Posterior vaginal compartment repairs: Where are the main anatomical defects?

INTRODUCTION AND HYPOTHESIS: Traditionally, it has been believed that posterior vaginal compartment prolapse was largely due to defects in the rectovaginal fascia, with surgical repairs concentrating on addressing this defect. We aimed to determine the relative size of defects at the different vaginal levels (I-III) following a large number of posterior vaginal compartment repairs (PRs) to determine whether this traditional viewpoint is still appropriate. METHODS: In a cross-sectional study of 300 consecutive PRs, mostly following prior or concomitant hysterectomy, two sets of markers of posterior compartment prolapse were used to measure anatomical defects at levels I-III: (i) from Pelvic Organ Prolapse Quantification (POP-Q) system points C, Ap, Bp, and genital hiatus (GH), and from Posterior Repair Quantification (PR-Q) perineal gap (PG), posterior vaginal-vault descent (PVVD), midvaginal laxity (MVL)-vault undisplaced, and rectovaginal fascial laxity (RVFL). RESULTS: The largest defects were found at level I (PVVD: mean 6.0 cm; point C, mean minus 0.9 cm), and level III (PG, mean 2.9 cm; GH, mean 3.7 cm). Level II defects (MVL-vault undisplaced, mean 1.3 cm; RVFL, mean 1.1 cm; points Ap, Bp, both mean 1.0 cm) were relatively small. CONCLUSIONS: This study suggests that the defects found at surgery for posterior vaginal compartment prolapse were more frequent at the vaginal vault (level I) and vaginal introitus (level III) than at midvagina (level II). These findings should have implications for surgical planning.

Perineorrhaphy quantitative assessment (Pe-QA).

INTRODUCTION AND HYPOTHESIS: Perineorrhaphy (Pe) has not been subject to a comprehensive perioperative quantitative assessment (QA). We wish to nominate such an assessment (Pe-QA) for any Pe, through testing the QA on the excision of the perineal gap (PG) at the time of posterior repair (PR). METHODS: At 50 consecutive PRs, the following measurements were taken pre- and postoperatively: (i) perineorrhaphy width (PW) equals PG [1]; (ii) perineorrhaphy depth (PD); (iii) perineal length (PL); (iv) midperineal thickness (MPT); (v) genital hiatus (GH) and (vi) total posterior vaginal length (TPVL). The total vaginal length was also measured. Surgical details deemed appropriate to each repair were recorded. RESULTS: The overall means and ranges (cm) were: (i) PW 2.9 (1.5-5.5); (ii) PD 1.6 (0.8-2.0); (iii) PL 2.9 (1.5-4.5); (iv) MPT 0.7 (0.4-1.1); (v) GH 3.9 (2.3-6.5); (vi) TPVL 9.2 (6.0-12.5). Excision of PG (100 % cases reducing PW and PD to zero) resulted in a mean 23.6 % increase in total vaginal length over that if the repair was commenced at the hymen, despite a 3.3 % decrease in the TPVL perioperatively. There was a mean 30.8 % reduction in the GH, a mean 27.6 % increase in the PL and a mean 57.1 % increase in the MPT. CONCLUSIONS: Pe and the anatomical results of such surgery can be subject to quantitative assessment allowing comparison studies between different forms of Pe and possibly other types of perineal surgeries.

Posterior repair quantification (PR-Q) using key anatomical indicators (KAI): preliminary report.

INTRODUCTION AND HYPOTHESIS: Posterior vaginal compartment repairs (PR) have traditionally involved a subjective approach. We aim to quantify such repairs using key anatomical indicators (KAI). METHODS: At 50 consecutive PRs: perineal gap (PG); posterior vaginal vault descent (PVVD); mid-vaginal laxity (MVL-vault undisplaced/displaced); and recto-vaginal fascial laxity (RVFL) were measured. The total posterior vaginal length (TPVL) and from POP-Q, TVL, GH, Ap, Bp C, D were also measured. Surgical details deemed appropriate to each repair were recorded. RESULTS: A mean preoperative PG of 2.5 cm was reduced to 0.0 cm postoperatively by excision (100 % cases) with an average increase of 21.6 % in total vaginal length over that if the repair was commenced at the hymen. There was an average reduction of 25.0 % in the genital hiatus (GH). Mean PVVD was 5.3 cm overall; 6.4 cm for 31 out of 50 (62 %) undergoing sacrospinous colpopexy; 3.5 cm for 19 out of 50 (38 %) with no ligamentous vault fixation. An approximate "cut-off" for PVVD of 5 cm may assist with the differentiation of cases where vault fixation may be desirable. Up to 52 % (1.4/2.7 cm) of preoperative MVL displacement was due to vaginal vault descent. The MVL undisplaced (mean 1.3 cm) may better guide vaginal mucosal trimming. RVFL averaged just 0.8 cm with 22 out of 50 (44 %) RVFL being 0.5 cm or less, and not requiring any RVF plicatory sutures. CONCLUSIONS: It is possible to use KAI to assist the planning and execution of posterior vaginal compartment surgery. The PG, PVVD, MVL, and RVFL can indicate surgical measures in the perineum, vaginal vault, vaginal mucosa, and recto-vaginal space respectively.

A preliminary anatomical basis for dual (uterosacral and sacrospinous ligaments) vaginal vault support at colporrhaphy. Dual-balanced vaginal vault support at colporrhaphy.

INTRODUCTION AND HYPOTHESIS: This study aims to assess anatomically the likely effects of dual vaginal vault support using the uterosacral (USL) and sacrospinous ligaments (SSL) at colporrhaphy. METHODS: Observations were made from 13 formalinized cadaver hemipelves to determine the vaginal vault support likely to be provided by traction on the (a) USLs and (b) the posterior vaginal vault towards the SSL. RESULTS: Traction on the USLs and SSLs both appeared to create a posterior and superior vector of vaginal vault tension, though that on the USLs appeared to be mainly on the anterior vaginal vault (and wall) with that on the SSL seemingly mostly on the posterior vaginal vault (and wall). CONCLUSIONS: Concomitant USL and SSL traction on the vaginal vault, now technically possible, appears, from these preliminary findings, to give complementary support to the anterior and posterior aspects of the vaginal vault and walls in a similar posterior and superior vector.

A standardised ultrasonic diagnosis and an accurate prevalence for the retroverted uterus in general gynaecology patients.

Transvaginal ultrasound with an empty bladder is recommended as a standardised ultrasonic technique for the accurate diagnosis of the retroverted uterus. Using this method, the prevalence of the retroverted uterus in 480 general gynaecological patients attending for subspecialist gynaecological ultrasound was 18%. The anteverting effect of the full bladder required for transabdominal ultrasound reduces the prevalence of the retroverted uterus to 13% (P < 0.001).