The Management of Post Hysterectomy Vaginal Vault Prolapse ...

Vaginal sacrospinous fixation is more suitable for physically frail women, because of the morbidity associatedwith abdominal surgery. 36 However, there was no difference in pain in one of the randomised trials thatcompared abdominal sacrocolpopexy and vaginal sacrospinous fixation. 26 Besides, the operative morbidityassociated with sacrocolpopexy is reduced when the procedure is done laparoscopically. 15Abdominal sacrocolpopexy is more suitable for sexually active women, as sacrospinous fixation is associatedwith exaggerated retroversion of the vagina, leading to a less physiological axis than followingsacrocolpopexy. 28,29Vaginal length is also well maintained after sacrocolpopexy 37 whereas sacrospinous fixation cancause vaginal narrowing and/or shortening, especially when carried out alongside repair of anteriorand/or posterior vaginal wall defects, leading to dyspareunia. 38Evidencelevel IV7.3 Operative details of sacrocolpopexy and sacrospinous fixationA number of randomised controlled studies have addressed specific steps of abdominal sacrocolpopexy andsacrospinous fixation.Should prophylactic continence surgery be performed at the time of sacrocolpopexy?It is not clear whether prophylactic continence surgery is beneficial in women who are urodynamicallycontinent and it should not be routinely recommended.A randomised controlled trial compared abdominal sacrocolpopexy with and without prophylacticBurch colposuspension. 39 The trial aimed at recruiting 480 women but was stopped after including322 women, when an interim analysis showed a significant difference in the incidence of stressincontinence at 3 months’ follow-up. All women underwent urodynamic assessment after prolapsereduction. Women who were continent as well as those with occult urodynamic stressincontinence were enrolled and the trial also included women having a hysterectomy. At 3 months’follow-up, the incidence of stress incontinence was 23.8% in the sacrocolpopexy with Burchcolposuspension group compared with 44.1% in the sacrocolpopexy only group (P < 0.001). Whenanalysis was limited to those who were continent on urodynamic assessment with prolapsereduction; the incidence was 20.8% in the sacrocolpopexy with Burch colposuspension group and38.2% in the sacrocolpopexy only group (P = 0.007). The majority of women were diagnosed tohave stress incontinence on the basis of their symptoms. There was no significant difference inoperative or postoperative complications, including voiding dysfunction, between the two groups.As tension-free vaginal tape (TVT) sling and similar slings are increasingly used as the first line incontinence surgery, it is difficult to recommend prophylactic continence surgery when performingsacrocolpopexy on the basis of this trial alone.AEvidencelevel IbWhat is the role of unilateral or bilateral sacrospinous fixation?There is no evidence to recommend bilateral or unilateral sacrospinous fixation.A retrospective study looked at 22 attempts to perform bilateral sacropsinous fixation in womenwith post-hysterectomy vaginal vault prolapse. 40 The procedure was only possible in 16 women(73%) and evaluation of the resulting tension from bilateral approach was the only criterion thatcould predict the feasibility of bilateral fixation. The bilateral approach takes 20–30 minutes moreand is associated with an additional blood loss of 25–50 ml. Follow-up ranged from 6 to 40 monthsand showed no recurrence of vault prolapse but 3 women (18.8%) had anterior vaginal wallprolapse. No randomised studies are available.CEvidencelevel IVRCOG Green-top Guideline No. 466 of 13