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Vaginal Vault Suspension

Vaginal Vault Suspension is a surgical concept intended to correct vaginal vault prolapse (VVP) that results from inadequate support of the vaginal apex typically seen in patients who have had a hysterectomy. Vaginal vault prolapse is a form of pelvic organ prolapse (POP). The vaginal vault will prolapse when there is damage and/or weakening of the pelvic connective tissue due to gravity or an increase in abdominal pressure with exertion. Prolapse is typically worse later in the day after being active, and better first thing in the morning after lying down all night. Fortunately, the suspension can be accomplished via different surgical approaches and different surgical procedures.

Did you know…
Approximately 3% of women in the United States report symptoms of vaginal bulging, but POP can be identified on examination in up to 50% of females? It has been reported that women in the US have a 13% risk of undergoing surgery for POP. Risk factors for developing VVP include parity (total number of pregnancies), vaginal delivery, age, obesity, menopause, chronic constipation, connective tissue disorders. It is unclear if a hysterectomy for non-POP conditions is a risk factor for developing POP.

What are the symptoms of VVP?
Inability to empty the bladder completely.
Sensation of having a full bladder at all times.
Sensation of pressure and/or bulge in the vagina.
Painful intercourse
Leaking urine when coughing, sneezing, or lifting.
Recurrent bladder infections (UTI’s)

How is a vaginal vault suspension performed?
There are several procedures that are categorized as vaginal vault suspensions. The type of suspension procedure is selected based on the surgical approach (vaginal, laparoscopic, abdominal), the degree of prolapse, the other surgical procedures planned, and surgeon experience. Patient selection is also of utmost importance when selecting a vaginal vault suspension.

What types of vaginal vault suspension procedure are there?
There are multiple vaginal vault suspension procedures described in the literature and performed. Here are the most common and effective ones:
A uterosacral ligament suspension. The uterosacral ligaments (fibro-connective tissues) are part of the natural support of the vaginal apex (uterus). They are named for their points of origin and insertion (sacrum and uterus). These can be shortened, approximated, and re-attached to the bladder and rectal support with sutures to re-establish support and eliminate the potential for an enterocele (hernia). They can also be suspended to the vaginal vault through sutures at the time of hysterectomy to prevent future VVP.

Sacrospinous Ligaments. These are very tough fibrous ligaments that extend between the sacrum and the sides of the boney pelvis at points called the ischial spines. The vaginal vault can be suspended to these ligaments in order to treat VPP and maintain a sexually functional vagina.

A sacrocolpopexy is a procedure in which the vagina is secured to the sacrum, providing the support and suspension of the vaginal vault. A piece of synthetic mesh or a biological graft is used to accomplish the procedure. The sacrocolpopexy is traditionally done through an abdominal incision, but can also be done using the robot, a laparoscope, or through the vagina.

What should I expect during a vaginal vault suspension?
The procedure is done while you are under general anesthesia. You will receive IV antibiotics and a vaginal douche prior to the procedure(s). You will have a catheter to drain urine during the case.

Will I need to follow any special post-surgical care instructions?
You will be given specific instruction to follow after your procedure. You will have a catheter to drain urine for at least 24 hours after surgery, and it may need to stay in place for several days after surgery. You should avoid any activity that increases your abdominal pressure such as heavy lifting, or constipation. You will be given a mild laxative to prevent constipation and generally should not lift anything heavier than a gallon of milk for six weeks until the scar tissue is strong. You should also avoid intercourse for six weeks to allow proper healing.

Are there any alternatives to treating POP?
Medical and behavioral management is always recommended prior to any surgical intervention. You will be required to learn pelvic floor muscle exercises (Kegel exercises), use estrogen cream in your vagina, or try a device called a pessary in your vagina to hold up the prolapse. If treatment is unsuccessful, contraindicated, and/or not tolerated, then surgery is your next choice.

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