preventing posthysterectomy prolapse

March 13, 2014Manila Doctors Hospital

Department of OB Gyn Postgraduate Course1

Can Post Hysterectomy Vault Prolapse be prevented?

Joanne Karen S. Aguinaldo, MD, FPOGS, FPSURPSSection of Urogynecology




Manila Doctors HospitalDepartment of Obstetrics and Gynecology

2014 Postgraduate courseCentury Park Hotel, Manila, Philippines



How often does post hysterectomy vault prolapse occur?

Can anything be done at the time of hysterectomy to prevent it?

Why does it develop?



How often? Jones et al (AJOG, 2010), Trends in Inpatient

Procedures in the US from 1979 to 2006

Objective: To describe the national trends for inpatient procedures for pelvic organ prolapse

Most common procedure<52 years: HYSTERECTOMY<52 years: HYSTERECTOMY>>52 years: REPAIR OF PELVIC ORGAN PROLAPSE52 years: REPAIR OF PELVIC ORGAN PROLAPSE





− Women <52 years: Significant Decline in number of hysterectomies

2. Women >52 years: No significant change in number

of prolapse surgeries





Total No. of Prolapse surgeries: 5,632,900<52 years: Decrease by half in cystoele and rectocoele repair>52 years: NO DECREASE Apical suspension procedures increased slowly SIGNIFICANT INCREASE in women >52 years9% of admissions prolapse of vaginal vault after hysterectomy



How often? Aiegmuller et al (Int Urogynecol J, 2010), Incidence of

Posthysterectomy Prolapse − Surveyed 65 of 86 public hospitals, 2005− Total number of hysterectomies− Total number of vault prolapse repair

Estimated frequency Surgery for posthysterectomy vault prolapseBetween 6% and 8%



How often? Manila Doctors Hospital

5 year review (2009 to 2013)5 year review (2009 to 2013)Hysterectomy:Hysterectomy: 18.4%18.4% of gynecologic admissions of gynecologic admissionsVaginal hysterectomy: Vaginal hysterectomy: 5.8%5.8% of hysterectomies of hysterectomies



How often? Philippine General Hospital, Section of Urogynecology

6 year review (2008 to 2013)6 year review (2008 to 2013)Surgery for vault prolapse:Surgery for vault prolapse:

8.4%8.4% of urogynecologic admissions of urogynecologic admissionsRepair of primary vault prolapse: Repair of primary vault prolapse:

66%66% of surgeries for vault prolapse of surgeries for vault prolapse



How often? Lukanovic et al (Int J Gynaecol Obstet, 2010), Risk

factors for vaginal prolapse after hysterectomy

− Retrospective review− 84 women who underwent repair of vaginal prolapse

after hysterectomy − versus 124 who underwent hysterectomy and had

no prolapse at the time of the study




factors for vaginal prolapse after hysterectomy− Higher number of vaginal deliveries− More difficult deliveries− Fewer cesareans− Complications after hysterectomy− Heavy physical work− Neurological disease− Hysterectomy for pelvic organ prolapse− Family history of pelvic organ prolapse




factors for vaginal prolapse after hysterectomy

Average number of years after hysterectomy that vaginal prolapse was corrected

− Premenopausal women: 16 years − Postmenopausal women: 7 years



Why?



Why?

Hysterectomy causes: the attenuation of the cardinal/uterosacral ligament

complex when they are excised during hysterectomy

the separation of the pubocervical fascia from the rectovaginal fascia

the separation of the pubocervical fascia, rectovaginal fascia from the cardinal/ uterosacral ligament complex



Can anything be done? Royal College of Obstetrics and Gynecology (RCOG)

and Bristish Society of Urogynecology (BSUG) Based on 3rd International Consultation on Incontinence

recommendations

Green-top Guideline No. 46 (2007) The Management of Post Hysterectomy Vaginal Vault Prolapse



Can anything be done?

Green-top Guideline No. 46 4. Prevention at the time of hysterectomyMcCall culdoplasty at the time of vaginal hysterectomy is a

recommended measure to prevent enteroecele formation. Grade A Recommendation



Can anything be done? Cruikshank et al (AJOG, 1999)

- Small RCT, 100 women- Comparison of 3 preventive techniques against

enterocoele formation performed during VH- 3 year follow-up

Conclusion: Mccall culdoplasty was more effective than vaginal Moschowitz procedure or peritoneal closure in preventing enterocoele formation.

Level of Evidence Ib



Can anything be done? McCall ML (Obstet Gynecol, 1957)

- Describes a technique approximating the uterosacral ligaments using continuous sutures as high as possible to obliterate the cul de sac

- Following vaginal hysterectomy



Can anything be done? Ostrzenski A (Int J Gynaecol Obstet, 1995)

- Describe an innovation performed during abdominal hysterectomy

- 10 year study, 250 women, mean age 43

Conclusion: Good postsurgical patient satisfaction, No symptoms or signs of dysfunctional vagina, prolapse or enterocoele formation.

Level of Evidence III



Can anything be done? Ostrzenski A (Int J Gynaecol Obstet, 1995)

- Incorporating the deep layers of uterosacral ligaments with the perirectal-paravaginal fascia in posterior culdoplasty

- Cardinal ligaments and superficial layers of the USL are approximated with the latero-posterior aspect of the vagina




Green-top Guideline No. 46 4. Prevention at the time of hysterectomySuturing the cardinal and uterosacral ligaments to the vaginal

cuff at the time of hysterectomy is a recommended measure to avoid vault prolapse.

Grade B Recommendation



Can anything be done? Cruikshank SH (AJOG, 1987)

- 112 patients, follow-up 7 to 42 months- Method:

Attaching the uterosacral and cardinal ligaments to the vaginal cuff

AND high circumferential obliteration of the pouch of Douglas

- Outcome: No cases of vault prolapse or enteroecele





Green-top Guideline No. 46 4. Prevention at the time of hysterectomySacrospinous fixation at the time of vaginal hysterectomy is

recommended when the vault descends to the introitus during closure.

Grade B Recommendation



Can anything be done? Cruikshank SH et al (AJOG, 1990)

- Retrospective study, 48 patients - Mean follow-up, 2 years.10 - Sacrospinous fixation at the time of vaginal hysterectomy

- Outcomes: One vault prolapse20 women with right buttock pain up to 6 weeks post op 5 women, developed anterior vaginal wall prolapse




Can anything be done? Colombo et al (AJOG 1998)

− Retrospective study, 124 women, follow-up 4 years − Objective: Sacrospinous fixation versus McCall’s culdoplasty

at the time vaginal hysterectomy in advance uterovaginal prolapse

− Outcomes: No significant difference in the incidence of vaginal vault

prolapse Sacrospinous fixation: longer to perform, associated with

significantly more blood loss, significant development of Grade 2 or 3 anterior vaginal wall prolapse





Prognostication of all gynecologic patients for hysterectomy

Reapproximation of the pelvic support structures at the apex (vault)



References1. Jones KA, Shepherd JP, Oliphant SS, Wang L, Bunker CH, Lowder JL. Trends in Inpatient Prolapse Procedures in the United States, 1979–

2006. Am J Obstet Gynecol. 2010 May ; 202(5): 501.e1–501.e7.

2. Aigmueller T, Dungl A, Hinterholzer S, Geiss I, Riss P. An estimation of the frequency of surgery for posthysterectomy vault prolapse. Int Urogynecol J. 2010 Mar;21(3):299-302.

3. Barrington JW, Edwards G. Posthysterectomy vault prolapse. Int Urogynecol J Pelvic Floor Dysfunct. 2000;11(4):241-5.

4. Lukanovic A, Drazic K. Risk factors for vaginal prolapse after hysterectomy. Int J Gynaecol Obstet. 2010 Jul;110(1):27-30.

5. Afifi R, Sayed AT. Post-hysterectomy vaginal vault prolapse. The Obstetrician & Gynaecologist 2005;7:89–97.

6. Green-top Guideline No.46. The management of post hysterectomy vaginal vault prolapse. Royal College of Obstetricians and Gynecologists

and British Society of Urogynaecology. 2007.

7. Cruikshank SH, Kovac SR. Randomized comparison of three surgical methods used at the time of vaginal hysterectomy to prevent posterior enterocele. Am J Obstet Gynecol 1999;180:859–65.

8. McCall ML. Posterior culdoplasty; surgical correction of enterocele during vaginal hysterectomy: a preliminary report. Obstet Gynecol

1957;10:595–602.

9. Wall LL. A technique for modified McCall culdeplasty at the time of abdominal hysterectomy. J Am Coll Surg 1994;178:507–9.

10. Ostrzenski A. A new simplified posterior culdoplasty and vaginal vault suspension during abdominal hysterectomy. Int J Gynaecol Obstet 1995;49:25–34.

11. Cruikshank SH. Preventing posthysterectomy vaginal vault prolapse and enterocele during vaginal hysterectomy. Am J Obstet Gynecol 1987;155:1433–40

12. Cruikshank SH, Cox DW. Sacrospinous ligament fixation at the time of transvaginal hysterectomy. Am J Obstet Gynecol 1990;162:1611–19.

13. Colombo M, Milani R. Sacrospinous ligament fixation and modified McCall culdoplasty during vaginal hysterectomy for advanced uterovaginal prolapse. Am J Obstet Gynecol 1998;79:13–20.




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