Vaginal Vault Prolapse, Sacrospinous Ligament Fixation, and Uterosacral Ligament Fixation Case File
Eugene C. Toy, MD, Konrad P. Harms, MD, Keith O. Reeves, MD, Cristo Papasakelariou, MD, FACOG
Case 23
A 63-year-old woman, G4P4, presents to her gynecologist with a chief complaint of a large nontender mass protruding “several inches” out of her vaginal introitus. She relates a history of a vaginal hysterectomy 15 years earlier for vaginal prolapse. She denies any urinary or fecal incontinence, and relates that the mass exiting the vagina precludes satisfactory sexual intercourse. She is in good health otherwise, has an active lifestyle, and wants to be able to return to her golf and tennis activities as soon as possible.
➤ What is the most likely diagnosis?
➤ What is your next step?
ANSWERS TO CASE 23:
Vaginal Vault Prolapse, Sacrospinous Ligament Fixation, and Uterosacral Ligament Fixation
Summary: A 63-year-old woman, who is physically active, presents with a large bulge exiting the vaginal introitus. Examination reveals that she has Grade 4 vaginal vault prolapse, using the Baden-Walker staging system (see Table 23–1).
➤ Most likely diagnosis: Vaginal vault prolapse post-hysterectomy.
➤ Next step: Make a preoperative evaluation, discuss treatment options with the patient, and then proceed with sacrospinous ligament fixation or uterosacral ligament fixation.
ANALYSIS
Objectives
- Be able to offer the patient appropriate options for therapy for pelvic organ prolapse based on evaluation of her symptoms, her physical findings, and her concerns regarding surgery.
- Understand the potential surgical complications of sacrospinous ligament fixation (SSLF) and uterosacral ligament fixation (USLF).
- Know how the SSLF and USLF procedures compare to each other regarding advantages and disadvantages, and to other solutions for pelvic organ prolapse.
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Table 23–1 BADEN-WALKER SYSTEM
FOR THE EVALUATION OF PELVIC ORGAN PROLAPSE ON PHYSICAL EXAMINATION
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Grade posterior urethral descent, lowest part other sites
Grade 0: Normal position for each respective site
Grade 1:Descent halfway to the hymen
Grade 2:Descent to the hymen
Grade 3:Descent halfway past the hymen
Grade 4:Maximum possible descent for
each site |
Considerations
This case is a 63 year-old woman in good health and physically active with vaginal vault prolapsed after hysterectomy. After a careful physical examination to ensure that there is no complicated reason for the prolapse, such as a pelvic tumor or ovarian cancer with ascites, the patient should be counseled on the options of therapy. In a patient who is a poor surgical candidate and not sexually active, a colpocleisis procedure is an option. In summary, this patient’s problem is a common complaint. As the “Baby Boomers” enter their postmenopausal years, many of them are going to experience pelvic organ prolapse and require the attention of gynecologists. Some 200,000 operative procedures for prolapse are performed annually in the United States, and some 25% to 29% of these surgical procedures are going to fail to achieve and/or to maintain their intended result over the rest of the patient’s lifetime. Not every patient who presents with pelvic organ prolapse is a surgical candidate, and knowing which patient will best avoid surgery is an important lesson to discern. Multiple surgical procedures have been described and performed for pelvic organ prolapse. The SSLF procedure has been a relatively popular vaginal approach to vaginal vault prolapse in the United States for about the past 25 years, and more recently the USLF has been widely used for vaginal vault prolapse. There are some unique benefits and risks for each procedure, and the gynecologic surgeon needs to know these to be able to discuss these operations knowledgeably with the patient and to be able to perform one of these operations on her if the patient and her surgeon decide that this is the preferred approach for her problem.
APPROACH TO
Sacrospinous Ligament Fixation
David Nichols and Clyde Randall popularized SSLF in the early 1980s in the United States. In the years since, several other vaginal approaches to vaginal vault prolapse have been introduced, including uterosacral ligament suspension, endopelvic fascial suspension, and other abdominal and laparoscopic approaches described for prolapse. Sze and Karram indicate that 40 separate operations have been described for these vaginal hernias.1 Of the 40 described, the two most frequently performed procedures in the Unites States today are the SSLF and the USLF.
CLINICAL PRESENTATION
Etiologic factors probably include menopause and advancing age, a history of vaginal delivery, especially of large babies requiring operative vaginal deliveries, disorders of connective tissue, and any condition that increases intra-abdominal pressure, such as obesity or chronic constipation. No studies demonstrate that weight loss will reverse extant prolapse, although weight loss and pelvic floor exercises may be beneficially combined with watchful waiting, and surgery may be avoided if symptoms do not worsen. While the use of estrogen creams will facilitate the surgical procedure itself, by making the vaginal mucosa thicker and more pliable, there is no data to support the use of estrogen either systemically or topically to reverse or treat pelvic organ prolapse.
Most parous women will have some degree of pelvic relaxation on physical examination, but the symptomatology she experiences does not necessarily have a direct relationship to her degree of prolapse. The presence of some prolapse without symptoms does not merit treatment, and no studies have been able to prove that there are effective measures that can prevent the condition from worsening. The patient’s history, general medical condition, and severity of symptoms must be carefully weighed when considering a therapeutic choice. Nonsurgical approaches include the use of a pessary, biofeedback training, and pelvic-floor rehabilitation. For the medically fragile patient, these less vigorous solutions may be a prudent first choice, with surgery being entertained only for worsening symptoms not responsive to a nonsurgical approach. Regardless of which surgical procedure is being considered, most authorities agree that the prolapse patient should be given the option of pessary use before proceeding to a surgical alternative.2 In general, most women may be successfully fitted with a pessary, even those with the more severe grades of prolapse (see Table 23–2 for grading stage of prolpase). However, the long-term success rate for pessary use is probably related to severity of prolapse, and many patients prefer surgery to long-term pessary use.
Recent prospective studies have shown that prolapse actually has the potential to wax and wane in individual women, being worse in some years than in others, with the pelvic structures presenting higher or lower in the pelvis when measured using the pelvic organ prolapse quantification (POP-Q) system.2 Based on this prospective study, it is also reasonable to tell a patient that excepting unusual circumstances, her prolapse is not likely to worsen dramatically over short periods of time.
Many patients are especially embarrassed discussing the symptoms associated with pelvic organ prolapse and will be hesitant to volunteer specific symptoms of urinary or fecal incontinence, or of having to splint and/or brace the perineum or vaginal floor to evacuate stool. The gynecologist must ask these questions and know this information to plan the correct therapeutic approach.
Choice of Surgical Procedure
If surgery is indicated for vaginal vault prolapse, the considerations include the fact that there is less apical failure with the abdominal sacrocolpopexy, and less postoperative stress urinary incontinence and dyspareunia with the abdominal approach, but at the expense of more complications, including all of those that accompany an abdominal procedure, especially bowel obstruction. The age and overall general health of the patient may tip the scales in favor of either the SSLF or the USLF procedure. Surgical series of patients older than 80 years describe successful repairs with good results, but with some
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Table 23–2 STAGES OF PELVIC
ORGAN PROLAPSE
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Stages are based on the maximal extent of prolapse
relative to the hymen, in one or more compartments.
Stage 0: No prolapse; anterior and posterior points are
all –3 cm, and C (cervix) or D (posterior fornix) is between TVL (total vaginal length)
and (TVL – 2) cm.
Stage I: The criteria for stage 0 are not met, and the
most distal prolapse is > 1 cm above the level of the hymen < –1 cm).
Stage II: The most distal prolapse is between 1 cm above
and 1 cm below the hymen (at least one point is –1, 0, or +1).
Stage III: The most distal prolapse is > 1 cm below the
hymen but no further than 2 cm less than TVL. Stage IV: Represents complete procidentia or vault
eversion; the most distal prolapse protrudes to at least (TVL – 2) cm.
Pelvic Organ Prolapse Quantification System
Six vaginal sites used in staging prolapse:
Points Aa and Ba anteriorly
Points Ap and Bp posteriorly
Point C for the cervix or vaginal apex
Point D for the posterior fornix (not measured after
hysterectomy)
Three additional measurements:
GH—genital hiatus
PB—perineal body
TVL—total vaginal length
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Data from Bump RC,Mattiasson A, Bo K, et al. The standardization of terminology of female pelvic
organ prolapse and pelvic floor dysfunction. Am J Obstet Gynecol. 1996; 175:10–17.
increased risk of blood loss in this patient population.3 For the patient who wishes to remain sexually active, a distinct advantage of the SSLF or the USLF is the fact that the vagina is not shortened by this procedure, and there is usually no painful coitus following SSLF or the USLF. For women who are potentially too medically compromised for a major surgical procedure and who do not plan to be sexually active, colpocleisis may be considered. The surgeon and the patient need to decide together what procedure to use, depending on the physical findings, the potential for complications based on the patient’s history, and what if any surgical procedure has failed previously. The SSLF and USLF procedures have the advantage of a transvaginal approach and a lower complication rate, albeit with a slightly higher failure rate over an extended time frame. For the patient wanting to avoid a laparotomy, this may be a minor consideration.
Recent studies, especially those using MRI data, have confirmed the importance of apical support of the vagina when repairing prolapse, and have demonstrated that an adequately supported vaginal cuff, whether obtained via SSLF or abdominal sacrocolpopexy, is capable of obviating some minor anterior or posterior wall repairs, as some minimal degrees of both cystocele and rectocele will disappear when the vagina is firmly anchored at its apex. This is not to state that large defects in the anterior and posterior wall should not be repaired if they are present— the best long-term results occur when all visible vaginal hernias are fixed. Further, apical support frequently maintains or restores vaginal length.4 The opposite result, undesirable vaginal foreshortening, is not uncommon following colporrhaphy. Finally, these same studies demonstrate that the long-term success rate of all types of surgery for prolapse is substantially enhanced when apical support is performed as a distinct part of the operative procedure.1,4,5,6,7
Details of the Sacrospinous Ligament Fixation Procedure
As initially popularized, the SSLF procedure was a unilateral operation, affixing the right side of the vaginal apex to the right sacrospinous ligament. The operation optimally required direct visualization of right sacrospinous ligament, penetration of the ligament with a Deschamps ligature carrier, and retrieval of the suture with a hook to pull the suture back out of the operative site. Then, using a free needle, the suture is passed through the vaginal mucosa, affixing the vaginal cuff to the ligament. The original operation is exacting in its requirements for expert knowledge of the anatomy, superb dissection technique, excellent assistance for visualization, and readily available support if there is injury to the abundant vasculature in the region of the sacrospinous ligament. Regardless, the operation has been quite successful in attaching the vaginal cuff to the posterior pelvis and eliminating vaginal vault prolapse. An evaluation comparing direct visualization with a needle driver, the Deschamps ligature carrier, or the Miya hook suggests that the direct visualization approach may cause the least number of complications, but this requires the greatest degree of surgical dissection to obtain this degree of visualization.8
Two refinements to the classic operative procedure merit consideration now. The first is to perform the operation using a Capio device (Boston Scientific Corporation, Natick, MA), a laparoscopic “throw-and-catch” suturing instrument that allows the surgeon to place sutures through the sacrospinous ligament without the degree of visualization required with the classic operation, and with less risk of vascular or neurologic complication, because of the smaller instrument and needle size. Second, one may consider doing the operation as a bilateral procedure if there is enough room at the vaginal cuff to facilitate this. A two-point suspension will lessen the risk of failure; also, if one side needs to be removed for postoperative pain, the contralateral side may remain in place and provide adequate long-term support. The bilateral approach requires that there should not be undue tension on the vaginal apex as the cuff is stretched between the sacrospinous ligaments. The theoretical concerns of bowel compromise arising from the bilateral procedure have not been demonstrated in the literature.
Initial descriptions of the operative procedure described the placement of absorbable suture into the ligament, and later reports detail the use of delayed absorbable or permanent suture. There are no randomized, prospective trials indicating a clear benefit for one over the other, but the longer the suture
remains in place, the greater the potential for beneficial fibrosis to affix the cuff to the ligament. Some experts suggest that there is a better long-term success rate with permanent suture, but if postoperative pain due to suture placement is a problem, it is likely to persist for as long as the suture remains in place.
Sacrospinous Ligament Fixation Complications
Complications of the procedure include hemorrhage, nerve injury, and damage to adjacent pelvic structures, including the subsequent onset of stress urinary incontinence. Hemorrhage is most common and will respond to direct ligation or the placement of vascular clips if the injured vessel can be seen and repaired. The inferior gluteal artery is probably the artery most frequently injured in doing the SSLF procedure. Alternative methods for control include consulting an invasive radiologist for arterial embolization. Venous injury may respond to packing the operative site firmly with laparotomy packs for as long as necessary to obtain hemostasis.
Pain is a not infrequent complication of SSLF, occurring some 3% to 5% of the time, and is due to involvement of nerve tissue in or near the coccygealsacrospinous ligament complex. Attention to placing the suture at least two finger-breadths medial to the ischial spine will avoid most of these problems, but there is significant aberrant nerve supply to this region, and postoperative pain is not uncommon. Minor pain is usually self-limited, and will resolve within 6 weeks. Severe pain involving the buttocks and posterior thigh requires removal of the sacrospinous ligament suture. Removal of the nerve-entrapping suture will result in dramatic pain relief within a few hours in most cases. Case reports indicate that removal of suture as long as 2 years after initial suture placement will provide prompt pain relief for entrapped nerve tissue.9 Injury to bowel and bladder are uncommon, but need to be recognized and repaired when they occur.
Sexual function following SSLF is usually improved or unchanged following the operation, if care is taken not to constrict the diameter of the vagina at its apex, especially if concurrent colporrhaphy is performed.10
The SSLF procedure will realign the long axis of the vagina into a more posterior orientation in the pelvis than had previously been the case, and this may result in new-onset stress urinary incontinence. The rate of cystocele formation following SSLF ranges from 18% to 92%.1 Preoperative urologic evaluation may delineate those patients with prolapse-reduced urinary incontinence who are most likely to experience this problem, and the planned operative procedure may benefit from the inclusion of anterior colporrhaphy or the placement of a tension-free vaginal tape (TVT) midurethral sling to prevent the occurrence of postsurgical incontinence.
Details of the Uterosacral Ligament Fixation Procedure
The USLF procedure may be done in conjunction with vaginal hysterectomy and colporrhaphy procedures, or as a standalone procedure in the patient who presents with vault prolapse following prior hysterectomy. With the vaginal cuff open following vaginal hysterectomy, or after opening the vaginal apex in vaginal vault prolapse cases, any enterocele present is opened and the hernia sac is excised and closed with a purse-string suture. Cut a laparotomy pack in half and place the half with the tail into pelvis, elevating the bowel out of the way. Narrow Briesky-Navritol retractors facilitate visualization at this part of the operation. Grasping the vaginal cuff at the 5 and 7 o’clock positions respectively and tugging with an Oschner clamp with one hand while palpating over the region of the ischial spines with the other index finger will confirm identification of the uterosacral ligament in the region posterior and medial to the spines. The ligament may be grasped with a long Allis clamp, and sutures (3-4 in number) placed through the ligament. It is important to go from lateral to medial when placing the sutures, to avoid the potential for ureteral injury. These sutures may be delayed absorbable, or permanent, but permanent suture should not be tied leaving the knots in the vagina. The sutures placed through the ligaments are then directed through the anterior and posterior vaginal mucosal (or submucosal surfaces, in the case of permanent suture), and tied after any colporrhaphy procedures are completed, elevating the vaginal cuff to the level of the ischial spines.
Uterosacral Ligament Fixation Complications
At the conclusion of the USLF procedure, it is routine to perform cystoscopy to be sure that there is no ureteral injury. IV furosemide and indigo carmine dye injected 5 to 7 minutes prior to cystoscopy will quickly and easily demonstrate normal ureteral function. The rate of ureteral injury has been reported to be as high as 11%.6 The failure rate for the USLF procedure is reported to be in the 13% to 15% range.6,7 Significant postoperative pain is not usually a problem following the USLF, nor are hemorrhage at the time of the procedure and infection, especially if prophylactic antibiotics are used preoperatively.
SSLF versus USLF?
When experienced gynecologic surgeons who have extensive experience with these operative procedures are asked which of the two they prefer, they usually choose the USLF over the SSLF. The USLF results in a more anatomic alignment of the vagina and has less postoperative pain. While there is the potential for ureteral injury, this should be detected and corrected at the time of surgery, with minimal prospect for long-term sequela. The SSLF increases the risk of cystocele, and the pain which can occur following this operation from pudendal nerve fiber entrapment is dramatic.
Comprehension Questions
23.1 A 58-year-old patient had a seemingly uneventful bilateral SSLF procedure for vaginal vault prolapse. On the day following surgery, she complains of extreme pain in the left buttocks radiating down the posterior left thigh, not relieved with morphine. What is your next course of action?
A. Consult the pain management service.
B. Consult a neurologist.
C. Take the patient back to the OR and remove the suture from the left sacrospinous ligament.
D. Send the patient for physical therapy.
23.2 A 63-year-old patient had SSLF for vaginal vault prolapse. At her 6- week postoperative check, she has apparently healed completely, with good support of the vaginal apex, but she complains of stress urinary incontinence which was not previously present. What is your next step?
A. Prescribe an anticholinergic drug.
B. Ask her to do Kegel exercises.
C. Urodynamic testing.
D. Counsel the patient regarding the need for an artificial urethra.
23.3 Your 61-year-old patient sought another opinion after you told her she needed anterior and posterior vaginal repairs and an SSLF or a USLF. The gynecologist she saw told her that she did not need either the SSLF or the USLF, and that they were unnecessary, complicated, and dangerous procedures, and the problem could be solved without doing anything more than anterior and posterior repairs. How do you counsel the patient at this point?
A. At this point, it is probably best to agree with her consultant gynecologist and opt for the anterior and posterior colporrhaphy procedures.
B. Tell her that without vaginal apical support, all other vaginal repair work is likely to fail, and discuss with her the relative risks and benefits of SSLF and USLF.
C. Offer her a pessary instead of surgical management.
D. Suggest only an abdominal sacrocolpopexy initially and vaginal repairs later if her problems persist.
ANSWERS
23.1 C. Severe pain following SSLF is due to nerve entrapment. If conservative measures fail, then surgical removal of the involved suture is the therapy of choice. Pain relief is usually prompt and dramatic once the suture is removed.
23.2 C. Urodynamic testing is needed for this patient. A sling will likely be necessary to restore the urethrovesical (U-V) angle altered by the SSLF procedure. Patients who have a SSLF procedure should be counseled that they may develop urinary incontinence that did not exist before the procedure. Some gynecologists will perform a prophylactic urinary procedure in anticipation of this complication.
23.3 B. The key to long-term vaginal wall support, especially anteriorly, is adequate support of the vaginal apex. The “gold standard” is abdominal sacrocolpopexy, and patients may be offered an abdominal approach as part of your preoperative discussion of surgical options, but the long-term potential for success of vaginal hernias requires adequate apical support, regardless of how it is achieved.
Clinical Pearls
See Table 1-2 for definition of level of evidence and strength of recommendation
➤ The major complication of the SSLF procedure is pain (Level A).
➤ If the patient complains of severe pain in the buttocks, radiating down the posterior thigh, remove the suture from the sacrospinous ligament on the involved side (Level B).
➤ When placing sutures in the sacrospinous ligament, leave the suture long enough to facilitate suture removal if this later becomes necessary (Level C).
➤ When doing the USLF procedure, do not cut the sutures after tying the knots until you are sure that there is no ureteral compromise. Wait until cystoscopy confirms the ureters are clear (Level B).
➤ Suspend the apex first, and then decide whether anterior or posterior colporrhaphy is still necessary (Level C).
➤ Do not do either of these operations for the first time without a more experienced gynecologist who is skilled in this procedure as your first assistant (Level C).
REFERENCES
1. Sze EHM, Karram MM. Transvaginal repair of vault prolapse: a review. Obstet Gynecol. 1997;89:466-475.
2. The American College of Obstetricians and Gynecologists. Pelvic organ prolapse. ACOG Practice Bulletin No. 85. Obstet Gynecol. 2007;110:717-730.
3. Nieminen K, Heinonen PK. Sacrospinous ligament fixation for massive genital prolapse in women aged over 80 years. BJOG. 2001;108:817-821.
4. Lowder JL, Park AJ, Ellison R, et al. The role of apical vaginal support in the appearance of anterior and posterior vaginal prolapse. Obstet Gynecol. 2008;111:152-157.
5. David-Montefiore E, Barranger E, Dubernard G, Nizard V, Antoine JM, Darai E. Functional results and quality-of-life after bilateral sacrospinous ligament fixation for genital prolapse. Eur J Obstet Gynecol Reprod Biol. 2007;132:209-213.
6. Silva WA, Pauls RN, Segal JL Rooney CM, Kleeman SD, Karram MM. Uterosacral ligament vault suspension: five year outcomes. Obstet Gynecol. 2006;108:255-263.
7. Shull BL, Bachofen C, Coates KW, Kuehl TJ. A transvaginal approach to repair of apical and other associated sites of pelvic organ prolapse with uterosacral ligaments. Am J Obstet Gynecol. 2000;183:1365-1373.
8. Miyazaki FS. Miya hook ligature carrier for sacrospinous ligament suspension. Obstet Gynecol. 1987;70:286-288.
9. Pollak J, Takacs P, Medina C. Complications of three sacrospinous ligament fixation techniques. Int J Gynaecol Obstet. 2007;99:18-22.
10. Holley RL, Varner RE, Gleason BP, Apffel LA, Scott S. Sexual function after sacrospinous ligament fixation for vaginal vault prolapse. J Reprod Med. 1996;41:355-358.
11. Bradley CS, Zimmerman MB, Qi Y, Nygaard IE. Natural history of pelvic organ prolapse in postmenopausal women. Obstet Gynecol. 2007;109:848-854.
12. Pohl JF, Frattarelli JL. Bilateral transvaginal sacrospinous colpopexy: preliminary experience. Am J Obstet Gynecol. 1997;177:1356-1361.
13. Kettel LM, Hebertson RM. An anatomic evaluation of the sacrospinous ligament colpopexy. Surg Gynecol Obstet. 1989;168:318-322.
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