Vaginal Vault Prolapse and Sacrocolpopexy
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Direct answer
Vaginal vault prolapse is descent of the vaginal apex after hysterectomy, repaired by sacrospinous fixation, uterosacral suspension or sacrocolpopexy. Sacrocolpopexy, which attaches a mesh from the vaginal apex to the sacral promontory, generally gives more durable apical support than vaginal fixation, at the cost of an abdominal or laparoscopic approach and a risk of mesh exposure. The choice depends on the degree of apical descent, the surgeon's experience, the patient's fitness and any coexisting anterior or posterior defects.
What you must remember
- Risk factors: previous hysterectomy, especially when done for prolapse, with pelvic floor weakness, chronic straining, obesity and higher parity adding to the risk.
- Sacrospinous fixation: a vaginal approach suturing the apex to the sacrospinous ligament, with risks of buttock pain, bleeding from the pudendal venous plexus and injury to adjacent rectum or sciatic structures.
- Uterosacral suspension: a vaginal approach suspending the apex to the uterosacral ligaments, where ureteric proximity makes cystoscopy after repair essential.
- Sacrocolpopexy: mesh from the vaginal apex to the anterior longitudinal ligament over the sacral promontory, the most durable apical option in comparative data.
- Posterior compartment: rectocoele and enterocoele need assessment at the same operation, since apical repair alone can leave a posterior defect.
- Mesh erosion: vaginal exposure of mesh is a recognised complication, so the patient needs counselling and follow-up.
- Obliterative alternative: colpocleisis suits frail women who no longer want sexual function.
A reasoned comparison of vaginal fixation and sacrocolpopexy
A 66-year-old woman had a vaginal hysterectomy 12 years ago and now has a vault bulge that is easily visible at the introitus, with a rectocoele and some urinary frequency. She is fit and sexually inactive but wants a durable result.
- Assess the posterior compartment. A rectocoele left untreated after apical fixation is a recognised source of failure, so it is assessed at the same time.
- Weigh the apical options. Compare the vaginal and abdominal approaches in the table below, setting the apical descent against operating time and anaesthetic risk.
- Match the operation to the patient. A woman with a large apical descent who is fit for an abdominal operation is generally offered sacrocolpopexy, while a frail patient with a smaller descent might be offered vaginal fixation.
| Feature | Sacrospinous fixation | Sacrocolpopexy |
|---|---|---|
| Approach | Vaginal | Abdominal or laparoscopic |
| Operating time | Shorter vaginal procedure | Longer anaesthetic |
| Characteristic risk | Buttock pain and pudendal bleeding | Mesh exposure into the vagina |
| Apical durability | Higher recurrence than mesh repair | More durable apical support |
Sacrospinous fixation suits a woman with a modest apical descent when a short operating time is the priority. Sacrocolpopexy gives anatomical support that does not depend on the sacrospinous ligament, so the operation follows the anatomy rather than the surgeon's habit.
Where the examiner tests the apex
Vault prolapse questions reward naming the complication with its operation.
- Trap: swapping the complications of the apical operations. Correct: sacrospinous fixation causes buttock pain and pudendal bleeding, uterosacral suspension needs cystoscopy because of ureteric proximity, and sacrocolpopexy carries mesh erosion.
- Trap: believing that repairing the apex solves all symptoms. Correct: persisting obstructed defaecation after vault repair suggests an unaddressed posterior defect.
- Trap: treating vault prolapse as a uterine problem. Correct: vault prolapse after hysterectomy is an apical compartment problem, so the treatment is apical support rather than hysterectomy.
Frequently asked questions
What is the main difference between sacrospinous fixation and sacrocolpopexy?
Sacrospinous fixation is a vaginal operation that suspends the vaginal apex to the sacrospinous ligament, whereas sacrocolpopexy attaches a mesh from the apex to the sacral promontory through an abdominal or laparoscopic approach. Sacrocolpopexy generally gives more durable apical support at the cost of a longer operation.
Which complication is specific to sacrospinous fixation?
Buttock pain and haemorrhage from the pudendal venous plexus are the characteristic complications of sacrospinous fixation. These arise because the sacrospinous ligament lies close to the pudendal vessels and sciatic structures during suturing.
Why must the posterior compartment be assessed before vault repair?
The posterior compartment must be assessed before vault repair because an untreated rectocoele or enterocoele can persist after apical fixation and cause obstructed defaecation. Repairing the apex alone does not address a posterior defect, so both compartments need treatment at the same operation.
What is the main long-term complication of sacrocolpopexy?
Vaginal erosion of the mesh is the main long-term complication of sacrocolpopexy, and it requires counselling and follow-up. Exposure may need trimming or removal of the exposed mesh, so women should be advised to report discharge or bleeding.