vaginal vault prolapse vault suspension

1. Vaginal Vault prolapse and vault
suspension
Dr Shivamurthy H M
Prof in obgyn
S N Medical college bagalkot
Karnataka
India

2. Introduction
• Vaginal prolapse is the herniation of the pelvic
organs to or beyond the vaginal walls.
• It is reported to be the most common reason for
hysterectomy in elderly .

3. • The number of women with pelvic organ
prolapse who are managed without
hospitalization and surgery and the number of
women with prolapse who never seek medical
treatment is not known.
• Incidence and prevalence estimates based on
surgical procedure rates almost certainly
underestimate the magnitude of the problem.

4. • Maintenance of normal vaginal anatomy depends
on the inter-relationships of intact pelvic floor
Neuromusculature, Ligaments, and Fascia.
• This complex relationship of vaginal support is
perhaps least understood at the vaginal apex or
vault.
• Without proper identification and correction of
vaginal vault prolapse, surgical correction of the
other vaginal compartments is recognized to likely
fail.

5. • This in part contributes to the 29.2% re-
operation rate of women who undergo pelvic
floor reconstruction. [2]
• In a nonhysterectomized woman, the vault, or
apex, is located posterior and superior to the
cervix (see the image below).
• After a hysterectomy, the scar site assumes the
position of the vaginal apex or vault.

6. VAGINAL CUFF CERVIX
APICAL ATTACHMENT
CUT CERVIX

7. Utero sacral
ligaments

8. CARDINAL
LIGAMENTS
CARDINAL
LIGAMENTS
Utero sacral
ligaments

9. CARDINAL
LIGAMENTS
CARDINAL
LIGAMENTS
RECTO VAGINAL
SHEATH

10. CARDINAL
LIGAMENTS
RECTO VAGINAL
SHEATH

11. RECTO VAGINAL
SHEATH
PERINEALBODY INFERIOR
ATTACHMENT

12. RECTO VAGINAL
SHEATH
EXTERNAL ANAL
SPHINCTURE

13. BULBO
CAVERNOUS
MUSCLE

14. TRANSEVERSE
PERINEAL MUSCLE
BULBO
CAVERNOUS
MUSCLE

15. Relevant Anatomy
• The vaginal apex is the site at which multiple vaginal
support structures converge.
• If the cervix is present, it serves as a strong
attachment point for the ligaments and fascia.
• A woman who has had a prior hysterectomy may not
have a strong attachment point, leading to vault
support weakness and potential prolapse.

16. • Level I support is composed of the
uterosacral/cardinal ligament complex that originates
at the cervix and upper vagina and inserts at the
pelvic sidewall and sacrum.
• This ligamentous complex suspends the uterus and
upper vagina in its normal orientation.
• It helps maintain vaginal length and normal vaginal
axis. Loss of level I support contributes to prolapse of
the vaginal apex.
3 levels the connective tissue support of
the vagina ( DeLancey )

17. Level II support
• comprises the paravaginal attachments of full
length of the vagina and are suspended by the arcus
tendineus fasciae pelvis (ATFP), or lateral pelvic white
line.
• Loss of level II support contributes to cystocele
(anterior vaginal prolapse).

18. Level III support is provided by
• The perineal membrane.
• Perineal body.
• Superficial and deep perineal muscles.

19. • These structures support and maintain the normal
anatomical position of the urethra and distal third of
the vagina.
• Disruption of this level of support anteriorly can
result in urethral hypermobility and stress
incontinence and posteriorly may result in a
rectocele or perineocele.

20. • As stated above, it is the level I support, the
uterosacral/cardinal ligament complex, that plays the
most important role in maintaining vaginal vault
support.
• The endopelvic fascia is the fibromuscular tissue
layer that underlies the vaginal epithelium.
• This layer envelopes the entire vaginal canal,
extending from apex to perineum and arcus
tendineus to arcus tendineus.

21. • The endopelvic fascia helps maintain the integrity of
the vaginal walls.
• Therefore, a tear in this layer causes herniation of the
underlying tissue.
• If a tear exists at the level of the vaginal apex, an
enterocele can develop anteriorly or posteriorly,
further leading to the breakdown of apical integrity.
• Reconstructive surgeons need to understand the
importance of this layer and its reattachment to the
vaginal apex in order to correct anterior or posterior
vaginal wall prolapse.
• If the fascia is of poor quality, a graft may be required
to reinforce the repair.

22. Contraindications to prolapse correction
• Contraindications to prolapse correction are based on
the patient’s medical comorbidities and the risk they
pose to surgery.
• Regional anesthesia can be used to lessen risk when
surgery is performed vaginally.
• Appropriate surgical clearance, use of pulsatile anti-
embolism stockings, prophylactic antibiotics, and
diligent positioning using Allen stirrups help minimize
perioperative complications.
• Atrophic, thinned, or ulcerated vaginal mucosa should
be pretreated with local estrogen for an appropriate
period of time.

23. Problem of Vault prolapse
• Multiple components to vaginal vault support
exist, including utero-sacral and cardinal
ligaments, endopelvic fascial envelopes, and
lateral paravaginal attachments.
• The relationship between these components is
both dynamic and static, and, when they are
damaged, vaginal vault prolapse ensues.
• With intact uterine , all of these structures attach
to the uterus and provide appropriate support.
• If during a hysterectomy these structures are not
firmly re-attached to the vaginal cuff, vault
prolapse can occur.

24. Frequency of Vault prolapse
• Data from women enrolled in the Women’s Health Initiative
reported that in women with an intact uterus, 41.1% had
some form of prolapse and 14.2% had uterine prolapse.
• Of those women who had a prior hysterectomy, almost 38%
had some form of prolapse.[3]
• In women who have had a prior hysterectomy, the
incidence of prolapse requiring surgical correction is 1% at
3 years and 5% at 17 years following their hysterectomy.[4]
• The risk of prolapse increases with advancing age.
• The incidence of prolapse likely increases as life expectancy
does.

25. Etiology of Vault prolapse
• Vaginal vault prolapse is a complex disorder not
usually caused by one inciting incidence.
• It results from a series of events that occur over a
women’s lifetime.
• Collagen disorders and race can play a role in the
development of vault prolapse, as can childbirth,
menopause, and previous pelvic floor surgery that
disrupted the apical support system.
• Any condition that chronically raises intra-abdominal
pressure, such as Chronic Obstructive Pulmonary
Diseaese (COPD), chronic constipation, and heavy
lifting, can also contribute to the breakdown of vault
support.

26. Presentation of Vault prolapse
• A woman’s symptoms are largely based on the severity of
her Polapse.
• With minimal or stage 1 prolapse, a woman may be
asymptomatic and not need any active intervention.
• As the prolapse progresses, women may experience vaginal
fullness, lower back pain, urinary or defecatory dysfunction,
dyspareunia, and pelvic pain.
• As prolapse worsens, the vault becomes exteriorized with a
palpable and visible bulge which may bleed from mucosal
ulcerations.

27. Evaluation of Vault prolapse
• Accurate identification of vaginal vault support is
critical for the correction of vaginal prolapse.
• Even to the experienced clinician, identifying apical
prolapse (especially in the presence of a large cystocele
or enterocele) is difficult (see image below).
• Most importantly, if the apical prolapse is not
corrected at the time of the initial prolapse repair
surgery, prompt recurrence of the prolapse may occur.
• It is also important to help guide for the surgical
procedure.

28. Cystocele and vault prolapse with visible dimple

29. • To evaluate for vault proplapse , the posterior blade of
a bivalved speculum is placed in the posterior fornix,
and the patient is asked to Valsalva while the blade is
slowly removed.

30. • If vault prolapse exists, the uterus descends further
down as the speculum is removed, and re-insertion
of the speculum re-suspends the uterus.
• If the vault is well supported, the uterus stays in
place despite Valsalva efforts.
Vault prolapse in presence of Uterus

31. • In a woman who has undergone hysterectomy,
the primary goal during the vaginal examination
is to identify the apical scar tissue resulting from
the prior hysterectomy.
• Significant prolapse may have stretched the apical
scar tissue band making it difficult to identify.
Vault prolapse in POST HYSTERECTOMY state

32. Vault prolapse in abscence of Uterus
• A bivalve speculum helps in visualization of the
apex.
• Redundant vaginal mucosa associated with
substantial prolapse may make this challenging.
• In most cases, the site of the prior uterosacral
cardinal ligament complex can usually be
identified as dimples on the lateral edges of the
apex.

33. • Using two right-angle speculum blades, or one blade
to retract the anterior wall and the examiners hand
to retract the posterior wall, the patient is asked to
Valsalva and the degree of vault prolapse is assessed.
• The tip of the speculum can then be placed between
the dimples to elevate the vault and assess the
degree of vault prolapse.
• This can also be done with the examiner’s hand by
elevating the dimples to their ipsilateral spines.

34. • As stated above, the evaluation should guide the
surgeon in planning the most appropriate surgical
approach.
• Most reconstructive surgeons prefer a vaginal
approach.
• However, the decision should be made based on
what is best for the patient and her anatomic
alterations.

35. • The importance of sexual function should be
assessed.
• If the patient has vaginal sexual dysfunction ,
then a sacrocolpopexy should be the primary
consideration, given it will avoid any vaginal
incisions and potentially avoid any vaginal
shortening or narrowing.[5]

36. • The examiner should also assess vaginal length.
• A woman whose apex reaches the ischial spines
without difficulty will likely be successful with a
vaginal procedure.
• If the apex does not reach the spines or reaches well
beyond them, she may be better served with either
an obliterative procedure or abdominal colpopexy.

37. • In today’s age of frequent graft use, the patient’s
history of prior reconstructive surgery should be
evaluated.
• This may lead to scarring or fibrosis around the sacral
promontory or sacrospinous ligaments.
• The presence of a paravaginal defect would be better
repaired abdominally.
• The quality of the patient’s tissue and the subsequent
need for a graft should also be assessed.

38. • Lastly, many women with pelvic organ
prolapse also have coexistent colorectal
problems that may require surgical correction.
• If this is the case, the surgical approach that
would best accommodate both procedures
should be considered.

39. Classification of vault prolpse
• Most use either the Baden Walker halfway system or the
Pelvic Organ Prolapse Quantification System (POP-Q)
classification.
• Stage 0 - No prolapse
• Stage I - Descent of the most distal portion of the prolapse
till 1 cm above the hymen
• Stage II - Descent of the most distal portion of the prolapse
between 1 cm above and 1 cm below the hymen
• Stage III - Descent of the most distal portion of the prolapse
beyond 1 cm below the hymen but less than total vaginal
length (TVL) -2 cm
• Stage IV- Total or complete vaginal eversion

40. Surgical Treatment
• The goal of surgery is the restoration of vaginal vault
support, as well as correction of all pelvic floor defects
in order to have the most successful outcome.[6, 7]
• Therefore, bladder function, sexual function, and
anterior and posterior support should all be assessed
prior to surgery and corrected along with apical
support.

41. Vaginal vault support procedures
• Vaginal vault support procedures can be
divided into abdominal and vaginal
approaches.
• The decision is based on the preoperative
physical examination and the patient’s sexual
function.

42. Vaginal Procedures
1 McCall culdoplasty
2 Uterosacral ligament suspension
3 Iliococcygeus suspension
4 Sacrospinous fixation
5 Obliterative Procedures

43. McCall Culdoplasty
• Introduced by McCall in 1957.
• Involves plication of the uterosacral ligaments in the midline while
reefing the cul-de-sac peritoneum, including full thickness of the
apical vaginal mucosa, in a posterior culdoplasty.
• It is typically done at the time of vaginal hysterectomy and uses
non-absorbable sutures, although delayed absorbable sutures
may be used.
• As a general rule, the authors try to place the uppermost suture
on the uterosacral ligament at a distance from the cuff equal to
the amount of vault prolapse present (see image below).

44. McCall culdoplasty.

45. • The ureters lay approximately 1-2 cm lateral to the
uterosacral ligaments at the level of the cervix, so
being cautious to not kink or injure the ureters when
placing the sutures is important.
• Cystoscopy with visualization of ureteral patency,
usually with administration of intravenous indigo
carmine, is recommended following the procedure.

46. • Webb et al followed patients up to 8.8 years
and reported 71% did not require any further
prolapse operation.
• They also found 82% were "very satisfied" or
"somewhat satisfied" with their results.[8]

47. Uterosacral ligament suspension
• Reattaching the uterosacral ligaments to the vaginal
apex is likely the most physiologic approach to vault
prolapse (see image below).
• The technique involves opening the vaginal wall over
the apical defect into the peritoneal cavity and
identifying the pubocervical fascia, rectovaginal
fascia, and uterosacral ligaments.

48. • A permanent 1-0 suture as well as one delayed
absorbable 1-0 suture is placed in the posteromedial
aspect of each uterosacral ligament 1-2 cm proximal
and medial to each ischial spine.
• Next, one arm of the permanent and the delayed
absorbable suture are placed through the
pubocervical and rectovaginal fascia as well as the
vaginal epithelium at the apex.
• After any additional vaginal repairs are completed,
the sutures are tied, elevating the vaginal vault.
• If extensive vaginal prolapse exists, redundant
peritoneal tissue can sometimes make identifying the
uterosacral ligaments difficult.

49. Uterosacral ligament suspension.

50. Uterosacral ligament suspension contd.
• Success rates for uterosacral ligament suspension are
87% to 90%, but ureteral injury has been reported to
be as high as 11%, making it a limiting factor in the
success of the technique. [9, 10]
• Given this reported high complication rate, cystoscopy
following suspension is essential.

51. Iliococcygeus suspension
• This technique involves elevating the apex to the
iliococcygeus muscle overlying fascia along the
lateral pelvic sidewall.
• It is a safe and simple procedure and can be done
without any vaginal incision by placing a
monofilament permanent suture into the muscle
through the vaginal wall either unilaterally or
bilaterally.

52. • It can be used when isolated unilateral vaginal vault
prolapse occurs, which can develop following a
unilateral sacrospinous fixation or as a result of a
high unilateral paravaginal defect.
• The presence of a permanent suture at the vaginal
apex can potentially cause dyspareunia, so this
technique should be used with caution in women
who are sexually active.
• It is most useful as a salvage procedure for unilateral
apical prolapse.

53. • The suspension can also be performed at the time of a
posterior wall dissection in which the sutures are placed
into the fascia overlying the iliococcygeus, anterior to the
ischial spine along the arcus tendineus fascia pelvis, and
incorporating the pubocervical fascia anteriorly and the
rectovaginal fascia posteriorly.
• Shull et al reported a 95% cure rate of vault prolapse
following iliococcygeus suspension; however, he also
found a 14% rate of prolapse at other sites during the
follow-up period. [11]
• A randomized controlled trial comparing iliococcygeus
suspension with sacrospinous fixation demonstrated
similar outcomes.[12]

54. Sacrospinous fixation
• Suspension of the vaginal apex to the
sacrospinous ligaments is one of the most
commonly performed vault suspension
procedures (see image below).
• It can be performed unilaterally or bilaterally,
but bilateral fixation avoids vaginal axis
deviation, giving a more physiologic correction
of the vaginal vault prolapse.

55. Bilateral sacrospinous fixation (SSF).

56. • Sacrospinous fixation is performed by entering the
pararectal space through a posterior wall dissection.
• The sacrospinous ligaments are identified, running from
the ischial spine to the sacrum.
• Next, 2 nonabsorbable sutures are placed through the
ligament, not around it, as the pudendal nerve and
vessels sit behind the ligament and damage to these
structures can cause significant morbidity.
• The first suture is placed 2 cm medial to the ischial
spine, and the second 1 cm medial to the first.
• Each suture is then passed through the vaginal apex so
that when tied the apex is reapproximated to the
ligament.
• Any additional reconstructive procedures are then
performed.

57. • The success rate of sacrospinous fixation is greater than
90% in multiple series. [13]
• The concern lies in the exaggerated horizontal axis in
which the procedure leaves the vagina, which increases
force on the anterior compartment with increases in
abdominal pressure.
• This is especially true if an anti-incontinence procedure
is performed at the same time.
• The rate of cystocele formation following sacrospinous
fixation is reported at 20%-30%. [14]
• Other complications of the procedure include
hemorrhage, vaginal shortening, sexual dysfunction, and
buttock pain.

58. Obliterative Procedures

59. Colpocleisis
• This is the simplest treatment for advanced
prolapse in women who are not, and will not, be
sexually active.
• A LeFort colpocleisis involves denuding rectangles
of vaginal epithelium on the anterior and
posterior vaginal wall and then approximating
them front to back to one another.
• This is combined with a high perineoplasty.
• The success rate for LeFort is above 95% and
postoperative pain is minimal.[1

60. Vaginal Kits ( MESH KIT )
• Vaginal mesh kits can be divided into trocar-based
kits that use a transobturator or transgluteal
approach to suspend the vagina and nontrocar kits
that use a transvaginal fixation method.
• The trocar guided kits include the Prolift (Ethicon,
Somerville, NJ), Apogee and Perigee (American
Medical Systems, Minnetonka, MN), and Avulta (CR
Bard, Murray Hill, NJ).

61. • Trocar guided kits use a precut sheet of graft
material with arms that are used for fixation.
[16]
• Nontrocar kits include Elevate (American
Medical Systems, Minnetonka, MN) and
Pinnacle and Uphold (Boston Scientific, Natick,
MA).
• With either type of kit some basic surgical
principles apply; the vagina should be well
estrogenized before surgery and any vaginal
pessary should be removed for 2 weeks prior
to surgery to avoid any vaginal epithelium
irritation.

62. • Exposure of the correct vesicovaginal and rectovaginal
planes can be accomplished through hydrodissection;
lidocaine with epinephrine, dilute pitressin, or normal
saline can be used.
• Correct hydrodissection should create a bubble in the
avascular space.
• Mesh should be placed loosely because it can contract
up to 20% after placement, which can compromise
vaginal length and caliber.

63. • On July 13, 2011, the FDA issued a statement that
serious complications are not rare with the use of
surgical mesh in transvaginal repair of pelvic organ
prolapse.
• The FDA reviewed the literature from 1996-2011 to
evaluate safety and effectiveness and found surgical
mesh in the transvaginal repair of pelvic organ prolapse
does not improve symptoms or quality of life more
than nonmesh repair.
• The review found that the most common complication
was erosion of the mesh through the vagina, which can
take multiple surgeries to repair and can be debilitating
in some women.
• Mesh contraction was also reported, which causes
vaginal shortening, tightening, and pain.

64. • The FDA’s update states, “Both mesh erosion and
mesh contraction may lead to severe pelvic pain,
painful sexual intercourse or an inability to engage in
sexual intercourse.
• Also, men may experience irritation and pain to the
penis during sexual intercourse when the mesh is
exposed in mesh erosion.”
• The FDA is continuing to review the literature
regarding surgical mesh in the treatment of stress
urinary incontinence and will issue a report at a later
date.

65. • See the full update regarding surgical mesh in
pelvic organ prolapse here: FDA Safety
Communication: Update on Serious
Complications Associated with Transvaginal
Placement of Surgical Mesh for Pelvic Organ
Prolapse

66. Apogee vaginal vault suspension
• The Apogee system (American Medical
Systems, Minnetonka, MN) creates
neoligaments that are analogous to the
Cardinal by anchoring graft arms at sites
adjacent to the ischial spines, at the
attachment of the arcus tendineus (see the
image below).

67. Apogee vaginal vault suspension
Apogee vault suspension kit: synthetic and biologic variations

68. Apogee vaginal vault suspension contd
• The technique is performed by accessing the
pararectal space and palpating the ischial spine
and arcus tendineus.
• A modified SPARC needle is passed through a
pararectal incision that is made 3 cm lateral and 3
cm posterior to the anus.
• The needle is then guided through the ipsilateral
levators and then through the iliococcygeus
muscle, ultimately anchoring into the arcus
tendineus at the level of the ischial spine.
• The exact anchoring point for the Apogee is 0.5-1
cm anterior to the ischial spine through the white
line.

69. • The polypropylene mesh arms are attached to the
needle and brought out through the para-anal
incision.
• The graft is secured to the vaginal apex and the
perineal body by interrupted delayed absorbable
sutures.
• This re-creates apical support from ischial spine to
ischial spine and gives a physiologic vaginal axis.
• Vaginal length averages 7-9 cm and success rate is
88% to 100% with minimal complications[17]
• It is available in synthetic polypropylene mesh and
biologic porcine dermis.

70. Prolift
• The Prolift system (Ethicon, Somerville, NJ) uses a slightly
curved C-shaped trocar to anchor either into the arcus
tendineus fascia pelvis (ATFP) or the sacrospinous
ligament, depending on the approach taken (see the
images below). The graft material is then laid down in a
tension-free fashion.
• Elmér et al found that the anatomic cure rate at one year
for anterior repair was 79%, 82% for posterior repair and
for combined anterior, and posterior repair cure rate was
81% and 86%, respectively.
• They also found that mesh erosions occurred in 11% of the
cases.[18] In another prospective trial, anatomic cure rate
at 12 months was found to be 91% with a 15% mesh
erosion rate.[19]

71. Prolift multicenter trial, Europe.

72. Prolift 1-year data

73. Avaulta
• The Avaulta System (CR Bard, Covington, GA) is another
trocar-based vaginal mesh kit.
• It is similar to the above mentioned kits as trocars are
used to fixate synthetic mesh (see the image below).
• Dissection is also similar and is done up to the level of
the ischial spines.
• The Anterior kit fixation point is 1-2 cm lateral and 3
cm posterior to the ATFP near the ischial spine.
• The Posterior fixation point is the sacrospinous
ligament at the ischial spine.
• The Avaulta comes as a posterior or an anterior kit.
• The posterior kit addresses both the vaginal vault and
the posterior vaginal compartment while the anterior
kit is used to treat cystoceles.

74. • A recent trial that followed patients out for an
average of 14 months found a surgical cure
rate of 81% using a definition of any POP-Q
point greater than 0 or any reports of vaginal
bulge.
• They reported a mesh erosion rate of 11.7%
and de novo pain in 3.3% of patients.[20]

75. Avaulta: 1-year results

76. Elevate
• The Elevate apical prolapse repair system
(American Medical Systems, Minnetonka, MN) is
a single-incision procedure that uses small
polypropylene fixation anchors to affix
polypropylene mesh arms to the sacrospinous
ligaments (see image below).
• The advantage is that the anchors are able to
access the sacrospinous ligament without going
through or behind it, avoiding potential
neurovascular complications.
• Additionally, the Elevate does not use external
needle passage avoiding the risk of long term
postoperative pain from banding or tension.

77. • The procedure is started with a midline vaginal incision
along the anterior or posterior vaginal walls, which is used
to access the sacrospinous ligaments and ischial spine
through the paravaginal space.
• Next, using either a retractor or the operator’s hand, the
rectum is swept medially for safety and the needle tip is
positioned onto the ligament approximately 2 cm medial to
the ischial spine to avoid neurovascular injury.
• The loose eyelets of the graft then slide over the fixation
rods until they engage the mesh part of the fixating arms.
• The graft is then trimmed and the apical portion of the
mesh is fixated to either the cervix or the vaginal apex.
• Final tensioning is then done and the fixating arms
trimmed. It is important to ensure that the mesh is flat and
the edges do not roll out.

78. • A recent prospective multicenter trial
demonstrated a cure rate of 92.5% at 12
months for the posterior wall and 89.2% apical
cure rate.
• Extrusion was seen in 6.5% of subjects.[21]

79. Elevate posterior

80. Elevate posterior

81. Pinnacle and Uphold
• The advantage to nontrocar kits is the
complete vaginal approach.
• These kits avoid the transobturator space so
surgeons who are not familiar or comfortable
with the area can still use a vaginal mesh kit
for suspension of the vagina.
• With a total vaginal approach, no blind
procedures exist; the mesh appendage
placement can be done under direct
visualization.

82. • The dissection for both the Uphold[22] and the
Pinnacle (Boston Scientific, Natick, MA) are
similar to that described for the Elevate system
(American Medical Systems, Minnetonka, MN).
• Once the sacrospinous ligament is palpated and
the insertion point has been cleaned off, the
ligament is penetrated using the Capio
transvaginal capturing device (Boston Scientific,
Natick, MA) to suture the mesh arms to the
sacrospinous ligament and the ATFP.
• The mesh arms are slowly and loosely tensioned
and the mesh is sutured flat.
• The vagina is then minimally trimmed, if needed,
keeping in mind that the epithelium will contract
as it heals, and closed.

83. Abdominal Procedures

84. Abdominal sacral colpopexy
• This is considered by most surgeons to be the
criterion standard procedure for repair of
vaginal vault prolapse (see image below). [23]
• Although the procedure requires an
abdominal incision and has a higher overall
morbidity compared to vaginal procedures, its
longevity and physiologic results as well as
having the least risk of sexual dysfunction and
dyspareunia make it very appealing.

85. Abdominal sacrocolpopexy.

86. • The procedure is begun through an abdominal
incision then exposing the sacral promontory by
incising the peritoneum between the right ureter
and the sigmoid colon.
• Sutures (2-0 polypropylene) or bone anchors are
used to place 2-3 sacral suspensory sutures.
• Next, the vaginal apex is identified using either
the operator’s hand or the obturator of an end-
to-end anastomosis rectal tool.
• The bladder and peritoneum are dissected off the
anterior vaginal wall and any fascial tears are
identified and repaired.

87. • The graft used for the procedure is synthetic
polypropylene graft with a long arm (4-5 cm) that
will extend down the posterior vagina, and a
shorter end (2-3 cm) that is secured to the
anterior vaginal wall.
• Typically, 3 rows of 2-0 polypropylene sutures are
placed along the back wall, and 2 rows are placed
along the anterior.
• Once secured to the graft the vault can be
suspended to the sacral promontory with
minimal tension.
• Prior to suspending the apex, a culdoplasty
should be performed to obliterate the cul-de-sac
and prevent future enterocele formation.

88. • After the vault is suspended, the abdomen is
copiously irrigated and the peritoneum closed.
• The major complications related to the
procedure are hemorrhage from the sacral
promontory and postoperative ileus.
• The risk of bleeding can be minimized by using
bone anchors on the sacral promontory.

89. Postoperative details
• Patients need to avoid any heavy lifting (over
5 pounds) for at least 6 weeks after surgery.
• At their 6-week postoperative visit, the
surgical site is assessed, and, if the area is well
healed, the patient is instructed to
progressively return to their usual daily
activities.
• Postmenopausal patients are instructed to
use vaginal estrogen (we use 1 g twice weekly)
to maintain integrity of the pelvic tissues.

90. Follow-up
• Patients are instructed to follow-up 3 months
after they return to normal activities to assess
the repair.
• The authors also continually follow our
patients to evaluate the integrity of the repair.

91. Complications

92. Complications
• Abdominal approach
• Bleeding is the most serious complication of
sacral colpopexy through injury to the
presacral venous plexus or the middle sacral
artery.
• Other injuries includes ureteral injury and
graft erosion.
• The erosion rate has been reported to be 3%
for sacral colpopexy.

93. Complications Vaginal approach
• The complications associated with vaginal
vault surgery are ureteral injury, injury to the
lower urinary tract, fistula formation, pelvic
infection, bowel injury, and graft exposure.
Sacrospinous ligament fixation carries the
additional risk of hemorrhage and nerve injury
through the pudendal neurovascular bundle.
• Recurrence of vault prolapse is also a
potential complication.

94. Complications Mesh kits
• Mesh extrusion is always a potential complication with
vaginal mesh kits at a rate of approximately 10% (7%-18%).
[24]
• Symptoms of mesh exposure or extrusion are vaginal
discharge, persistent bleeding, pain, dyspareunia, partner
pain, dysuria, and recurrent urinary tract infections.
• Examination reveals any exposed mesh. Management can
be conservative with vaginal estrogen or trimming of the
mesh in the office.
• If conservative measures fail or the exposure is too large to
be managed in the office, excision with operative vaginal
closure after excision of the exposed mesh may be
required.

95. • Pelvic reconstructive surgeons should be
extremely familiar with the evaluation and
treatment of vaginal vault prolapse.
• Multiple techniques are available for the
restoration of vaginal vault support and most are
very effective at suspending the vaginal apex.
• The primary challenge is identifying the vaginal
vault in women with advanced degrees of vaginal
prolapse.
• The surgical approach should be based on both
patient’s needs and the surgeon’s evaluation.
Summary