Arch Gynecol Obstet (2001) 265:21–25

© Springer-Verlag 2001

O R I G I N A L A RT I C L E

T. Lantzsch · C. Goepel · M. Wolters · H. Koelbl H.D. Methfessel

Sacrospinous ligament fixation for vaginal vault prolapse

Received: 3 April 2000 / Accepted: 26 July 2000

Abstract Introduction. To assess intra- and postoperative complications and to look for long term follow-up results in women with sacrospinous ligament fixation. Methods. Between 1988 and 1999, 200 women (mean age 59.8 years, range 33 to 83 years) underwent vaginal unilateral sacrospinous ligament fixation. 172 patients had had prior hysterectomy. In 28 patients concomitant hysterectomy and sacrospinous ligament fixation was performed. Sacrospinous ligament fixation was combined with the following procedures: 109 enterocele repairs (54.5%), 88 anterior colporrhaphies (44%), 57 reconstructions of urogenital diaphragma (28.5%) and 23 posterior colporrhaphies (11.5%). Additional Burch colposuspension and a Stamey procedure were carried out in 7 (3.5%) and 15 (7.5%) patients, respectively. Results. All 200 patients were analysed for intra- and postoperative complications. Urinary tract infection (n = 16, 8.0%), temporary irritation of the sciatic nerve (n = 15, 7.5%), temporary partial ureteral obstruction (n = 11, 5.5%) and blood loss less than 400 ml (n = 7, 3.5%), occurred in the postoperative phase. Long-term data (range from 6 months to 9 years, mean 4.8 years) exist for 123 patients. 119 were completely cured without any signs of urinary incontinence and prolapse. At follow-up 4 patients (3.25%) showed recurrent vaginal vault prolapse. Recurrent cystoceles, rectoceles, enteroceles, were found in 10 cases (8.1%), one (0.8%) and one (0.8%), respectively. Two patients with complete recurrence of vaginal vault prolapse successfully underwent colpectomy and repeated sacrospinous ligament fixation, respectively. Conclusions. Sacrospinous ligament fixation is an effective and safe procedure with a low recurrence and complication rate.

T. Lantzsch (✉) · C. Goepel · M. Wolters · H. Koelbl H.D. Methfessel Department of Gynecology, Martin Luther University, Magdeburger Straße 24, 06097 Halle/Saale, Germany e-mail: [email protected] Tel.: 0049-0345-557 1847, Fax: 0049-0345-557 1501

Keywords Sacrospinous ligament fixation · Vaginal vault prolapse · Long term follow-up · Intraoperative complications · Postoperative complications

Introduction Vaginal vault prolapse after hysterectomy is a rare complication ranging between 0,2% to 0.5% [29]. In 1892 Zweifel [38] described a parasacral fixation of the vaginal vault to the tuberosacral ligament. In 1927, Miller [17] introduced a transvaginal technique for vaginal vault fixation near the base of the sacro-uterine ligament, approximately 11/2 inches below the promontory of the sacrum. In contrast, the abdominal approach has been emphasized by other study groups, making a laparotomy necessary [3, 16]. In 1951 Amreich first published a case report of sacrospinous ligament fixation by selecting a parasacral approach after resection of the coccygeal bone [2]. Sederl and Richter fixed the vaginal vault at the sacrospinous ligament alone by the vaginal route and showed long-term follow-up data of this operation [30, 31, 33]. In 1971 Nichols and Randall introduced the sacrospinous ligament fixation in the United States [21, 22, 27]. Long-term follow up data for recurrence are rarely presented in the literature ranging between 1 and 8% [31]. In this study we present our intra- and postoperative complications and long-term follow-up data in a large series of patients.

Materials and methods Between 1988 and 1999 200 patients with vaginal vault prolapse were selected for sacrospinous ligament fixation. Prior to surgery all patients underwent clinical examination and a clinical stress test with a bladder volume of 300 ml after repositioning the vaginal vault to detect masked genuine stress incontinence. In patients with demonstrable genuine stress incontinence additional antiincontinence surgery was carried out. The sequence of operative steps was as follows: Initially, all patients received a suprapubic catheter. The anterior wall defect of the vaginal prolapse was operated on as the first

22 Table 1 Procedures combined with sacrospinous ligament fixation (n = 200)

Table 2 Intraoperative and postoperative complications of 200 patients undergoing sacrospinous ligament fixation

Procedures combined with sacrospinous ligament fixation

No. of patients

Intra- and postoperative complications

Patients

Percent

Resection of enterocele Anterior colporraphia Reconstruction of urogenital diaphragm Vaginal hysterectomy Colpoperineoplasty Posterior colporrhaphia Vaginal colposuspension according to Raz [16] Abdominal colposuspension according to Burch [17]

109 88 57 28 24 23 15

Urinary tract infection Temporary sciatic neuralgia Voiding dysfunction (urinary retention > 100 ml) Temporary partial urethral obstruction (right kidney) Bleeding Thrombosis Cerebral apoplexy

16 15

8.0 7.5

11 7

5.5 3.5

7 1 1

3.5 0.5 0.5

7

step of the procedure. Following the anterior and superior wall reattachment, attention was turned to the posterior wall. A transverse incision was made at the introitus marking the lateral extremes of the transverse incision and bringing them together as they will be when the procedure has been completed to make sure the introitus was of adequate size. The pararectal space was opened by digital separation of the rectal pillar. The region of the ischial spine, the sacrospinous ligament and the coccygeus muscle was located with the surgeons finger. Two specula and an illuminating speculum (Vario retractor system BT 80, Aesculap AG®, Tuttlingen, Germany) helped to find the correct position for the sutures. With a Deschamps ligature carrier, one suture of Prolene was placed through the sacrospinous ligament 2 cm medial to the ischial spine. Each end of the suture was sewn underneath the surface of the posterior vaginal wall. The remaining wound in the anterior and posterior wall was closed. Apex of the suture remained unclosed to drain. The suture was then tied while the vaginal apex was digitally advanced up towards the sacrospinous ligament. One must be certain that vaginal mucosa is in close proximity to the ligament. The suture was not to be positioned around the ligament and at least 2 cm from the ischial spine since the pudendal vessels and nerves are close to this ligament, in that region. 123 out of 200 patients were available for long-term follow-up postoperatively (range 6 months to 9 years, mean 4, 8 years). In 77 patients it was not able to evaluate follow-up. Evaluations included history, physical examination for assessment of cyto-, rectoand enterocele, recurrent vaginal vault prolapse and testing for urinary stress incontinence. All patients were evaluated with the same criteria.

Results The patients ages at the time of operation ranged from 33 to 83 years (mean 59.8 yrs). 14 patients were nulliparous, 43 primiparous, and 143 subjects had had two or more labors. Twenty-one (10.5%) women had first-degree, one hundred-thirteen (56.5%) second degree, and thirty-eight (19%) third degree of vaginal vault prolapse [6]. At the time of surgery 12 patients (54.5%) had first-degree, 7 (31.8%) had second-degree, and 3 (13.7%) had third degree incontinence [14]. In 172 cases hysterectomy had been performed in previous surgery. In 28 patients with massive uterine prolapse sacrospinous ligament fixation was performed strictly following vaginal hysterectomy. We combined vaginal fixation with colposuspension by vaginal approach according to Stamey and Raz in

15 cases (7.5%) and by abdominal approach according to Burch in 7 cases (3.5%) [7, 28, 35]. Table 1 shows the operative procedures used for pelvic reconstruction in 200 patients. Sacrospinous ligament fixation was successfully performed in all 200 patients. Postoperative complications are listed in Table 2. Urinary tract infection occurred in 8% of our patients and responded to antibiotic treatment in all cases. Sciatic neuralgia was found in 7,5%. In one case the sciatic neuralgia required temporary infiltration with xylocaine. All the other patients recuperated spontaneously. There was a low frequency of intraoperative and postoperative blood-loss. Only one patient required blood transfusion. In this patient we found a haematoma in the right ischiorectal space which evacuated spontaneously. All patients revealing voiding dysfunction (residual volume >50 ml) had concomitant Burch colposuspension. Nine patients normalized within four weeks postoperatively. In two cases voiding dysfunction persisted 12 weeks postoperatively but normalized subsequently. In seven cases we observed a temporary urinary stasis of the right kidney as a result of a partial ureteral obstruction. Our therapy was to insert an ureteral stent in two cases for six weeks. One patient showed a transient cerebral ischaemia. Our study included one death after apoplexy on the fifth postoperative day. 119 patients (96.7%) were treated successfully without signs of recurrent vaginal vault prolaps in long-term follow-up. Recurrence rate of cystocele was 10 cases (8.1%), one rectocele (0.8%) and one enterocele (0.8%). 4 (3.25) patients suffered from recurrence of vaginal vault prolapse. Two of these four patients underwent repeat surgery, which included one colpectomy and one repeated sacrospinous ligament fixation. All woman without recurrence of vaginal vault prolapse were content with the surgical result.

Discussion Vaginal vault prolapse often is a consequence of prior hysterectomy, either as a consequence or as an expectable result of a coexisting pelvic floor defect at the time of primary surgery. Other causes are inborn or age dependent insufficiency of soft tissue, damage of the pelvic floor

23 Table 3 Postoperative complications (n) of sacrospinous ligament fixation. Review of the literature (+ Transient nerve injury)

Table 4 Recurrence of vaginal vault prolapse. Review of the literature

Investigators

Patients

Urinary tract infection

Sciatic nerve injury

Voiding dysfunction

Transfusion

Death

Imparato et al. [13] Nichols [21] Penalver et al. [26] Pasley [25] Chapin [9] Morley et al. [20] Monk et al. [19] Carey et al. [8] Backer [4] Cruikshank [10] Dellas et al. [11] Our results

179 163 160 156 134 100 69 64 51 48 45 200

– – 16 16 – 5 – – – 4 8 16

2 2 2 1 0 2 2 3 5 20+ 2 15+

– – – 15 – 16 – – – 4 – 11

1 – 7 3 4 6 1 – 0 2 4 1

0 1 0 1 1 0 0 0 0 0 0 1

Investigators

Patients operated

Patients available for follow-up

Recurrence [n]

Percent [%]

Paraiso et al. [24] Albrich [1] Imparato et al. [13] Nichols [21] Penalvr et al. [26] Pasley [25] Chapin [9] Morley et al. [20] Veronikis et al. [37] Monk et al. [19] Carey et al. [8] Backer [4] Cruikshank [10] Our results

243 216 179 163 160 156 134 100 71 69 64 51 48 200

243 169 155 163 160 144 112 92 58 61 63 51 48 123

20 5 4 5 10 8 5 3 0 1 1 0 1 4

8.2 3.2 2.6 3.1 6.2 5.6 4.5 3.3 0 1.6 1.5 0 2 3.2

after birth and obesity with abdomino-pelvic imbalance [21, 23, 36]. Modern knowledge about sexuality of aged woman with increasing life expectancy showed the important role of this operation. Thus this procedure conserved the ability of sexual intercourse. Holley compared preoperative and postoperative sexual activity of 35 patients and showed a constant or higher frequence of sexual intercourse postoperatively. There was also no association between surgery and dyspareunia. The study included women with first and second degree vaginal vault prolapse. Adequate coital function was restored in the majority of sexual active patients [12]. Other standard operations like colpectomy or colpocleisis are more stressful and may cause considerable blood-loss. The sacrospinous ligament fixation can be operated bloodless in a short time. Aim of the procedure is to support the vagina in the anatomically correct posterior inclination. We prefer the vaginal route since all compartemental defects of the pelvic floor, if existing, can be managed from the same access, giving satisfying results. Preoperative conservative therapy with pessaries and local estrogen treatment is often necessary as one pillar of success. Thus, vaginal tissue, often scarified, is improved and elongation of the vagina can be consequently achieved and the use of alloplastic material with unpredictable long-term complications

(foreign-body reactions) can be avoided. Non absorbable soft sutures are prefered over resorbable. Complications in our series were infrequent and temporary. The most significant problems were temporary urinary tract infections and voiding dysfunction. It was found in patients with combination of sacrospinous ligament fixation and incontinence operation. The reason could be the result of dislocation of vesico-urethral region with right-sited and dorsocranial fixation of the vaginal vault and ventral fixation in combination with colposuspension. Postoperative sciatic neuralgia was induced by the traction of the suture in the ligament. This tension is transmitted to the sciatic nerve. The very impressive pain resolves spontaneously after 2 or 3 weeks. In case of persistance transvaginal infiltration anesthesia with xylocaine might be helpful. To determine existing nerve fibers within the substance of the ligament Barksdale investigated the histology of the ligament [5]. Six sacrospinous ligaments were removed from 4 fixed female bodies. Representative segments were taken from the lateral (ischial), middle and medial (sacral) portions. Nerve tissue was found in all parts of the ligament. The highest concentration was located in the center of the ligament, the lowest and smallest in number nearby the ischial spine. It was also described that the number of nociceptors and nerves in the ligament differ with a wide range. We suggest that

24

localisation and depth of the suture could influence on the occurrence and the intensity of sciatic neuralgia. The most common postoperative complication of sacrospinous ligament fixation is urinary tract infection which occurred up to 10% (Table 3). Temporary sciatic neuralgia and voiding dysfunction are impressive for the women but unimportant in long-term results, there is a complete disappearance of symptoms after all. The studies of Cruikshank, Dellas and our results includes women with sciatic nerve injury, which were discharged from the hospital without symptoms [10, 11]. The main causes of intraoperative and postoperative death in patients with sacrospinous ligament fixation are acute myocardial infarction or cerebral apoplexy. There was no case of hemorrhagic shock as a result of operative bloodloss in literature. The incidence of recurrent vaginal vault prolapse after sacrospinous ligament fixation reaches from one to eight percent (Table 4). Typical pelvic support defect after sacrospinous ligament fixation mostly involve the anterior segment. Albrich describes a rate of 19,5% for cystocele in 169 women with a follow-up of 10 years [1]. Other authors reported similar results with the same technique [4, 8, 10, 13, 18, 19, 20, 34, 37]. There seems to be a correlation between time of followup and amount of incidence. Cystocele is conditioned by opening the anterior compartment caused by fixation at the ligament. Some authors showed recurrent rectocele and sometimes an urethral syndrome [11, 15, 18, 32]. Sacrospinous ligament fixation is a safe and effective technique for the management of vaginal vault prolapse. It is possible to execute simultaneous correction of cystocele, rectocele and enterocele by the same route. Also the combination with abdominal or vaginal colposuspension in incontinent women is practicable. But in these cases the operating surgeon have to take care of the different directions of traction. Vaginal sacrospinous ligament fixation usually can be performed in a shorter time implying a shorter hospital stay and decreased postoperative discomfort for the patient.

References 1. Albrich W (1996) Vaginale sakrospinale Fixation – Anatomische Grundlagen, chirurgische Technik und Ergebnisse. Gynakologe 29:665–670 2. Amreich J (1951) Ätiologie und Operation des Scheidenstumpfprolapses. Wien Klin Wochenschr 63:74–77 3. Arthur HG, Savage D (1957) Uterine prolapse and prolapse of vaginal vault treated by sacral hysteropexy. J Obstet Gynecol Br Emp 64:355–360 4. Backer Jr MH (1992) Success with sacrospinous suspension of the prolapsed vaginal vault. Surg Gynecol Obstet 175:419–420 5. Barksdale PA, Gasser RF, Gauthier CM, Elkins TE, Wall LL (1997) Intraligamentous nerves as a potential source of pain after sacrospinous ligament fixation of the vaginal apex. Int Urogynecol J PElvic Floor Dysfunct 8:121–125 6. Beecham CT (1980) Classification of vaginal relaxation. Am J Obstet Gynecol 136:957–958

7. Burch JC (1961) Urethrovaginal fixation to Cooper’s ligament for correction of stress incontinence, cystocele and prolapse. Am J Obstet Gynecol 81:281–290 8. Carey MP, Slack MC (1994) Vaginal vault prolapse. Br J Hosp Med 51:47–420 9. Chapin DS (1997) Teaching sacrospinous colpopexy. Am J Obstet Gynecol 177:1330–1336 10. Cruikshank SH, Cox DW (1990) Sacrospinous ligament fixation at the time of transvaginal hystrectomy. Am J Obstet Gynecol 162:1611–1619 11. Dellas A, Almendral AC (1995) Zur operativen Behandlung des Scheidenvorfalls nach Hysterektomie. Geburtshilfe Frauenheilkd 55:244–246 12. Holley RL, Varner RE, Gleason BP, Apffel LA, Scott S (1995) Recurrent pelvic support defects after sacrospinous ligament fixation for vaginal vault prolapse. J Am Coll Surg 180: 444–448 13. Imperato E, Aspesi G, Rovetta E, Presti M (1992) Surgical management and preention of vaginal vault prolapse. Surg Gynecol Obstet 175:233–237 14. Ingleman-Sundberg A (1952) Urinary incontinence in women, excluding fistulas. Acta Obstet Gynecol Scand 31:266–275 15. Kettel LM, Hebertson RM (1989) An anatomic evaluation of the sacrospinous ligament colpopexy. Surg Gynecol Obstet 168–173 16. Lane FE (1962) Repair of post-hysterectomy vaginal vault prolapse. Obstet Gynecol 20:72–77 17. Miller NF (1927) A new method of correcting complete inversion of the vagina with or without complete prolapse, two cases. Surg Gynecol Obstet 44:550–554 18. Miyazaki FS (1987) Miya Hook ligature carrier for sacrospinous ligament suspension. Obstet Gynecol 70:286–288 19. Monk BJ, Ramp H, Montz FJ, Febherz TB (1991) Sacrospinous fixation for vaginal vault prolapse. Complications and results. J Gynecol Surg 7:87–92 20. Morley GW, DeLancey JO (1988) Sacrospinous ligament fixation for eversion of the vagina (see comments). Am J Obstet Gynecol 158:872–881 21. Nichols D (1982) Sacrospinous fixation for massive eversion of the vagina. AM J Obstet Gynecol 142:901–904 22. Nichols DH (1992) Enterocele and massive eversion of the vagina. In: Thompson JD, Rock JA (eds) TeLind’s operative gynecology. Lippincott, Philadelphia 23. Nichols DH (1993) Massive eversion of the vagina. Technique of transvaginal sacrospinous fixation. In Nicholson DH (ed) Gynecologic and obstetric surgery. Mosby, St Luis 24. Paraiso MF, Ballard LA, Waltrs MD, Lee JC, Mitchinson AR (1996) Pelvic support defects and visceral and sexual function in women treated with sacrospinous ligament suspension and pelvic reconstruction. Am J Obstet Gynecol 175: 1423–1431 25. Pasley WW (1995) Sacrospinous suspension: a local practitioner’s experience. Am J Obstet Gynecol 173:440–448 26. Penalver M, Mekki Y, Lafferty H, Escobar M, Angioli R (1998) Should sacrospinous ligament fixation for the management of pelvic support defects be part of a residency program procedure? The University of Miami experience. Am J Obstet Gynecol 178:326–329 27. Randall C, Nichols D (1971) Surgical treatment of vaginal prolapse. Obstet Gynecol 38:327–332 28. Raz S (1981) Modified bladder neck suspension for female stress incontinence. Urology 17:82 29. Richter K (1963) Die Prophylaxe und Therapie des Scheidenvorfalles nach Uterusexstirpation. Geburtshilfe Frauenheilkd 23:1063–1080 30. Richter K (1967) Die operative Behandlung des prolabierten Scheidengrundes nach Uterusexstirpation. Ein Beitrag zur Vaginaefixatio sacrotuberalis nach Amreich. Geburtshilfe Frauenheilkd 27:941–954 31. Richter K, Albrich W (1981) Long term results following fixation of the vagina on the sacrospinal ligament by the vaginal route. Am J Obstet Gynecol 141:811–816

25 32. Ridley JH (1976) A composite vaginal vault suspension using fascia lata. Am J Obstet Gynecol 126:590–595 33. Sederl J (1958) Zur Operation des Prolapses der blind endigenden Scheide. Geburtshilfe Frauenheilkd 18:824–828 34. Shull BL, Capen CV, Riggs MW, Kuehl ThJ (1992) Preoperative and postoperative analysis of site-specific pelvic support defects in 81 women treated with sacrospinous ligament suspension and pelvic reconstruction. Am J Obstet Gynecol 166:1764–1771

35. Stamey TA (1973) Endoscopy suspension of the vesical neck for urinary incontinence. Surg Gynecol Obstet 136:547 36. Symmonds RE, Pratt JH (1960) Vaginal prolapse following hysterectomy. Am J Obstet Gynecol 79:899–909 37. Veronikis DK, Nichols DH (1997) Ligature carrier specifically designed for transvaginal sacrospinous colpopexy. Obstet Gynecol 89:478–481 38. Zweifel P (1892) Vorlesungen über klinische Gynäkologie. Hirschwald, Berlin