Vaginal Vault Prolapse: Options for Transvaginal Surgical Repair

Abstract

Apical compartment prolapse results from failure of the uterosacral and cardinal ligament complex. Apical prolapse should always be assessed and the need for concomitant apical repair should be considered when planning a surgery for the anterior and posterior compartment. Transvaginal repair techniques offer the most minimally invasive surgical approach. No transvaginal repair technique has been shown to be superior in regard to either anatomic or symptomatic cure. The most common transvaginal repair techniques for the vaginal apex are sacrospinous ligament suspension and uterosacral ligament suspension. Both can be performed with or without the uterus in situ. Sacrospinous ligament fixation procedure involves the fixation of the apex of the vagina to the sacrospinous ligament, typically performed unilaterally, and more commonly performed for post-hysterectomy prolapse. Uterosacral ligament suspension involves placing one or more sutures into the bilateral uterosacral ligaments. It is commonly performed at the time of vaginal hysterectomy when intraperitoneal access has already been achieved. Five-year outcome data for both techniques has shown that approximately half of patients will have some recurrent bulge symptoms and be found to have prolapse to the level of the hymen. Ten percent of patients require retreatment (pessary or surgery) and the five-year mark.