Post-hysterectomy vaginal vault prolapse

Highlights

• Post-hysterectomy vaginal vault prolapse is a recognised although rare complication following both abdominal and vaginal hysterectomy and the risk is increased in women following vaginal surgery for urogenital prolapse.

• Primary prevention can be performed at the time of hysterectomy.

• Whilst all women will initially benefit from conservative measures, surgical intervention remains integral in the effective management of women with post-hysterectomy vaginal vault prolapse.

• Women should be counselled carefully regarding the route of surgery, the role of concomitant continence surgery, and the long-term risks which may be associated with the use of abdominal mesh.

• Given the complexity of the management of post-hysterectomy vaginal vault prolapse, these patients are best managed in a tertiary centre within the auspices of a multidisciplinary team that includes urogynaecologists, urologists and colorectal surgeons.

Abstract

Post-hysterectomy vaginal vault prolapse (PHVP) is a recognised although rare complication following both abdominal and vaginal hysterectomy and the risk is increased in women following vaginal surgery for urogenital prolapse. The management of PHVP remains challenging and whilst many women will initially benefit from conservative measures, the majority will ultimately require surgery.

The purpose of this paper is to review the prevalence and risk factors associated with PHVP as well to give an overview of the clinical management of this often complicated problem. The role of prophylactic primary prevention procedures at the time of hysterectomy will be discussed as well as initial conservative management.

Surgery, however, remains integral in managing these complex patients and the vaginal and abdominal approach to managing PHVP will be reviewed in detail, in addition to both laparoscopic and robotic approaches.

Introduction

Urogenital prolapse is a common condition which can be distressing and is known to have a significant effect on health related quality of life (HRQoL) [1]. However some degree of prolapse is found on examination in 40%–60% of parous women [2]. Although many women may remain asymptomatic the rate of surgery has been reported to be 10–30 per 10,000 women and this is likely to increase further with an ageing population1. Whilst anterior compartment prolapse is frequently cited as the most common site of urogenital prolapse there is a growing recognition that loss of apical vaginal support may increase the risk of both anterior and posterior compartment prolapse and that failure to adequately support the vaginal vault may lead to surgical failure [2]. Consequently Post Hysterectomy Vaginal Vault Prolapse (PHVP) may commonly be associated with prolapse in other compartments and may increase the risk of surgical failure.

The aim of this review is to examine the incidence of PHVP as well as associated identifying risk factors. The role of preventative strategies will also be discussed in addition to reviewing the evidence for current conservative and surgical management.

PHVP involves the loss of apical support to the vagina and, by definition can only occur following hysterectomy [3]. It has recently been defined as ‘descent of the apex of the vagina (vaginal vault or cuff scar after hysterectomy) [4]. The degree of PHVP may then be defined and measured objectively using the Pelvic Organ Prolapse Quantification (POPQ) system [5] allowing objective clinical staging.

The search terms “apical prolapse” and “vault prolapse” were entered into Pubmed utilising MEDLINE, EMBASE and the Cochrane Library from 1996 to present. We included published reports in which outcomes of any management for apical vaginal prolapse were described. We particularly assessed reports where different techniques were compared in randomised studies or as part of a systematic review of surgical interventions (Table 1).

The prevalence of PHVP historically has been reported to range from 0.2% to 43% [6], [7], [8] although more recent data would suggest an incidence of 11.6% following hysterectomy for prolapse and 1.8% for other pathology [9]. Whilst not all women with vaginal vault descent will require surgery a large national study from Austria reporting on 7 645 hysterectomies and 577 procedures for PHVP had estimated a rate of surgical repair of 6%–8% [10].