Apical vault repair, the cornerstone or pelvic vault reconstruction

Abstract

Pelvic organ prolapse remains a difficult problem for pelvic reconstructive surgery. Before new surgical procedures can be developed a good understanding of pelvic anatomy is necessary. It is widely held that the etiology of pelvic organ prolapse is secondary to stretch neuropathy following childbirth and chronic cough or constipation. Several transvaginal and transabdominal procedures have been developed over the years. With the increasing use of laparoscopy, a new variation on existing culdeplasty techniques has been developed. Following anatomical principles, the apical vault repair reestablishes the pericervical ring at the vaginal apex. The incorporation of pubocervical fascia, uterosacral-cardinal ligament and the rectovaginal fascia provides a strong anchor for the vaginal apex. In addition, the repair should help prevent future transverse cystocele, rectocele, enterocele and apical vault prolapse. Early outcome studies suggest that the apical vault repair should be used routinely with laparoscopic urethropexy, laparoscopic hysterectomy and the repair of pelvic organ prolapse. Good apical vault support is considered the cornerstone of pelvic reconstruction.

Uterine preservation during surgery for uterovaginal prolapse: a review

“…Ross later described the pericervical fascia as the cornerstone of pelvic reconstruction [9]; this structure, however, is not always addressed during vaginal hysterectomy with anterior and posterior colporrhaphy. Since that time, various authors have reported their experiences with reconstructive pelvic surgery with uterine preservation.…”

Post-hysterectomy vaginal vault prolapse

“…3,5,6 The reconstruction of the vaginal tube requires that the upper edges of the pubocervical and rectovaginal fascia should be closed; reestablishing suspension requires that the repaired vagina be suspended to a normal segment of the cardinal/uterosacral ligament complex 3,5,6 ( Figure 4) or some other procedure like sacrocolpopexy or sacrospinous fixation. 5 Good apical vault support is the corner stone of pelvic reconstruction 7 when this is achieved, repair of level II support failure to reattach the rectovaginal fascia laterally to the iliococcygeal fascia and/or attach the pubocervical fascia anteriorly to arcus tendinous fascia pelvis (paravaginal repair) should be considered. 3,5,6 Concurrent anterior and/or posterior repair of midline fascial defect is also undertaken when appropriate.…”

“…17,18,19,20 The abdominal approach includes sacrocolpopexy 1,21,22 and abdominal uterosacral suspension. 21 Laparoscopic sacrocolpopexy 7 and laparoscopic uterosacral suspension have also been described. 3,6 Transvaginal uterosacral suspension…”

“…Concurrent plication of uterosacral ligaments or other forms of culdoplasty have been advocated to prevent later formation of enterocele below the vault suspension. 1,6,7,25 Different types of meshes have been used: Marlex®, Gore-Tex®, Mersilene®, Teflon® and Prolene®. The results and the complications, mainly mesh erosion, are similar.…”

“…The proponents of the laparoscopic approach 6,31 argue that it gives better vision, a global view of the pelvis and clearer definition of fascial defects thus allowing a rational repair. The principles of treatment are the same 3,6,7,31,32 as for open surgical techniques.…”