Video of uterovaginal procidentia repair incorporating a high extraperitoneal uterosacral vault suspension.

INTRODUCTION AND HYPOTHESIS: Women with high-grade uterovaginal prolapse have a higher incidence of levator injury, larger levator hiatal defects, and are at a greater risk of recurrent prolapse after pelvic organ prolapse (POP) surgery. RCOG guidelines have recommended prophylactic sacrospinous suspension at the time of vaginal hysterectomy, whenever there is a marked uterovaginal prolapse. The aim of the video is to describe our surgical approach at the time of surgery for advanced POP, and describe the technique for modified McCall high extraperitoneal vault suspension. METHODS: We have modified the McCall culdoplasty by extending the dissection of the middle portion of the uterosacral/cardinal ligaments so that the sutures can be placed higher and more laterally extraperitoneally to re-support the vaginal cuff at the time of a vaginal hysterectomy. RESULTS: The video highlights the surgical technique used for apical support at the time of surgery for advanced POP. CONCLUSIONS: This video demonstrates our modified McCall technique for vault suspension at the time of vaginal surgery for advanced POP. This technique could be considered an alternative technique to other modes of apical support.

Technique of extraperitoneal uterosacral ligament suspension for apical suspension.

AIM OF THE VIDEO/INTRODUCTION: Vaginal vault prolapse can occur alone or in combination with anterior or posterior compartment prolapse. Apical prolapse has shown a strong correlation with anterior wall prolapse and a moderate correlation with posterior wall prolapse. The McCall culdoplasty uses the extraperitoneal vaginal approach to support the vault at the time of hysterectomy. Sacrospinous fixation and ileococcygeus suspension with or without mesh have also been used for the treatment of vaginal vault prolapse. The uterosacral ligaments can also be used to re-suspend the vaginal vault using the extraperitoneal or transperitoneal approach. With the extraperitoneal approach, the peritoneal sac, which can be difficult to access at times, especially when there are dense pelvic adhesions, does not need to be opened. The extraperitoneal approach also carries a lower risk of ureteric injury, as the ureters and the bladder can be retracted from the field using a Breisky-Navratil retractor. METHODS: This video, which documents the surgical treatment of a woman with a complete vaginal eversion and grade 3 pelvic organ prolapse (POP), was recorded in a live workshop during the 2015 Urogynaecology and Reconstructive Pelvic Surgery Conference, held in Chennai, India, in January 2015. It is aimed at educating interested surgeons in the technique of extraperitoneal uterosacral suspension. CONCLUSIONS: This video demonstrates the extraperitoneal approach to uterosacral ligament suspension for apical support in women with vaginal vault prolapse.

Surgery for pelvic organ prolapse.

OBJECTIVES: : Surgery for pelvic organ prolapse (POP) is common with increasing high-quality evidence to guide surgical practice. Yet many important basic questions remain, including the optimal timing for POP surgery, the optimal preoperative evaluation of urinary tract function, and the postoperative outcome assessment. This manuscript reviews traditional surgical approaches for POP. METHODS: : Formal and hand-searching of prolapse literature was conducted by the committee on Pelvic Organ Prolapse Surgery for the most recent International Consultation on Incontinence. The committee (authors) was composed of prolapse specialists from around the world. Consensus recommendations were made following literature abstraction. RESULTS: : Surgical correction of POP can be divided into 2 main categories as follows: reconstructive procedures to correct anterior and posterior wall defects and resuspend the vaginal apex or obliterative procedures to close off the vagina. Reconstructive surgery may use the vaginal route or the abdominal route. CONCLUSIONS: : In addition to recommendations within the report, the committee reaffirms that in planning surgery, the individual patient's risk for surgery, risk of recurrence, previous treatments, and surgical goals are all considered in deciding on obliterative versus reconstructive procedures, and in deciding whether the vaginal or the abdominal approach will be used for reconstructive repairs.