Vaginal Vault Prolapse Post-hysterectomy Case File

Vaginal Vault Prolapse Post-hysterectomy Case File

Eugene C. Toy, MD, Konrad P. Harms, MD, Keith O. Reeves, MD, Cristo Papasakelariou, MD, FACOG

Case 25

A 64-year-old woman presents with a chief complaint of a mass protruding from her vagina. She denies stress urinary incontinence, but she has to splint her posterior vagina to have bowel movements. She had vaginal surgery for a similar problem 5 years ago, and she brought copies of the operative reports. Your review of her records reveals that she had a routine anterior and posterior colporrhaphy, but no other pelvic surgery was performed at that time. She had a vaginal hysterectomy 20 years earlier for vaginal prolapse. Her past medical history includes an appendectomy for a ruptured appendix and two subsequent laparotomies for intestinal obstruction following the appendectomy. Physical examination confirms that the vaginal cuff exits the vagina with a Valsalva maneuver, and she also has extremely thin, atrophic vaginal mucosa. Repositioning the vaginal cuff at the apex and asking the patient to repeat the Valsalva maneuver demonstrates a large seconddegree cystocele and a large second-degree rectocele.

➤ What is the most likely diagnosis?

➤ What is the best therapy for this condition?

ANSWERS TO CASE 25:

Vaginal Vault Prolapse Post-hysterectomy

Summary: A 64-year-old woman presents with vaginal vault prolapse following prior hysterectomy and anterior and posterior repairs. She is not a good candidate for abdominal surgery because of intestinal obstruction following appendectomy surgery. She has failed conventional vaginal repair surgery.

➤ Most likely diagnosis: Recurrent vaginal vault prolapse and failed conventional cystocele and rectocele repair.

➤ Best therapy: Vaginal paravaginal defect repair using biological graft tissue, and posterior colporrhaphy using biological graft tissue. Support of the vaginal apex, whether by sacrospinous ligament fixation or uterosacral ligament suspension is critical to the long-term success of the operative procedures to repair the cystocele and the rectocele.

ANALYSIS

Objectives

1. Become familiar with the concepts for using graft tissue in vaginal reconstructive surgery.
2. Know the indications for using graft tissue in vaginal reconstructive surgery.
3. Learn the contraindications and complications associated with the use of graft tissue in the vagina.

Considerations

This case report details a 64-year-old patient who had undergone previous surgery for pelvic organ prolapse without long-term success. Her vaginal tissue is thin, atrophic, and weak, and she is not likely to benefit from an operative procedure which duplicates prior failed attempts. Additionally, she is not likely to consent to an abdominal operation which will place her at risk for another episode of intestinal obstruction. Facing such a surgical challenge, some gynecologists would consider the use of graft tissue to reinforce the vaginal repairs which this patient requires.

The initial approach to this patient should include urologic evaluation to see if her urinary continence is due to the fact that the urethra is kinked because of the degree of prolapse she is experiencing. Whether she will need a mid-urethral sling as part of the combined operative procedures for repair of pelvic floor relaxation, or later, if urinary incontinence develops following surgery, needs to be discussed preoperatively. Randomized trials have shown that the patient who is stress continent prior to surgery for prolapse may become incontinent following surgery, and that placement of tension-free vaginal tape (TVT) as an adjunct to the prolapse surgery will statistically reduce the likelihood of postoperative stress incontinence.

Grafts have been employed in vaginal vault prolapse surgery for over 50 years, but their use is still controversial. The decision to proceed with the use of graft tissue should be considered only when the patient’s endogenous tissue is inadequate for a nongrafted repair. Additionally, the prolapse should have a significant negative impact on the patient’s quality of life, and the degree of prolapse should be to the vaginal introitus or beyond.1

Any discussion of graft tissue is incomplete without some consideration of the significant cost of using these materials. Several square inches of synthetic or biological materials usually cost about $1000. The cost equation also must include the increased cost of OR time to position these products correctly.2,3

APPROACH TO

Using Graft Tissue in Vaginal Hernia Repairs

DEFINITIONS

XENOGRAFT: A surgical graft of tissue from one species to an unlike species (or genus or family).

MESH GRAFT: Prosthetic nonabsorbable porous material used to give strength or bulk for surgical repairs of pelvic organ prolapsed.

BIOLOGICAL GRAFT: A portion of living tissue that is used to join to another living tissue. It can be from the same organism (autologous) or same species, or different species (xenograft).

CLINICAL APPROACH

There are two broad categories of graft material available for use in vaginal hernia repairs, those being either synthetic or biological products. Within these two categories, there are many of material available. Any listing of the choices available is somewhat futile, as the field is being inundated on a regular basis with new products and materials too rapidly for the individual surgeon to remain current with the choices available. Additionally, there is a dearth of randomized, prospective, controlled trials clearly demonstrating the superiority of one product over another.3 No matter which type of graft tissue is chosen, surgeons should not believe that graft tissue use will compensate for mediocre performance in the OR, or for choosing a patient who is not a good candidate for graft surgery. Many authorities in this field are of the opinion that the use of any type of graft tissue should be reserved for those select patients in whom a conventional operative procedure has already resulted in failure.4

This is a controversial arena with a dearth of prospective randomized clinical trials to substantiate claims of effectiveness and safety. ACOG published a practice bulletin in February 2007 in reaction to the FDA warning of numerous vaginal mesh erosions and complications and the plethora of graft products and “kits” for the correction of pelvic organ prolapse. The initial ACOG publication described these products as “experimental.” Enough protest ensued over the use of the word “experimental” that the Practice Bulletin was withdrawn and republished in August 2007 without the use of that descriptive language.3 However, surgeons should not, based on the current state of the art, be using graft tissue indiscriminately just because it is possible to do so, and the discerning surgeon should be able to determine those situations that appropriate and inappropriate for the use of graft tissue.

Synthetic Graft Tissue

A comparison of synthetic to biological material demonstrates that the synthetic product may have, at least initially, greater success rates, but the biological product is probably better tolerated for a longer duration of time. Synthetic grafts are indeed permanent, and erosion of the graft through a vaginal or intestinal wall into the vagina or the bowel lumen is a lifetime risk after graft placement. Surgical case series that report several months to a few years of successful symptom relief do not predict the future safe compartmentalization of synthetic mesh in anterior or posterior hernia repairs. Vaginal tissue ages, atrophies, and loses its innate tensile strength, which predisposes the graft tissue to erode through a previously intact vaginal wall.

Permanent graft products are most likely to be successfully incorporated into the hernia spaces they are designed to reinforce if their pore size is large enough to allow ingrowth of new endogenous fibrous tissue and blood supply. Synthetic graft products with small, tight interstices are less prone to be well integrated into the surrounding tissue, which may result in graft erosion or infection. When using synthetic graft tissue for repairing cystoceles and rectoceles, the vaginal mucosal thickness covering the graft should be as thick as possible, to reduce the risk of erosion and to ensure a good blood supply to the endogenous tissue overlying the graft.

If graft erosion of synthetic mesh occurs into the vagina, it may respond to several weeks of topical application of an estrogen cream to encourage overgrowth of vaginal epithelium. If this is not successful, trimming the protuberant mesh until it is flush with or slightly beneath the mucosal surface may stimulate successful overgrowth of vaginal mucosa. Infected mesh must be removed.

The consequence of graft tissue eroding through the vaginal mucosa has created a new descriptive term, “hispareunia,” describing the phenomenon experienced by the male partner of a patient who encounters sharp, stubby synthetic graft material eroding through the vagina with the potential to lacerate his penis.5

Biological Graft Tissue

The ideal biological graft is sterile, noncarcinogenic, inert, durable, inexpensive, easy to use, and maintains its shape. Biological grafts are contraindicated in patients with the following conditions: heavy smoking, morbid obesity, poorly controlled diabetes, on systemic corticosteroids, immunocompromised, active pelvic or vaginal infection, or prior pelvic irradiation. Biological graft tissue may be autologous graft tissue from rectus fascia of fascia lata, or allograft tissue from fascia lata or dura mater, or xenograft tissue from porcine or bovine sources. Xenograft tissue has been treated to remove the cellular component, leaving only a collagen matrix, which has minimal potential to trigger a rejection phenomenon. Recent evidence indicates that cadaveric fascial tissue in abdominal sacrocolpopexy should no longer be used. The variable thickness and strength of cadaveric dermis, compared to the consistency of bovine and porcine source tissue, make the latter preferable to the former. Clear superiority of bovine versus porcine tissue has not been demonstrated in any long-term prospective trials. Xenograft tissue does have the advantage of providing a scaffold-type matrix for endogenous tissue to use in fabricating the ingrowth of new fibrous tissue with its own neovascularization, but it degenerates over time and does not provide the long-term strength of synthetic material.

In summary, grafts are probably more useful in repairing the anterior rather than the posterior vaginal wall. Patient selection is critical, and patients should be counseled, in a carefully described and documented consent process, that although grafts are being used more commonly, this technology is still relatively new and expensive, with unique potential complications. Gynecologic surgeons need to gain knowledge and experience with graft materials if they plan to use them to correct pelvic floor defects, and be able to handle the complications which may ensue following graft placement. Given the rapid introduction of new graft products, surgeons should demand data demonstrating that new materials are safe and effective.6

Comprehension Questions

25.1 A healthy 55-year-old woman presents with a symptomatic cystocele, rectocele, and enterocele. She had a vaginal hysterectomy for uterine prolapse performed 10 years previously. Which operative procedure should be avoided in this patient?

A. Anterior and posterior colporrhaphy using synthetic graft material, sacrospinous ligament fixation

B. Conventional anterior and posterior colporrhaphy, enterocele repair via sacrospinous ligament fixation or uterosacral ligament suspension

C. Laparoscopic sacrospinous ligament fixation with conventional anterior and posterior colporrhaphy

D. Abdominal sacrocolpopexy, Burch procedure, conventional posterior colporrhaphy

25.2 A 58-year-old patient returns 6 weeks following vaginal repair surgery for recurrent cystocele. She is afebrile, but complains of persistent vaginal discharge. She has not been using any medication vaginally. Bovine graft tissue was used to repair the cystocele, and a 1.5 × 1.0 cm portion of graft material is visible 3 cm inside the introitus in the anterior repair suture line. What is the therapy of choice?

A. Return the patient to the operating room and remove the graft.

B. Start the patient on oral antibiotic therapy.

C. Trim the exposed graft in the clinic.

D. Instruct the patient to begin using estrogen vaginal cream.

25.3 A 48-year-old woman weighing 265 lb (120.20 kg), with a 10-year history of systemic lupus erythematosus presents with cystocele and rectocele. She states that multiple types of pessaries have not controlled her prolapse symptoms. She is taking oral steroids and methotrexate to control her lupus. What vaginal graft tissue is indicated for repairing this patient’s prolapse?

A. Polypropylene mesh

B. Fetal bovine fascia

C. Porcine mesh

D. None of the above

ANSWERS

25.1 A. The use of graft tissue is not usually needed the first time when a patient has vaginal repair surgery if her endogenous tissue is satisfactory. Graft tissue can lead to erosion, infection, or pain.

25.2 D. Vaginal estrogen cream use for several weeks will stimulate the vaginal mucosa to cover the visible graft tissue. This has very little systemic absorption and works well in strengthening the tissue locally.

25.3 D. The use of any type of graft tissue is contraindicated in morbidly obese patients, and in patients who are using systemic steroids.

Clinical Pearls

See Table 1-2 for definition of level of evidence and strength of recommendation

➤ Soak the graft in an antibiotic solution before using it to reduce the risk of postoperative infection (Level B).

➤ Sew the graft into place—do not simply lay it into a cystocele or rectocele space and expect it to stay in the intended position. These materials have a propensity to migrate and bunch if not anchored with suture (Level B).

➤ Cover the defect with the graft such that it lays flat and smooth, but not under tension (Level C).

➤ Use the carpenter’s adage of “Measure twice, cut once” when working with graft tissue. This material is too expensive to waste. Be sure you do not create “a square peg to go into a round hole.” Make a pattern using some sterile paper, and then cut the graft using the pattern as a guide. Err on the side of making it too big and then trim excess graft on the edges after suturing it into place (Level C).

REFERENCES

1. Davila GW, Drutz H, Deprest J. International Urogynecological Association: the usage of grafts in pelvic reconstructive surgery symposium 2005. Int Urogynecol J. 2006;17:S51-S55. 

2. Norton P. New technology in gynecologic surgery: is new necessarily better? Obstet Gynecol. 2006;108:707-708. 

3. American College of Obstetricians and Gynecologists. Pelvic organ prolapse. ACOG Practice Bulletin No. 85. Obstet Gynecol. 2007;110:717-730. 

4. Botros SM, Sand PK. Cystocele and rectocele repair: more success with mesh? OBG Mgmt. 2006;18:30-43. 

5. Brubaker L. Partner dyspareunia (hispareunia). Int Urogynecol J. 2006;17:311. 

6. Karram M. Pelvic organ prolapse: which operation for which patient? OBG Mgmt. 2006;18:72-84.

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