Anatomical and functional results of McCall culdoplasty in the prevention of enteroceles and vaginal vault prolapse after vaginal hysterectomy

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1 Int Urogynecol J (2008) 19: DOI /s ORIGINAL ARTICLE Anatomical and functional results of McCall culdoplasty in the prevention of enteroceles and vaginal vault prolapse after vaginal hysterectomy Gautier Chene & Anne-Sylvie Tardieu & Denis Savary & Mikael Krief & Carole Boda & Marie-Claude Anton-Bousquet & Aslam Mansoor Received: 28 June 2007 / Accepted: 14 December 2007 / Published online: 15 January 2008 # International Urogynecology Journal 2007 Abstract The objective of the study is to evaluate the anatomical and functional results of the McCall culdoplasty in the treatment of moderate hysterocele and the prevention of enterocele and vaginal vault prolapse after vaginal hysterectomy. Using a modified McCall procedure, 185 patients underwent vaginal hysterectomy for mild or moderate uterine prolapse. Pre- and post-operative assessments were carried out using the International Continence Society staging system. The 24-month follow-up showed stable 89.2% incidence of stage 0 vaginal vault prolapse (point C) and a 10% incidence of stage 1 vaginal vault prolapse that was well tolerated and did not require revision surgery. Functional analysis showed satisfactory sexual function at 24 months post-surgery for 81.2% of patients. The McCall culdoplasty did not lead to a disruption of the vaginal axis and gave excellent anatomical and functional results in maintaining support after vaginal hysterectomy, especially in sexually active patients. Keywords McCall culdoplasty. Enterocele. Vaginal hysterectomy. Uterovaginal prolapse. Vaginal vault prolapse. Cystocele G. Chene (*) Obstetrics & Gynecology, North Hospital, CHU, St Etienne, France chenegautier@yahoo.fr A.-S. Tardieu : D. Savary : M. Krief : C. Boda : M.-C. Anton-Bousquet : A. Mansoor Obstetrics & Gynecology, Issoire Hospital, Issoire, France Introduction Enterocele and vaginal vault prolapse account for up to 16% of the mid-term and long-term complications associated with curative surgery for urogenital prolapse in vaginal hysterectomy [1]. Both these complications carry the risk of modifying the normal vaginal axis and thereby decompensating the superior and posterior vaginal wall, which in turn will cause a recurrence of the original urogenital prolapse. Furthermore, with the hernia represented by the enterocele, there is a risk of obstruction or incarceration of the bowel loops [2]. An enterocele is a peritoneal pouch that normally contains loops of small intestine or omentum and progressively disrupts the recto-vaginal Denonvilliers fascia (level II). Vaginal vault prolapse is not necessarily associated with enterocele but is rather the consequence of weak floor muscles allowing the uterosacral and cardinal ligaments to slip into the paracolpium (level I) [3]. In both cases, the predisposing causes include perineal obstetrical and surgical trauma (tears in the upper vaginal fascia) and abdominal hyperpressure (obesity, persistent constipation, and chronic cough). There are several surgical procedures that have been described as preventing vaginal vault prolapse and enterocele. This retrospective study reports the mid-term anatomical and functional results of a modified McCall culdoplasty technique. Materials and methods Our data were taken from a computer database containing the case files of 690 patients who underwent curative vaginal hysterectomy for mild or moderate hysterocele with

2 1008 Int Urogynecol J (2008) 19: Table 1 Pre-operative demographic characteristics of patients; the values are means, with extremes given in brackets (n=185) Means Age 60 (33 92) BMI (kg/m 2 ) ( ) Parity 2 (0 11) Birth weight of baby >4,000 g 20 (10.8%) Persistent constipation 4 (2%) Chronic cough 6 (3%) curative treatment for associated urogenital prolapse between 1998 and 2005 by two physicians. Cystocele and rectocele repair were done either with autologous tissue or Prolene mesh (Ethicon, Johnson & Johnson, USA). All the patients who had undergone vaginal hysterectomy for uterine prolapse with shortening of uterosacral, cardinal ligaments, and uterosacral ligament fixation of the posterior vaginal fornix using a modified McCall technique during this period were enrolled. All pre- and post-operative examinations systematically included a standardized medical interview primarily focused on screening for urogynecological and (or) digestive disorders and dyspareunia, together with a quality-of-life assessment based on the conti-life scale [4]. A full clinical urogenital examination was performed, assessing pelvic disorders under effort with Valsalva's maneuver and at rest. A pre-operative clinical urogynecological examination was systematically carried out to collect the preoperative clinical data. The clinical assessments complied with the International Continence Society (ICS) pelvic organ prolapse quantification staging systems. For greater accuracy, the measurements were carried out using a flexible graduated hysterometer (Flexible Hysterometer CH 10 ref 1502S10, CCD international, France). Each patient was seen and examined at 2, 12 15, and 24 months post-operatively. In addition to an interview and the quality-of-life questionnaire, a complete urogynecological examination was carried out to assess pelvic static, with special emphasis on the posterior superior vaginal segment and all other secondary decompensation. Vaginal length was measured from the introitus to the vaginal vault using a flexible graduated hysterometer. The quality of sexual activity was assessed using specific questioning to estimate the severity of any dyspareunia and whether sexual activity had stopped. Since the description of the McCall culdoplasty technique [5], many modifications of McCall original technique have been described ( external and internal McCall) [6]. This modified McCall culdoplasty technique was used during hysterectomy (peritonization was performed by closure of the pouch of Douglas by means of a pouch string suture (Prolene 0)), with intraperitoneal hitching of only uterosacral ligaments without taking the cardinal ligaments in the suture, thus keeping the ureters distant from the peritoneal suture. In contrast to the original McCall technique, a suture was placed on each side, incorporating the vagina and the uterosacral pedicles in a semipouch string fashion. The effect of this suture was to suspend the posterior vagina to the uterosacral ligaments on each side, while at the same time maintaining sufficient vaginal length. Success criteria The criteria used to compare results were the same as those of Montella and Morrill [7]. After the McCall culdoplasty, we considered a vaginal vault at point C (< 2 cm) or stage 0 as a successful outcome. The other cases were classified as failures, even when there was an improvement over the pre-operative situation. Results A total of 185 patients underwent vaginal hysterectomy for mild or moderate uterine prolapse. McCall culdoplasty was systematically carried out. Associated with this surgery were 122 curative treatments for cystocele, 140 for urinary incontinence, and 117 for rectocele. Sixty-three patients presented no cystocele, 68 no rectocele, and underwent vaginal hysterectomy with or Table 2 Associated surgical procedures performed with vaginal hysterectomy and McCall culdoplasty, intra-operative complications, and post-operative data Post-operative data Treatment for cystocele 122 Halban fascioplasty 74 (60.6%) Intervesico-vaginal mesh 48 (39.3%) Suburethral sling (TVT or TOT) 140 Treatment for rectocele 117 Levator ani myorrhaphy + denonvilliers 73 (62.3%) prerectal plication Denonvilliers prerectal plication alone 44 (37.6%) Intra-operative complications Bladder injury 2 (1.1%; 1 TVT; 1 cystocele repair) Rectal injury 1 (0.5%; posterior repair) Blood loss >500 ml 2 (1.1%; without any transfusion) Post-operative data Length of hospital stay 6.1 days (2 21) Urinary infection 14 (7.5%) Perineal abscess 1 (0.5%)

3 Int Urogynecol J (2008) 19: Table 3 Pre- and post-operative ICS stage of the uterus and posthysterectomy cuff (n=185). Post-operative ICS stage of cystocele (n=63) and rectocele (n=68) of patients who presented no pre-operative cystocele or rectocele Vaginal vault: point C Stage 0 10 (5.4%) 185 (100%) 167 (90.2%) 158 (89.2%) Vaginal vault: point C Stage (65.4%) 0 17 (9.2%) 18 (10%) Vaginal vault: point C Stage 2 49 (26.5%) 0 1 (0.6%) 1 (0.6%) Vaginal vault: point C Stage 3 5 (2.7%) Lost to follow-up (4.3%) Cystocele (n=63) Stage (3%) 1 (1.5%) Stage (1.5%) Stage Rectocele (n=68) Stage (1.5%) Stage (3%) 2 (3%) Stage without curative treatment for urinary incontinence using suburethral TVT or transobturator tape (Table 3). A routine cystoscopy visualizing urine flow from ureters is performed at the end of the operation. The demographic data are summarized in Table 1. Surgical details, operative complications, and post-operative data are given in Table 2. Anatomical results All the patients were seen again 2, 12 15, and 24 months post-operatively. The vaginal vault remained entirely in place in 90.2% of cases at months, and subsequently at 24 months. Stage 1 decompensation involved only 9.2% of cases at 12 months and 10% at 24 months (Table 3). However, it caused no functional symptoms. The one patient with stage 2 needed no surgical treatment. Analysis of the possible occurrence of cystocele and rectocele (secondary decompensation) involved only the patients who showed no urogenital prolapse. There were 3% of cystoceles and 4.5% rectoceles at 24 months involving the patients who presented no pre-operative cystocele or rectocele. In this group, lower digestive symptoms were infrequent and involved 1% for rectal pressure, 1.6% for terminal constipation, and 4.2% for incomplete emptying of the rectum. The results are set out in Tables 3 and 4. Functional results On the 85 sexually active patients post-operatively, only five patients (5.8%) suffered from deep dyspareunia at 2 months, but there was no vaginal stenosis. At 12 months, these cases of deep dyspareunia vanished in four patients, and persisted, without being incapacitating, in one patient (Table 5). Eight (9.4%) other patients reported intromission dyspareunia at 2 months, and 0 at 12 and 24 months. We retained intromission dyspareunia only after the correction of vulvo-vaginal dryness with local oestrogeneotherapy. Post-operative vaginal length (measured by flexible graduated hysterometer) was preserved for 177 patients (9 10 cm) and less than 7 cm only in eight patients (9.4%). Six of them were not sexually active pre-operatively. In the two remaining patients, there was no correlation between short vagina and sexual life. Functional analysis showed satisfactory sexual function at 24 months post-surgery for 81.2% of patients. Discussion Our study records excellent results at 12 months confirmed at 24 months: the McCall culdoplasty technique using nonabsorbable suture, thus, seems to be very effective in Table 4 Lower digestive symptoms for the 68 patients who received no treatment for rectocele Rectal pressure 1 (1.5%) 2 (2.9%) 2 (2.9%) 2 (2.9%) Terminal constipation 3 (4.4%) 3 (4.4%) 2 (2.9%) 3 (4.4%) Incomplete emptying of the rectum 4 (5.9%) 6 (8.8%) 6 (8.8%) 8 (11.7%)

4 1010 Int Urogynecol J (2008) 19: Table 5 Characteristics of pre- and post-operative sexual activity (n=85) Sexual activity 85 (100%) 85 (100%) 85 (100%) 77 (90.5%) Satisfactory sexual activity 80 (94%) 72 (84.7%) 74 (87%) 69 (81.2%) Intromission dyspareunia 0 8 (9.4%) 0 0 Deep dyspareunia 1 (1.2%) 5 (5.8%) 1 (1.2%) 1 (1.2%) supporting the vaginal vault. Our results are consistent with those of other reports: 90% success at 12 months for Montella and Morrill [7], 90.9% at 24 and 36 months for Cruikshank and Kovac [2], and 93.5% for Colombo and Milani [8](Table 6). These excellent results probably derive from the durable reconstruction of the vaginal vault by the hitching of the uterosacral and cardinal ligaments, which ensures an efficient suspension of the posterior superior vagina and maintenance of the physiological length and axis of the vagina. But, if the McCall culdoplasty is an efficient technique for moderate prolapse, the number of severe prolapse in our series (n=54) seems to be too small to give definitive conclusions for all stages. However, like Montella and Morrill [7], we recorded only those patients who presented no prolapse of the vaginal vault or prior enterocele and who had undergone preventive culdoplasty and vaginal vault fixation. The other studies recorded different populations presenting complex urogynecological prolapses with associated prolapse of the vaginal vault (but with no clear indication of the pre-operative staging), in which case McCall culdoplasty is then considered to be curative, and consequently the results need to be moderated. In another unpublished series distinct from the one we present here, there were three cases of ureteral complications that required surgery, with ureteral reimplantation in one case. In addition, a fourth patient presented dyspareunia linked to a constriction of the vaginal vault that had to be dealt with surgically. These four cases lie outside the scope of our study, as these patients presented a prior prolapse of the vaginal vault. Concerning the risk of enterocele, the diagnosis is usually made from a clinical picture of lower digestive symptoms with rectal pressure, terminal constipation, and incomplete emptying of the rectum [9]. However, (a) the rates are practically identical to the pre-operative rates in our subgroup without rectocele, and (b) some authors consider that these lower digestive symptoms are in no way specific to an enterocele [10]. The absence of a direct connection between digestive symptoms and McCall culdoplasty could therefore be expected. Other techniques have also been described: Richter sacrospinous ligament fixation [11], which is very effective for the treatment of vaginal vault prolapse, remains controversial for prevention, as it shifts the vaginal axis and can lead to up to 22% decompensation of the anterior level [8, 12]. Considering the subgroup of 63 and 68 patients in our series, we observed no decompensation of anterior (only 3%) and (or) posterior levels (only 4.5%), probably because of the preservation of the vaginal length and axis, which is consistent with the scant data reported in the literature on this subject. In addition, sacrospinous ligament fixation is a more delicate technique that carries a risk of vascular and nervous system complications (sciatic and pudendal lesion and damage to perirectal vessels) [11, 13]. The few studies Table 6 Post-operative ICS stage of the posthysterectomy cuff (review of the literature) 2 months 12 months 24 months 36 months months Our study Stage 0 100% (185/185) 90.2% (167/185) 89.2% (158/177) Stage I 9.2% (17/185) 10% (18/177) Stage II 0.6% (1/185) 0.6% (1/177; 8 drop out Montella and Morrill [5] Stage 0 100% (43/43) 90% (39/43) Stage I 7% (3/43) Stage II 3% (1/43) Cruikshank and Kovac [2] Stage I 100% (33/33) 91% (30/33) 91% (30/33) Stage II 6% (2/33; 1 dropout) 6% (2/33; 1 dropout) Colombo and Milani [6] Stage % (58/62) Stage II 5% (3/62; 1 dropout)

5 Int Urogynecol J (2008) 19: that have compared the McCall and Richter techniques have concluded that the McCall technique is to be preferred [8]. Likewise, McCall culdoplasty also proves more efficacious than a simple peritoneal suture of the vaginal vault or a Moschcowitz type culdoplasty [2]. In addition to these very good anatomical results, the McCall technique gives equally good functional results with a satisfactory sexual function at 24 months postsurgery for 81.2% of patients. Our results are consistent with those of Colombo and Milani who found a sexual activity maintained with no dyspareunia in 75% [8]. Instances of intromission dyspareunia were resolved at 12 months and can probably be explained by complications arising from perineorrhaphy (scarring tissue of the perinal body, narrowing of the introitus during posterior colporrhaphy, or perineorrhaphy). Cases of deep dyspareunia practically disappeared at 12 months post-operatively and can probably be explained by the healing process or vulvovaginal dryness corrected by the application of vaginal suppositories and a topical estrogen-based moisturizer (local estrogenotherapy) [14]. We found no correlation between post-operative vaginal length and deep dyspareunia: Of the eight patients with a vaginal length of less than 7 cm, none complained of deep dyspareunia. By contrast, two patients with deep dyspareunia had a measured vaginal length of 10 cm. No immediate, early, or late complications arising from narrowing of the vaginal vault were recorded. So, vaginal anatomy measured by length does not seem to be correlated well with sexual function, particularly symptoms of deep dyspareunia and vaginal dryness [15]. Conclusion The McCall technique ensures a secure hold for the vaginal vault during vaginal hysterectomy for the treatment of mild and moderate uterine prolapse. It rebuilds a support for the vaginal vault by tying up the complex formed by the uterosacral-cardinal ligaments. The McCall culdoplasty proved both anatomically and functionally efficient for the prevention of vaginal vault prolapse and enterocele after vaginal hysterectomy. Conflicts of interest References None. 1. Ranney B (1981) Enterocele, vaginal prolapse, pelvic hernia: recognition and treatment. Am J Obstet Gynecol 140: Cruikshank SH, Kovac R (1999) Randomized comparison of three surgical methods used at the time of vaginal hysterectomy to prevent posterior enterocele. Am J Obstet Gynecol 180: DeLancey JOL (1992) Anatomic aspects of vaginal eversion after hysterectomy. Am J Obstet Gynecol 166: Amarenco G, Arnould B, Carita P, Haab F, Labat JJ, Richard F (2003) European psychometric validation of the CONTILIFE : a quality of life questionnaire for urinary incontinence. Eur Urol 43 (3): McCall ML (1957) Posterior culdeplasty: surgical correction of enterocele during vaginal hysterectomy; a preliminary report. Obstet Gynecol 10: Lee Ra (1992) Atlas of gynecologic surgery. WB Saunders, Philadelphia 7. Montella JM, Morrill MY (2005) Effectiveness of the McCall culdeplasty in maintaining support after vaginal hysterectomy. Int Urogynecol J 16: Colombo M, Milani R (1998) Sacrospinous ligament fixation and modified McCall culdoplasty during vaginal hysterectomy for advanced uterovaginal prolapse. Am J Obstet Gynecol 179: Holley RL (1994) Enterocele: a review. Obstet Gynecol Surv 49: Chou Q, Weber AW, Piedmonte MR (2000) Clinical presentation of enterocele. Obstetv Gynecol 96: Richter K (1982) Massive eversion of the vagina: pathogenesis, diagnosis, and therapy of the true prolapse of the vaginal stump. Clin Obstet Gynecol 25: Carey MP, Slack MC (1994) Transvaginal sacrospinous colpopexy for vault and marked uterovaginal prolapse. Br J Obstet Gynaecol 101: Alevizon SJ, Finan MA (1996) Sacrospinous colpopexy: management of postoperative pudendal nerve entrapment. Obstet Gynecol 88: Given FT, Muhlendorf IK, Brownong GM (1993) Vaginal length and sexual function after colpopexy for complete uterovaginal eversion. Am J Obstet Gynecol 169: Weber AM, Walters MD, Shover LR, Mitchinson A (1995) Vaginal anatomy and sexual function. Obstet Gynecol 86: