preoperative urodynamics, concomitant pelvic pathology, and medical history). Often, concurrent vaginal surgery is required to complete adequate reconstruction. In either technique, carefully exclude enterocele, and repair enterocele if found. When performing defect-specific repair, this is accomplished abdominally by incising the peritoneum at the vaginal cuff and identifying the endopelvic fascia. If a break is found, it is repaired with interrupted permanent sutures (see Figure 15). Conversely, a traditional Moschcowitz or Halban procedure is recommended by some urogynecologists.
Abdominal sacral colpopexy may be performed with fascia, but most often is performed with a permanent mesh, such as Mersilene or Prolene. The author prefers a Y configuration, with the distal end of the graft attached to the anterior and posterior aspects of the vaginal cuff and spacing allowed between the crux of the Y and the vaginal cuff (see Figure 16). This decreases the amount of mesh in contact with the vagina, which may be important in the prevention of subsequent erosion. Each arm of the mesh is attached to the vagina with 4-5 interrupted stitches of permanent suture, taking care to incorporate endopelvic fascia in each bite. The proximal aspect of the mesh is attached to the anterior sacral fascia at the level of S3 with permanent suture (see Figure 17, Figure 18, Figure 19). Reperitonealization is important to avoid subsequent entrapment of the bowel within the mesh. Formal culdoplasty, such as atraditional Moschcowitz or Halban procedure, has been advocated, though the author has not found it necessary as long as the enterocele has been repaired as described and the vagina is attached to level S3 and not higher. Take care to avoid damage to the bladder and rectum during dissection, as well as the ureters, particularly on the right side. Cautiously proceed with the dissection in the presacral space, and pay attention to avoid damage to the mid sacral vessels. Meticulously avoid putting tension upon the vagina with the mesh in place.
High uterosacral reattachment is performed using the same principles discussed previously. A relaxing incision medial to the ureter occasionally may be helpful to avoid damage or distortion to the ureter. Reconstruction of the continuity of endopelvic fascia is the cornerstone of therapy. The author finds a Moschcowitz or Halban culdoplasty to be unnecessary. Maintain an adequate hiatus between the sigmoid and vagina after the sutures are tied by allowing 2 fingerbreadths. Avoid upward tension upon the vagina.
As discussed previously, the uterosacral reattachment with fascial reconstruction may be performed vaginally or abdominally. Using the same principles, this procedure is amenable to the laparoscopic approach as well (see Figure 20). Similarly, sacral colpopexy also has been reported via the laparoscopic approach. These remain as potentially useful surgical approaches if care is taken not to alter the operation in a way that fundamentally changes and weakens the reconstruction, eg, use of coils or tacks.
Postoperatively, stool softeners have been suggested, though they are not mandatory unless a concomitant anal sphincteroplasty has been performed or the patient has a propensity for developing severe constipation. If stool softeners are indicated, administer for 2 weeks.
Follow-up care: Patients usually are seen 2 weeks and 6 weeks following surgery. For long-term follow-up, they are monitored every 6-12 months, as needed.
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COMPLICATIONS |
Hemorrhage; operative site infection; and damage to the bowel, bladder, and ureters are the most common complications during reconstructive pelvic surgery, regardless of the route or method chosen. Dyspareunia also may develop, especially when posterior vaginal incisions are employed. Additional complications shared by all pelvic surgeries, eg, thromboembolism, cardiac events, or pneumonias, require meticulous preoperative and postoperative management and adequate prevention strategies (see Preoperative Details, Postoperative Details). Of particular concern to the urogynecologist is the development of postoperative urinary retention and severe constipation, which have less to do with the actual vault suspension and more to do with the preoperative and postoperative management and concurrent surgical procedures.
Sacrospinous ligament fixation can result in severe hemorrhage from the inferior gluteal, internal pudendal vessels, or the hypogastric venous plexus. Damage to these structures is best avoided as delineated above (see Sacrospinous ligament fixation). In the event of such hemorrhage, initial packing is most beneficial with individual and careful ligation using clips or suture. Hypogastric artery ligation is only helpful if the internal pudendal artery is hemorrhaging. The most common vessel injured is the superior gluteal artery.
Another complication of sacrospinous ligament fixation is buttock pain on the side of fixation. This occurs in 15% of patients and usually resolves spontaneously by 6 weeks, requiring reassurance and nonsteroidal anti-inflammatory agents.
Other possible complications of sacrospinous ligament fixation include damage to the sciatic nerve, rectal injury, vaginal stenosis, and subsequent defects of anterior compartments. Damage to the sciatic nerve is possible and necessitates removal of the offending suture. Rectal injury may occur and is best avoided by adequate medial retraction of the rectum during the procedure. Vaginal stenosis may occur if excessive amounts of the vagina are removed during anterior and/or posterior colporrhaphy, concurrent with sacrospinous ligament fixation. Because of the posterior displacement of the upper vagina, patients are prone to subsequent anterior compartment defects at a rate of approximately 8%.
Colpocleisis is a safe procedure and, in fact, is used in patients who otherwise may not be good surgical candidates for more extensive reconstruction. Immediate complications are rare but may include bleeding, infection, urinary retention, and urgency. Postoperative stress incontinence may occur in 10% of cases when the vesical neck and/or urethra are not adequately supported. To avoid this if true occult or obvious SUI exists preoperatively, a TVT may be included in the procedure, or if no incontinence is demonstrable, a suburethral plication may prevent future incontinence.
Abdominal sacral colpopexy may result in life-threatening hemorrhage from the presacral venous plexus. Such bleeding may be particularly difficult to control because of extensive anastomosis, lack of venous valves, and retraction of the vessels into the sacral bone when they are completely severed. Because of the likelihood that packing with laparotomy packs may exacerbate bleeding upon their removal and further shearing of these delicate veins, careful application of pressure with a gloved finger is the initial maneuver to arrest such hemorrhaging. Bleeding may be stopped by clips, cautery, or suture, remaining keenly aware of the location of the iliac vessels, ureters, and rectum. If these measures are unsuccessful, sterile stainless steel thumbtacks may be used at the point of bleeding from a retracted presacral vessel. Bone wax also has been used successfully in the management of such bleeding.
Other early complications of abdominal sacral colpopexy include mesh infection, bowel obstruction, and ileus. Mesh erosion is a late complication and occurs in 3-7% of cases. Suspect the diagnosis of mesh infection in a patient following abdominal sacral colpopexy with mesh at any interval when the patient complains of persistent vaginal discharge, bleeding, and/or dyspareunia.
Conservative measures using estrogen vaginal cream may be tried first, though results have been disappointing. Some physicians advocate an abdominal approach to remove the entire mesh. Dissection in this circumstance tends to be quite difficult because of scarring and should be attempted only if a more conservative vaginal approach has failed or is associated with postoperative infection. If possible, leaving the sacral attachment is prudent because of the potential for severe hemorrhage from the scarred presacral space. Vaginally excising the eroded mesh as deep as is safely accessible, undermining and freshening the edges of the involved vagina, and closing it primarily with delayed-absorbable sutures generally is preferable. Recurrence of apical prolapse usually is not seen following mesh excision, though it may be related to close temporal proximity to the original surgery. Despite this, do not delay management of mesh erosion.
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OUTCOME AND PROGNOSIS |
Sacrospinous ligament fixation has been reviewed by Sze and Karram. They report an overall failure rate of 19%, a reoperation rate for recurrent prolapse of 2.7%, and a reoperation rate for apical recurrence of 1.8%. Abdominal sacral colpopexy has an overall failure rate of less than 10%, as reported by multiple studies. Destructive operations, such as the LeFort procedure, also have a success rate of over 90%.
Benson et al report in the only randomized comparison between abdominal and vaginal approaches to pelvic floor defects to date. They report a reoperation rate of 12% (5 of 42) for recurrent apical prolapse when performed vaginally and a reoperation rate of 2.6% (1 of 38) when performed abdominally. They report unsatisfactory results leading to reoperation in 33% of the vaginal group versus reoperation in 16% of the abdominal group, with a mean follow-up of 2.5 years (range of 1-5.5 y). Although multiple procedures were performed in this study in both groups, abdominal sacral colpopexy was performed in all of the patients with the abdominal approach, while bilateral sacrospinous ligament fixation was performed in all patients in the vaginal group. The conclusions of this study, therefore, are more relevant to the overall choice of approach (abdominal vs vaginal) rather than the specific procedures used for the suspension of the apex. Possible explanations for the differences seen include surgically induced neuropathy that is demonstrated following vaginal repair but not abdominal repair. Surgically induced neuropathy also has been correlated to subsequent failed vaginal repair.
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FUTURE AND CONTROVERSIES |
Section 9 of 11 
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A paucity of well-controlled comparative studies regarding the treatment of apical prolapse are available in literature. The concept of defect-specific repair in female pelvic reconstructive surgery is one that has been embraced by many but not by all urogynecologists and pelvic surgeons. Whether long-term outcomes are improved using this concept remains to be seen through well-designed studies with long-term follow-up. The surgeon who is managing these complex problems of the pelvic floor should be proficient in a variety of procedures and approaches so that the patient may be fitted for the surgery that is the most appropriate for her specific set of problems.
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PICTURES |
| Caption: Picture 1. Posthysterectomy vaginal vault prolapse |
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| Caption: Picture 3. Levels of support as described by DeLancey. Note that level I refers to apical (or uterovaginal) support. |
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| Caption: Picture 5. Early enterocele with no vault prolapse. Note contact of peritoneal contents with vaginal mucosa, with no intervening endopelvic fascia. |
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| Caption: Picture 6. Progressive enterocele, now demonstrating true vaginal vault prolapse |
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| Caption: Picture 7. Massive enterocele with total vaginal vault prolapse |
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| Caption: Picture 9. Sacrospinous ligament fixation. The right sacrospinous ligament is being penetrated using the Nichols-Veronikis ligature carrier. |
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| Caption: Picture 10. The anatomy surrounding the right ischial spine |
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| Caption: Picture 15. Transabdominal repair of the large enterocele noted in Picture 2. Note interrupted permanent sutures used for repair. |
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| Caption: Picture 19. Note the axis of the vagina and the attachment of the mesh to the sacrum at sacral level 3 (S3). |
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| Caption: Picture 20. Bilateral uterosacral reattachment has been performed laparoscopically with a permanent suture in a patient who desired retention of the uterus. |
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BIBLIOGRAPHY |
