The ideal procedure is sacrocolpopexy . Vaginal hysterecotmy is no longer indicated in procedentia treatment.

Unless there´s demonstrable weekness of uterosacral ligaments the vaginal vault is to be fixed to this ligament. In the Kowac´s modified approach we use the uterosacral ligament reforced by paracolpos.

Sacrospinous ligament fixation (pexy)

optimal study, JAMA 2014 , no diferences betwen ssl or mccall

Thank you Carlos for the reference, I will look it up.

The best treatment is colposacropexy, vaginal approaches are possible but for me are indicated only if sacropexy has contraindications on the basis of age, general health status, anesthesiological problem, obesity

For patients who do not desire sexual activity, (elderly, widows) the best option is surgery, Le Fort. For patients with sexual activity, colposacropexia is an good option.

Agree with Angelo. No sex, colpocleisis. LeFort or any of it's modifications. For the post hyst we prefer the Marshall or the Labhart. If reconstruction needed, SCP is a great option but according to CARE trial long term results are not what we thought and the best defecatory results are accomplished if planned as a step procedure as SCPerineopexies were not the good they looked in early reports. This is our standard.

The JAMA report mentioned by Carlos is not exactly a posthyst trial, and mainly refers to high USL rather than the McCall procedure. Anyway I agree with Alsaeed, SSF is a great procedure too (of course if vagina is not short) and for sure simpler, extra peritoneal and with less complications (mainly ureteric) than HUSLS when treating posthysterectomy prolapse

Sacrospinous ligament fixation unilateral, only.!

I continue to think colposacropexy is the best procedure especially in patients with sexual activity and in the guidelines it is considered the gold standard. The long term results of the CARE study reflect the fundamental bias this paper has: 1) the study is multicenter and the technical aspects of the surgery are not reported. We do not know how the procedure was performed. Not all the colposacropexy are similar, if you fix the mesh/meshes (absorbable or not absorbable??) only with a couple of stitches on the vaginal vault is different from using two polypropilene meshes fixed with several stitches on the anterior and posterior vaginal wall preparing enough vaginal walls to correct all the vaginal defects; 2) the objective of the Care study was to define the role of Burch colposuspension associated to CSP and it was not designed for long term anatomical follow-up 3) many patients were lost to the follow-up

I agree with you about CARE trial. The whole you said . And absolutely agree that wasn't the main objective as it wasn't posterrior wall symptoms evolution found etc etc. They found what they found and good or not they loyalty published the results. On their defense I have to say that if you look at the authors, they are all from major centers in the US. All of them sub specialists in Urogyne from well known and respected centers. As for sure happens with you we don't see that amount of long term complications/failuers. Just my question/concern is what happens in the hands of general ob/gyn or urologic surgeons who are not subspecilists. Or in the hands of trainees as probably in whose hands were many of the CARE trial surgeries. May be it's not a surgery for everybody. The recent AUGS statement about SCP stablishes that. Definitely agree with you, for the sexually active, aims should be towards making better and better SCP.

carefull with sacrocolpo . many problems arise in USA at now.

Female Pelvic Med Reconstr Surg. 2013 Nov-Dec;19(6):333-8. doi: 10.1097/SPV.0b013e3182a330c1.

Pelvic mesh complications in women before and after the 2011 FDA public health notification.

Rice NT1, Hu Y, Slaughter JC, Ward RM.

CONCLUSIONS: Whereas the number of patient-perceived mesh a complications increased after the FDA notification, neither the frequency, type, or location of complications changed. The complications were not limited to transvaginal mesh, and an unexpectedly high proportion of the complications were related to sacral colpopexy and midurethral sling procedures.

PMID:

24165446

[PubMed - indexed for MEDLINE]

Read it!

Obstet Gynecol Int. 2013;2013:926313. doi: 10.1155/2013/926313. Epub 2013 Sep 8.

Mesh exposure and associated risk factors in women undergoing transvaginal prolapse repair with mesh.

Frankman EA1, Alperin M, Sutkin G, Meyn L, Zyczynski HM.

Author information

Abstract

Objective. To determine frequency, rate, and risk factors associated with mesh exposure in women undergoing transvaginal prolapse repair with polypropylene mesh. Methods. Retrospective chart review was performed for all women who underwent Prolift Pelvic Floor Repair System (Gynecare, Somerville, NJ) between September 2005 and September 2008. Multivariable logistic regression was performed to identify risk factors for mesh exposure. Results. 201 women underwent Prolift. Mesh exposure occurred in 12% (24/201). Median time to mesh exposure was 62 days (range: 10-372). When mesh was placed in the anterior compartment, the frequency of mesh exposure was higher than that when mesh was placed in the posterior compartment (8.7% versus 2.9%, P = 0.04). Independent risk factors for mesh exposure were diabetes (AOR = 7.7, 95% CI 1.6-37.6; P = 0.01) and surgeon (AOR = 7.3, 95% CI 1.9-28.6; P = 0.004). Conclusion. Women with diabetes have a 7-fold increased risk for mesh exposure after transvaginal prolapse repair using Prolift. The variable rate of mesh exposure amongst surgeons may be related to technique. The anterior vaginal wall may be at higher risk of mesh exposure as compared to the posterior vaginal wall.

PMID:

24194763

[PubMed]

PMCID:

PMC3782123

PS :SURGEON EXPERIENCE ? MOST IMPORTANT TIPS DO WORK WELL?

Agree with you Carlos!. There is still a lot to be learnt about meshes. If you happen to read the famous paper "Complication and reoperation rates after apical vaginal prolapse surgical repair" at O&G Feb 2009 113: 367 where transvaginal meshes are considered "very dangerous procedures" with high reopertion rates…. you will notice that for some reason the authors forgot to include their own papers about complications of vaginal procedures in the literature. Just as an example "The incidence of ureteral obstruction and the value of intraoperative cystoscopy during vaginal surgery for pelvic organ prolapse at AJOG 2006 194 1478 which was written during the period considered in there study was not included. And many others.

So, still a lot to be learn about meshes in POP surgery. A lot to be written. Anyway for recurrent posthyst POP we prefer SCP. Obrigado por compartilhar. Abraco!

We all agree on the alert on the use of meshes but we need to underline the problem is particularly important when the vaginal approach is used. It has a lower impact when abdominal/laparoscopic approach is used. I agree with Carlo Sarsotti that the expertise is fundamental and it is true both for the SCP and SSF. We'll have the best results in the best hands. However it is true for all the fields of surgery and if general gynecologists or urologists are not subspecialized they should be invited to not perform in particular secondary procedures. We should need to certified centers able to treat them with all the approaches tailored to the patients

In my private practice and university, we have been study a lot transvaginal mesh for treatment of apical and enlarge anterior defect.Now we used trocarless mesh with bilateral ssf fixation .I agree with costantini and we have performed uterus sparring surgeries . Rate of erosion is less than 2% and antomical and subjectives outcomes are same matched SCP. IN general we don't have paper to compare SCP X Transvaginal Mesh (VAULT STUDY ) HAVE IN COURSE.

Tomorow put news papers.

This is developing in to a healthy discussion! I quite agree with your points and the point Carlos Sartossi made about general ob/gyn surgeons and the challenge of using mesh is especially true for low resource areas like where I practice. In the hospital i practice we dont use mesh for prolapse surgery not only because it is not readily available but because of the cost. For this reason most of the surgeries for UV prolapse are vaginal hysterectomies or uterine suspension. For us it is very important to consider less sophisticated procedures that would be affordable to the majority of clients.

Having said that, what are your experiences with prolapse of the vaginal vault after a vaginal hysterectomy has been done? Is mesh procedure still an option? Thinking out loud, can one try to an abdominal procedure where the stumps of the uterosacral ligaments and that of the lateral cervical are identified that apposed to each other? What would be your views on this as a treatment for prolapsed vault post vaginal hysterectomy?

Well when dont have mesh available use Ssf or mccall, but In OPTIMAL study, jama 2014 , mathews have 60% of objetives cures.what do you do In recurrency?

Surgeon experience In most important tip to surgiríes work well.

Hi all!! Thanks for posting!! As Aisha said this is a becoming a "global" discussion of surgeons with absolutely different medical/social realities. Not to mention economics and resources. Undoubtedly means that there is not only one truth!

What is clear too is that surgeon's training is a matter of concern, and that as Elisabetta said, rescue treatments should probably be in the hands of sub specialists.

Do you have any regulations/guidelines about this in your countries?

Posthyst vault prolapse is not that frequent for us because uterine preservation is our standard of care as uterus is a valuable for our ladies. We prefer SSF Hysteropexies using a mesh as our results taught us that they are not that good just by using sutures.

At the moment we use a sling type mesh.

I would like to know what is your standard for hysteropexy.

As Carlos said TV mesh colpopexy is an option for vault prolapse. It is for us, but not our first choice. When for medical reasons (in a sexually active patient) we consider that a patient is not a good candidate for SCP, then SSF is our option. We usually do it using a sling type mesh like Carlos, and with anterior mesh reinforcement if significant AWP is present.

We do this wih commercial kits if available, but if not we use a "home made kit" as resterilisation of PPL is usual, safe and legal in our country. Besides that, fortunately we don't have the attorney's mesh business developed in the US after FDA awareness. So TV PPL mesh use is part of our armamentarium. The use of biologics for reinforcement extremely unfrequent in our country due to cost and availability as well

HUS colpopexy (with or without McCsll procedure) is a nice and effective surgery. It's our choice when we go vaginally and a VH is done. We do them abdominally for teaching purposes to our fellows, preferrable through the scope, but as I said before if we go abdominally we prefer SCP

Will love to hear about my questions.

Thanks for sharing and have a nice week end!

Interestingly today I received the regional adaptations of NCCN guidelines. A good idea to be taken into account by Urogyne www.nccn.org/about/news/ebulletin/ebulletindetail.aspx?ebulletinid=342

http://www.nccn.org/international/international_adaptations.aspx

It is true that the skill of the surgeon will make a difference, but even in the best hands a foreign material will not give the same results and more complications, as compared to natural body fascia. I recommend using fascia for vault suspension if vault prolapse occurs after vaginal hysterectomy. Vault prolapse following vaginal hysterectomy should be rare if the sutures on the uterosacral ligaments are kept long, and tied together after the vaginal hysterectomy. This also minimises the risk for an enterocele.

Thanks and regards to my colleagues,

Johan (JT) Nel.

Surgical Treatment of Vaginal Apex Prolapse

Walters, Mark D.; Ridgeway, Beri M.

Obstetrics & Gynecology. 121(2, PART 1):354-374, February 2013.

We all are running behind evidence. Mccall,s or sacrospinous or scarocolpopexy-- these are the techniques. Choose one of them and feel the operation - just do it. Otherwise, you have to find evidence, finest mesh etc.

Dear Johan Nel,

Vault prolapse following VH is rare, but it happens some times. It has been suggested long ago that it is the inability of surgeon to recognize the posterior enterocele and correct it during VH which results in post VH vault prolapse. There are different types of posterior enterocele, inability to identify during VH is, I think common. Inability to correct anterior and posterior prolapse with GH reduction is also responsible for it.

Hi Prabhat: M. Walters paper clearly states the role of McCall culdoplasty in treating mild apical prolapse, mainly during VH. Even in it's "High version", being High Uterosacral ligament suspension (an absolutely different surgery) a much better option for the advanced cases both during VH or for the treatment of post hysterectomy vault prolapse

Yes Sir,

I think this operation ("High version") has been uploaded in website.

yes we do get refferal cases of vault prolaspses, if there is eversion of vagina with big vault prolapses h i do sacrospinous fixation.sometimes we get  cases of failure of the repair of the vault prolapse so abdominal sacropexy works well.prevention is always better. high uterosacral advancement helps much.mesh colpopexy is another option in affordable cases.

4th November 2014

Thanks to my colleagues for all the interesting answers!

The McCall Culdoplasty is dangerous, as any "blind "procedure"!

The best aproach, in my professional opininion, therefore remains vaginal suspension to the anterior uterosacral ligament, using the patient's own fascia,  rather than mesh, which is foreign material. This can be done via a low mini-laparotomy, the total length being shorter, than the adding of all the  laparoscopic incicions. Laporoscopic surgery has the  danger of not being able to palpate the near-lying ureter.

I state this after sub-specialist training in gynaecologial surgery and more than 30 years of experience of gynaecological surgery in a counrtry, which has only 50% of the doctors required, and therefore exposes one to a huge number of patients.

We all aim for improvement in success rates and less complications in gynaecological surgery! I sincerely hope my answer helps!

Kind regards to all my colleagues,

Johan (JT) Nel M.B.Ch.B.; M.Med. (O.& G.); M.R.C.O.G.; F.C.O.G. (S.A.); F.R.C.S.Ed.; F.R.C.O.G.

It has been an interesting and enlightening discussion and I thank you all for your contributions. I do agree with Carlos' suggestion that perhaps rescue operations like this should be done by sub specialist who are expected to have had not only specialist training but also years of experience or a high number of surgeries in that field.

But I also find Johan's response to be practical and, especially in areas where the relevant sub specialists are not available, it may be an option for the general gynaecologist.

Thank you so much for a lively discussion as I look forward to more interesting contributions, and thank you for the reference Prabhat

Kind regards,

Aisha

Another important procedure is Michigan modification of sacrospinous fixation. Evidences are limited.