Transvaginal culdosuspension: technique and results

ADULT UROLOGY

TRANSVAGINAL CULDOSUSPENSION: TECHNIQUE AND RESULTS CRAIG V. COMITER, SANDIP P. VASAVADA,

AND

SHLOMO RAZ

ABSTRACT Objectives. Numerous techniques have been described for supporting the vaginal vault after enterocele repair and hysterectomy. We describe a transvaginal culdosuspension that obliterates the cul-de-sac and supports the vaginal cuff high on the levator plate. The normal vaginal axis is restored, and adequate vaginal depth is provided for normal sexual activity. Methods. One hundred four patients, aged 48 to 90 years (mean age 71), underwent transvaginal culdosuspension in conjunction with enterocele repair (62 patients), vaginal hysterectomy (20 patients), or both (22 patients). Two culdosuspension sutures support the vaginal vault to the origin of the sacrouterine and cardinal ligaments, and the cul-de-sac is obliterated with two pursestring sutures. Concomitant prolapse was repaired in 82 patients, bladder neck suspension in 50, cystocele repair in 45, and rectocele repair in 76. Results. One hundred patients were followed up at a mean of 17.3 months (range 6.5 to 35). Recurrence of enterocele or vault prolapse occurred in 4 patients. All patients who had preoperative stress incontinence were cured of leakage. Complications were rare, and there were no instances of vaginal foreshortening, urinary retention, vaginal skin necrosis, bladder perforation, or rectovaginal fistula. Conclusions. Transvaginal culdosuspension is a safe and effective procedure for treating and preventing enterocele and vaginal vault prolapse. This technique restores the normal vaginal depth and axis, resulting in a sexually functional vagina. UROLOGY 54: 819–822, 1999. © 1999, Elsevier Science Inc.

T

he proximal vagina is held over the levator plate by the sacrouterine and cardinal ligaments, pointing toward spinal segments S2-S4.1,2 The distal vagina forms an angle of 45 degrees from the vertical, supported by the anterior pull of the levator ani. With coughing or straining, reflex contraction of the pubococcygeus pulls the distal vagina anteriorly, increasing the curvature between the proximal and distal segments. Abdominal forces are thus directed downward on the proximal vagina, compressing it against the hammock of the rectum, prerectal fascia, and levator plate. This anatomic relationship may be altered after bladder neck suspension, hysterectomy, or with pelvic floor relaxation (PFR). A poor levator response to straining results in insufficient vaginal angulation, with the proximal vagina becoming more vertically oriented. Abdominal forces may then act on the vaginal apex, and in the presence of From the Department of Urology, University of California, Los Angeles, California Reprint requests: Craig Comiter, M.D., 6442 North Camino Katrina, Tucson, AZ 85718 Submitted: April 28, 1999, accepted (with revisions): May 21, 1999 © 1999, ELSEVIER SCIENCE INC. ALL RIGHTS RESERVED

concomitant separation of the sacrouterine ligaments (after hysterectomy), can expose the cul-desac, thereby predisposing to enterocele formation. Numerous techniques have been described for repairing enterocele and preventing vault prolapse after hysterectomy. In each approach, the surgeon must occlude the pouch of Douglas and narrow the levator hiatus, while supporting the vaginal vault and restoring the normal vaginal angulation. We describe our transvaginal culdosuspension after enterocele repair and hysterectomy. MATERIAL AND METHODS One hundred four patients, 48 to 90 years old (mean age 71), underwent transvaginal culdosuspension in conjunction with transvaginal hysterectomy (20 patients), enterocele repair (62 patients), or both (22 patients). Hysterectomy was indicated for moderate to severe uterine prolapse (grade 3 or greater) with symptomatic cystocele and/or pelvic floor relaxation and was performed as previously described.3 In patients with a posthysterectomy enterocele, repair was performed as previously described.4 After hysterectomy or repair of the enterocele, a laparotomy pad was inserted intraperitoneally to protect the bowel. Culdosuspension sutures were used to provide vaginal vault support and obliterate the cul-de-sac. A No. 1 synthetic absorb0090-4295/99/$20.00 PII S0090-4295(99)00266-6 819

lapse was repaired in 82 patients: bladder neck suspension in 50 (vaginal wall sling),5 cystocele in 45 (4-defect repair),6 and rectocele in 76.

RESULTS

FIGURE 1. (A) Culdosuspension suture placed through the vaginal wall (starting within the introitus) high on the lateral fornix—defining the new apex. The suture then passes pararectally through the sacrouterine ligament, across the midline (incorporating the prerectal fascia), and through the contralateral sacrouterine ligament. The suture is reversed, traversing the same structures, and exiting the vagina 1 cm from the entry. (B) Photograph demonstrating culdosuspension suture. able suture (SAS) was placed through the vaginal wall (starting within the introitus) high on the lateral fornix and defining the new apex. The suture was then passed pararectally through the sacrouterine ligament, across the midline (incorporating the prerectal fascia), and through the contralateral sacrouterine ligament. The suture was reversed, traversed the same structures, and exited the vaginal wall 1 cm from the entry (Fig. 1). An identical suture was placed in the opposite direction starting from the contralateral vaginal fornix. These culdosuspension sutures were left untied. The peritoneal cavity was closed with two pursestring sutures (No. 1 SAS), incorporating the sacrouterine ligaments, prerectal fascia, perivesical fascia, and posterior peritoneal surface of the bladder. The second pursestring suture incorporated a Dexon mesh, which reduced the bowel as the laparotomy pad was removed. These pursestring sutures were placed slightly more proximal than the culdosuspension sutures. High suture placement ensures adequate vaginal depth. The dissolvable mesh was left in situ, and the pursestring sutures were tied, obliterating the pouch of Douglas. The vaginal wall was trimmed and closed with a 2-0 SAS, and the culdosuspension sutures were tied. Concomitant pelvic pro820

Of 104 patients, 100 were available for follow-up (mean 17.3 months, range 6.5 to 35). Follow-up consisted of a detailed history and physical examination. Cure was defined as minimal (grade 1) or no vault prolapse and no cystocele or rectocele. The mean age was 70.1 years and did not differ significantly between those undergoing hysterectomy and those undergoing enterocele repair. Patients not undergoing hysterectomy were discharged home on the day of surgery; patients who underwent hysterectomy stayed an average of 2 days in the hospital. Recurrent enterocele or vault prolapse occurred in 4 patients (3 after enterocele repair and 1 after hysterectomy). All 45 patients with stress incontinence underwent a concomitant bladder neck suspension, and all were cured. Four individuals (9%) developed new onset urgency incontinence. In the 4 patients with recurrent prolapse, repeated transvaginal culdosuspension was performed, and each was free of prolapse at last follow-up. Perioperative complications included ileus in 2 patients, cuff infection in 2, ureteral obstruction in 1, and prolonged dyspareunia in 1. Both individuals with ileus were treated nonoperatively. Both vaginal cuff infections drained spontaneously and did not require operative intervention. The solitary case of ureteral obstruction necessitated ureteral neocystotomy. The case of prolonged dyspareunia resolved after 6 months. No patient required a transfusion. There were no instances of vaginal foreshortening, skin necrosis, urinary retention, bladder perforation, or rectovaginal fistula. COMMENT The proximal vagina lies nearly flat over the backboard provided by the rectum, prerectal fascia, and levator plate. During stress maneuvers, the pubococcygeus contracts, pulling the distal vagina anteriorly, exaggerating the normal posterior angulation of the proximal vagina. Intra-abdominal pressures are then directed toward the posterior vaginal wall and levator plate, rather than pushing the vault out the introitus1,2 (Fig. 2). An enterocele may form after a change in the vaginal axis.7 Bladder neck suspension without proper repair of concomitant PFR results in anterior displacement of the vagina, leaving the cul-de-sac unprotected. With inadequate support of the vaginal cuff after hysterectomy, separation of the sacrouterine and UROLOGY 54 (5), 1999

FIGURE 2. Magnetic resonance image demonstrating normal vaginal axis. The proximal vagina points toward spinal segments S2-S4. Note the nearly horizontal orientation of the proximal vagina on the levator plate. The distal vagina forms an angle of 30° to 45° from the vertical, supported by the anterior pull of the levator ani.

cardinal ligaments may then predispose to peritoneal herniation through the vaginal apex. The incidence of enterocele after the Burch colposuspension may be as high as 15%.4 After hysterectomy, vault prolapse occurs at a rate of 0.2% to 43%,8 with most series claiming a rate of less than 5%.9 Several principles govern enterocele repair and prevention of recurrent vault prolapse: high ligation of the hernia sac, obliteration of the cul-desac, adequate cuff support, and repair of concomitant prolapse and PFR. Numerous surgical techniques ranging from transabdominal to laparoscopic to transvaginal have been described. For those patients with significant contraindications to surgery, a pessary is an option. Although pessary use may succeed in a woman with adequate perineal outlet support, it may precipitate incontinence, interfere with sexual relations, or cause skin erosion, vaginal infection, and even bladder or rectal injury.10 One of the original abdominal approaches for enterocele repair, the Moschkowitz procedure,11 uses four pursestring sutures placed around the cul-de-sac. Peritoneal sutures are placed through the posterior vaginal wall, sacrouterine ligaments, sigmoid serosal surface, and pelvic sidewalls. Although the pouch of Douglas is obliterated, the normal vaginal axis is not necessarily restored. With concomitant vault prolapse, culposacropexy and repair of PFR will restore the normal proximal vaginal orientation and support. After obliterating the cul-de-sac, a graft is used to support the vaginal apex to the sacral promontory. Various graft materials have been used, including autologous fascia, donor tissue, and synthetic substances.12–14 Transabdominal culposacropexy is associated with a low risk (10%) of recurrent prolapse,15,16 but may be UROLOGY 54 (5), 1999

complicated by bleeding from the presacral vessels, enterotomy, ureteral injury, cystotomy, proctotomy, extrafascial wound infections, or small bowel obstruction.14 In an effort to minimize the invasiveness of culdoplasty, various investigators have described a laparoscopic approach,17–19 relying on a Moschkowitz-type obliteration of the cul-de-sac and a vault suspension to the anterior rectus fascia,19 sacral promontory,17 or sacrouterine ligament.18 Early results indicate a low complication rate and a recurrence rate of less than 10%. Compared with transabdominal surgery, laparoscopic techniques provide faster recovery, less pain, and better cosmesis. A transvaginal approach eliminates the morbidity of laparoscopy and laparotomy, yet permits concomitant vaginal reconstructive surgery. The McCall culdoplasty20 obliterates any enterocele, closes the redundant cul-de-sac, and approximates the sacrouterine ligaments. Each side of the posterior vaginal wall is sutured to the ipsilateral sacrouterine ligaments, restoring the normal proximal vaginal orientation. Vaginal depth is preserved by inserting a suture from outside the vagina, through the vaginal wall and peritoneum, and then incorporating both uterosacral ligaments and the anterior serosa of the sigmoid colon, and finally exiting through the peritoneum and vaginal wall adjacent to the site of entry. This clever innovation pushes the proximal vagina posteriorly toward the sacrouterine ligaments while the suture is tied. Given21 reported a 95% success rate in 44 patients, with a cuff infection rate of only 4%. The Mayo technique uses a modified McCall suture, with a recurrent prolapse rate of only 16% in the patients available for follow-up.22 Despite passing the sutures from the introitus to the sterile peritoneal cavity, cuff infections are rare. With transvaginal sacrospinous fixation, the pararectal space is sharply dissected at the ischial spine, and a suture is passed through the coccygeus muscle overlying sacrospinous ligament and the full thickness of the undersurface of the vaginal wall. This technique has a high success rate, ranging from 85% to 95%.23,24 Although a laparotomy is avoided, this procedure has been associated with a 10% to 24% complication rate.25,26 The inferior gluteal vessels, hypogastric venous plexus, and internal pudendal vessels may be damaged. The sciatic nerve (superior) and pudendal nerve (inferior) are in close proximity to the sacrospinous ligament, and moderate to severe buttock pain has been reported in 10% to 15% of patients. Meeks27 described a method of transvaginal suspension to the ileococcygeus fascia that was associated with a very low rate of recurrent prolapse but had a 37% complication rate. 821

In our transvaginal culdosuspension, we incorporate an absorbable mesh in the proximal pursestring suture. The mesh reduces the bowel contents, keeping them out of harm’s way during suture tying, and fills the dead space between the vaginal cuff and peritoneum. The Dexon mesh dissolves after 6 weeks and has not been associated with any complications. The pursestring sutures obliterate the cul-de-sac in a similar fashion to the Moschkowitz sutures, but are placed more proximally, so as to include the tissue near the sacral insertion of the sacrouterine ligament. Since no sutures are placed through the sacrospinous ligament, the pudendal vessels, sciatic nerve, and hypogastric vessels are less likely to be injured. By modifying the McCall culdoplasty and suturing each vaginal fornix to both sacrouterine ligaments, our transvaginal culdosuspension obliterates the cul-de-sac, supports the cuff, preserves vaginal depth, and restores the normal proximal vaginal curve over the levator plate. We believe that placing the suture high at the lateral fornix helps to restore normal vaginal depth. The intraperitoneal approach avoids the potentially bloody extraperitoneal dissection described in most sacrospinous fixations, allowing for clear vision and precise suture placement. Moreover, the transfer of a suture from the vaginal introitus to the sterile pelvic space does not appear to be associated with a high infection rate. Only 2 patients developed a mild cuff infection, both of which drained spontaneously; neither patient required rehospitalization. Only 1 patient complained of prolonged dyspareunia, and no patient developed vaginal shortening. CONCLUSIONS Transvaginal culdosuspension is a safe and effective procedure for treating and preventing recurrent vaginal prolapse. This technique obviates the need for a laparotomy or sacrospinous fixation and is associated with a very low complication rate. By returning the vaginal cuff to a high position on the levator plate, the normal vaginal depth and proximal vaginal orientation are restored, leaving a sexually functional vagina. REFERENCES 1. Wahle GR, Young GPH, and Raz S: Anatomy and pathophysiology of pelvic support, in Raz S (Ed): Female Urology. Philadelphia, WB Saunders, 1996, pp 57–79. 2. Karram MM, and Walters MD: Pelvic organ prolapse: enterocele and vaginal vault prolapse, in Walters MD, and Karram MM (Eds): Clinical Urogynecology. St. Louis, Mosby, 1996, pp 236 –260. 3. Rovner ES, Ginsberg DA, and Raz S: Vaginal hysterectomy, in Graham S (Ed): Glenn’s Urologic Surgery. Philadelphia, Lippincott-Raven, 1998, pp 383–388.

822

4. Chopra A, Raz S, and Stothers L: Enterocele and vault prolapse, in Raz S (Ed): Female Urology. Philadelphia, WB Saunders, 1996, pp 465– 473. 5. Raz S, Siegel AL, Short JL, et al: Vaginal wall sling. J Urol 141: 43– 46, 1989. 6. Safir MH, Gousse AE, Rovner ES, et al: 4-Defect repair of grade 4 cystocele. J Urol 161: 587–594, 1999. 7. Chopra A, Stothers L, and Raz S: Uterine prolapse, in Raz S (Ed): Female Urology. Philadelphia, WB Saunders, 1996, pp 457– 464. 8. Cruikshank SH: Sacrospinous fixation—should this be performed at the time of trans-vaginal hysterectomy? Am J Obstet Gynecol 164: 1072–1077, 1991. 9. Scotti RJ: Prophylactic sacrospinous fixation discouraged. Am J Obstet Gynecol 166: 1022–1025, 1992. 10. Zeitlin MP, and Lebherz TB: Pessaries in the geriatric patient. J Am Geriatr Soc 40: 635– 639, 1992. 11. Moschkowitz AV: The pathogenesis, anatomy and cure of prolapse of the rectum. Surg Gynecol Obstet 15: 7–14, 1912. 12. Baker KR, Beresford JM, and Campbell C: Colposacropexy with Prolene mesh. Surg Gynecol Obstet 171: 51–55, 1990. 13. Lansman HH: Posthysterectomy vault prolapse: sacral colpopexy with dura mater graft. Obstet Gynecol 63: 557– 561, 1984. 14. Nichols DH: Relaxed vaginal outlet, rectocele, and enterocele, in Mattingly RF, and Thompson JD (Eds): Te Linde’s Operative Gynecology. Philadelphia, JB Lippincott, 1985, pp 569 –594. 15. Valaitis SR, and Stanton SL: Sacrocolpopexy: a retrospective study of a clinician’s experience. Br J Obstet Gynaecol 101: 518 –523, 1994. 16. Creighton SM, and Stanton SL: The surgical management of vaginal vault prolapse. Br J Obstet Gynaecol 98: 115– 122, 1991. 17. Ross JW: Techniques of laparoscopic repair of total vault eversion after hysterectomy. J Am Assoc Gynecol Laparosc 4: 173–183, 1997. 18. Ostrzenski A: Laparoscopic colposuspension for total vaginal prolapse. Int J Gynaecol Obstet 55: 147–152, 1996. 19. Fedele L, Garsia S, Bianchi S, et al: A new laparoscopic procedure for the correction of vaginal vault prolapse. J Urol 159: 1179 –1182, 1998. 20. McCall ML: Posterior culdeplasty: surgical correction of enterocele during vaginal hysterectomy: a preliminary report. Obstet Gynecol 10: 595–598, 1957. 21. Given MP: “Posterior culdeplasty”: revisited. Am J Obstet Gynecol 153: 135–139, 1985. 22. Webb MJ, Aronson MP, Ferguson LK, et al: Posthysterectomy vaginal vault prolapse: primary repair in 693 patients. Obstet Gynecol 92: 281–285, 1998. 23. Albo M, Dupont MI, and Raz S: Transvaginal correction of pelvic prolapse. J Endourol 10: 231–238, 1996. 24. Carey MP, and Slack MC: Transvaginal sacro-spinous colpopexy for vault and marked uterovaginal prolapse. Br J Obstet Gynaecol 101: 536 –540, 1994. 25. Brieger GM, Korda AR, and Houghton LR: Abdominoperineal repair of pulsion enterocele. J Obstet Gynaecol Res 22: 151–155, 1996. 26. Penalver A, Mekki Y, Lafferty H, et al: Should sacrospinous fixation for the management of pelvic support defects be a part of a residency program procedure? The University of Miami experience. Am J Obstet Gynecol 178: 322–327, 1998. 27. Meeks GR: Repair of vaginal vault prolapse by suspension of the vagina to iliococcygeus (prespinous) fascia. Am J Obstet Gynecol 171: 1444 –1452, 1994.

UROLOGY 54 (5), 1999