Atlanta Center for Laparoscopic Urogynecology
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Vaginal Vault Suspension
Laparoscopic And Minimally Invasive Procedures
Overview
Vaginal vault prolapse occurs when the apex of the vagina (upper 1/3 of the vagina) has broken away from its original support structure known as the uterosacral ligaments. The uterosacral ligaments hold up the apex and the uterus when the uterus is in place (Figure 1). When a patient has a hysterectomy, the uterosacral ligaments must be cut to remove the uterus. In an attempt at preventing future vaginal apex or vault prolapse, the uterosacral ligaments should be attached to the apex of the vagina after the uterus has been removed.
If the patient did not have her uterosacral ligament attached to the vaginal apex or the uterosacral ligaments did not remain attached after the surgery, the patient risks ending up with vaginal vault prolapse after the hysterectomy (Figure 2). As the prolapse continues to pull down, it will increase the risk of anterior and posterior paravaginal defects.
Laparoscopy Fig 1
Figure 1 – Uterine & vaginal vault prolapse
The uterus begins to prolapse because of the broken uterosacral ligament.
Laparoscopy Fig 2
Figure 2 – Vault prolapse
If the uterus is removed (hysterectomy) and the surgeon does not reattach the uterosacral ligament the patient is left with a vaginal vault prolapse.
Likewise, if the patient has uterovaginal prolapse and has a hysterectomy without regard to precise closure of the vaginal cuff (ie the area where the uterus is detached from the vagina), she may end up with an enterocele (ie a hernia) and a vaginal vault prolapse (Figure 4). Once the uterus is removed the surgeon needs to meticulously repair the edges of the support system of both the anterior (pubocervical fascia) and posterior (rectovaginal fascia) vaginal walls. If the surgeon only closes the vaginal skin and does not incorporate the supportive layers the patient will be left with an enterocele, which is a true hernia at the top of the vagina.
Laparoscopy Fig 3
Figure 3 – Uterine & vaginal vault prolapse
The uterus begins to prolapse because of the broken uterosacral ligament.
Laparoscopy Fig 4
Figure 4 – Vault prolapse & Enterocele
If the uterus is removed (hysterectomy) and the surgeon does not reattach the apex of the pubocervical and rectovaginal fascia and only closes the vaginal epithelium (skin) the patient is left with an enterocele which is a true hernia at the top of the vagina (fig 4)., Additionally, if the vault is not reattached to thealso by not reattaching the uterosacral ligaments (like in figure 2) the patient also is left with a vaginal vault prolapse in addition to the enterocele (Fig 4).
It is vital that a vaginal vault suspension be completed at the time of prolapse surgery if vault prolapse is evident, which in many cases it is.
Vaginal vault prolapse can also occur in many patients months or years after a hysterectomy in conjunction with other pelvic floor defects such as cystocele, rectocele, or enterocele. It is very important that the surgeon evaluates for vault prolapse in any patient presenting with prolapse, because in many cases what appears to the unexperienced examiner to be a cystocele or rectocele is actually vault prolapse. This misdiagosis leads to improper or incomplete repair and usually causes shortening of the vagina because the apex is not suspended up to its natural position. In many cases vault suspensions are not completed by some surgeons secondary to being more advanced difficult surgical procedures that require experience and training and therefore add considerable time to the procedure in inexperienced hands.
Symptoms such as urinary frequency, urgency, nocturia, abnormal emptying of the bladder and pelvic pain (described as the “posterior fornix syndrome”) that may occur with vault prolapse or after prolapse surgery without vault suspension are relieved many times following proper vault suspension as seen in the below sections.
Treatment options for vault prolapse
Patients that experience vaginal vault prolapse often feel pressure, pain, protrusion and/or dyspareunia (painful intercourse). There are different degrees of prolapse from mild to severe. If the prolapse is mild, Dr. Miklos and Moore can offer a non-surgical approach such as pelvic floor exercises (Kegal exercises) and/or pessaries. If the prolapse is moderate or severe (extending outside the vagina), serious problems such as urinary retention, dilated ureter or kidney and vaginal ulcers may occur and surgery is the next step.
Surgical Options for Vault Prolapse
- Moderate Prolapse
- Severe Prolapse Causing Medical Problems
- Failure of Pessary Management
- Symptomatic Prolapse (pressure, pain)
- Painful Intercourse
There are many ways to perform vaginal vault suspension. Drs. Miklos and Moore will discuss the surgical options after a complete physical examination and a discussion with the patient. Please click below for more detail:
Indications for vaginal vault suspension surgery
- Laparoscopic Uterosacral Ligament Suspension
- Laparoscopic Sacral Colpopexy
- Sacrospinous Ligament Suspension
- Elevate Procedures