Grand Rounds

What is the Best Approach to Repair Vaginal Vault Prolapse following Hysterectomy?

BACKGROUND AND PURPOSE:

There is lack of high level evidence regarding best approach to repair vaginal vault prolapse following hysterectomy
Malika et al. (Female Pelvic Medicine & Reconstructive Surgery, 2017) compared vaginal, open and robotic surgical approaches for the management of posthysterectomy vaginal vault prolapse

Questionnaire-based retrospective study
Patients who had undergone surgery for posthysterectomy apical vaginal prolapse
Three techniques compared
- Mayo-McCall culdoplasty (MMC)
- Open abdominal sacrocolpopexy (ASC)
- Robotic sacrocolpopexy (RSC)
Baseline characteristics and perioperative outcomes were abstracted from electronic health records
Validated questionnaires were used to do cross sectional data for current pelvic floor symptoms
Survival free of retreatment was estimated with Kaplan-Meier method

337 people completed at least a validated or abbreviated questionnaire
Overall, there were no differences when comparing long-term posttreatment symptoms and quality of life among the 3 groups but some domain differences
Urogenital Distress: MMC group had a greater median score (more distress) than patients who had undergone ASC (20.8 vs 8.3, P=0.02)
Colorectal-Anal Distress: MMC had a greater median Colorectal-Anal Distress score (18.8 vs 12.5, P=0.04) compared to RSC
- Otherwise, there were no significant differences in the long-term posttreatment symptoms and quality of life between these 2 procedures
There was no significant difference in 5-year survival free of retreatment for MMC (94.0%) versus RSC (95.5%) and ASC (94.8%) versus RSC (92.1%)
However, patients who had MMC were more likely to have retreatment than patients who had ASC during the first 10 years
- 10-year survival free of retreatment: 81.1% vs 95.4%; hazard ratio, 3.68 (95% CI 1.51–8.98)
Authors recommend long-term follow up under the AUGS Registry

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