Poster 49: High Uterosacral Ligament Fixation with Porcine Dermis Graft Augmentation for Vaginal Vault Suspension: A Clinical Study

OBJECTIVE: We describe a new technique in the surgical treatment of symptomatic vaginal vault prolapse using porcine dermis (PD) to augment the site-specific defect repair of pubocervical fascia (PCF) and rectovaginal fascia (RVF) utilizing the proximal uterosacral ligaments (PUL) for vaginal repair. METHODS: A retrospective chart review identified all patients who had surgical repair of the vaginal vault prolapse by suspension of the vagina to the PUL bilaterally augmented by PD graft from August 2001 to December 2004. All patients underwent postoperative site-specific examinations on follow up. TECHNIQUE: A midline transverse incision is made in the vaginal epithelium at the apex of the cuff and the epithelium is opened to identify the enterocele sac. The sac is dissected from surrounding tissue, entered and repaired using a purse-string suture of 0-Vicryl high in the sac neck. The PUL is identified bilaterally. In cases of attenuated or absent PUL, the ischial spine is palpated on either side and a 1–0 PDS suture is placed at approximately 1 cm medial and posterior to the ischial spine on either side. Similarly, two 1–0 PDS sutures are placed to the PCF anteriorly at about 1 and 11 o'clock, and 2 posteriorly at about 3 and 9 o'clock to the RVF, providing a total of 6 fixation points. A 4 X 7 cm PD graft is trimmed to cover the defect, securing it by the previously described sutures. The PCF and RVF sutures are tied bringing the graft in contact with the reduced enterocele. Both ends of the PUL sutures are threaded through the graft at approximately the 5 and 7 o'clock position, and through the vagina on both sides. Any concurrent anterior or posterior vaginal wall repairs are performed and routine closure of the vaginal wall is performed. The PUL sutures are then tied, fixing the vagina to the PUL and maintaining a symmetrical midline position. A cystoscopy with injection of IV indigo blue is performed to document integrity of the ureters and bladder. RESULTS: Sixteen patients with symptomatic vaginal vault prolapse underwent suspension of the vagina to PUL with PD graft augmentation. Posthysterectomy vault prolapse was present in all patients. All had concurrent pelvic floor defect repairs for correction of the anterior and posterior vaginal wall prolapse. Mean age was 69.2 (51–85) years and mean parity was 3 births. Length of procedure was estimated at 40 (30–75) minutes. Mean estimated blood loss was 65 (50–120) mL. Duration of hospital stay was 1.3 (1–3) days. No major intraoperative or postoperative complications were reported. There were no intraoperative injuries and none of the patients required a transfusion. One patient had postoperative febrile morbidity, which responded to intravenous antibiotics. The patients were followed with repeat site-specific examination at an average of 17.5 (6–30) months. Three patients (19%) experienced recurrent defects, involving the apical and anterior vaginal walls. Thirteen (81%) women were noted to have surgical cure on follow-up. CONCLUSIONS: Suspension of the vagina to the PUL with PD graft for repair of vaginal vault prolapse appears to be associated with an acceptable cure rate and minimal complications. The anterior and apical vaginal walls remain susceptible to recurrence. In order to ascertain the effectiveness of this new technique, prospective randomized trials with larger series and longer follow up are warranted.