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

Int Urogynecol J (2016) 27:741 745 DOI 10.1007/s00192-015-2874-7 ORIGINAL ARTICLE Posterior vaginal compartment repairs: Where are the main anatomical defects? Bernard T. Haylen 1 & Sushen Naidoo 2 & Stephen J. Kerr 3 & Chin H. Yong 2 & Warwick Birrell 4 Received: 1 August 2015 /Accepted: 16 October 2015 /Published online: 12 November 2015 # The International Urogynecological Association 2015 Abstract 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 vaginalvault 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 Electronic supplementary material The online version of this article (doi:10.1007/s00192-015-2874-7) contains supplementary material, which is available to authorized users. * Bernard T. Haylen bernard@haylen.co 1 2 3 4 St. Vincent s Clinic, Suite 904, 438 Victoria Street, Darlinghurst 2010, NSW, Australia St. Vincent s Hospital, Darlinghurst, NSW, Australia Kirby Institute, University of New South Wales, Kensington, NSW, Australia Mater Hospital, North Sydney, NSW, Australia (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. Keywords Prolapsesurgery. Posterior vaginal compartment. Pelvic organ prolapse. Key anatomical indicators (KAI). Anatomical defects. Posterior Repair Quantification (PR-Q) Introduction Traditionally, it has been believed that posterior vaginal compartment prolapse was largely due to defects in the rectovaginal fascia (level II [1]). Surgical repairs have tended to concentrate on addressing these defects [2 4] by using either native tissues or augmentation with a prosthesis. Attention to the vaginal introitus (level III [1]) was generally included, although there were uncertainties [2, 3] as to whether the repair at this level should commence at or below the hymen. There has been some evidence for the contribution of vaginal vault defects to anterior level II compartment defects [5]. The main anatomical defects at posterior vaginal compartment repairs (PR) have not, to date, been clearly identified in the literature, leaving uncertainty regarding optimum surgical approaches. Our recent preliminary report [6] of 50 cases examining additional intraoperative measurements at PR [Posterior Repair Quantification (PR-Q)] [6] suggested that the defects at PR seemed to be more frequent at levels I and III than at level II [1].

742 Int Urogynecol J (2016) 27:741 745 We employed a larger study to determine with more certainty the relative size of anatomical defects at the different vaginal levels (I III) at PR. We used two sets of available measurements: (i) Pelvic Organ Prolapse Quantification (POP-Q) [7] and (ii) PR-Q, the latter having recently been described [6]. Patients and methods This was a cross-sectional study of 300 consecutive PRs, mostly following prior or concomitant hysterectomy and concomitant anterior colporrhaphy and was an extension of the study of 50 PR cases used in our preliminary report [6] but focussing on anatomical defects. Data collection was from December 2013 to December 2014 at St. Vincent s and Mater Hospitals, Sydney. Patients were assessed clinically in their rooms using the POP-Q [7] to determine the need for prolapse surgery. All POP-Q [7] and PR-Q [6] measurements were taken immediately prior to the PR and at the end of any concomitant prolapse surgeries. No patients were excluded from PR. Postoperative measurements were not included, as the study objective was to identify the relative size of preoperative anatomical defects at different vaginal levels. The following posterior prolapse markers were measured: (i) from POP-Q [7], points C, Ap, and Bp (point D not included, as the vast majority were posthysterectomy), and genital hiatus (GH); and from PR-Q [6], perineal gap (PG), posterior vaginal-vault descent (PVVD), midvaginal laxity (MVL) vault undisplaced, and rectovaginal fascial laxity (RVFL); MVL vault displaced [6] (by traction) was also measured. Each measurement by the primary surgeon received visual confirmation by an observer/surgical assistant. The bladder was re-emptied prior to this examination to prevent any limitation of aspects of prolapse extent [8]. The four PR-Q markers possibly less familiar to readers are described [6]. 1. Perineal gap: level III The line of the labia minora was visually followed posteriorly until the perineum was reached on either side. At this point, Moynihan (Littlewood) forceps were applied on each side of the labia. Gentle bilateral traction will show any deficient anterior perineum. Closer inspection allows marking (by surgical marker) of the junction of the much-thinned-out area medially and the start of thicker perineal tissue laterally, closer to the forceps. This section between surgical marks is the PG, which was measured with a surgical ruler in centimeters to one decimal point. Figure 1 shows how the PG might be assessed and its width measured. 2. Posterior vaginal-vault descent: level I [1] Total posterior vaginal length (TPVL) [6] was measured from the center of the PG to the vaginal vault. A Fig. 1 Perineal gap (PG): thinned-out medial area (cm) between Moynihan forceps placed bilaterally where the line of the labia minora meets the perineum Moynihan forceps, oriented horizontally, was applied in the midline 1 cm below and posterior to the vaginal-vault line (prior hysterectomy) or junction of the cervix and posterior vaginal vault if the uterus remained in situ. Gentle inferior traction was then placed on the forceps to assess vaginal-vault descent. The distance between the PG and the point of attachment of the Moynihan forceps under maximum displacement was called the perineal gap Moynihan (PGMOYN) distance. PVVD was then calculated using the formula below: PVVD ¼ TPVL PGMOYN Figure 2a shows the TPVL from which the PGMOYN distance (Fig. 2b) needs to be subtracted to determine PVVD. 3. Midvaginal laxity vault undisplaced (level II) [1] Gentle inferior traction on the Moynihan forceps was replaced by slight superior tension toward the vaginal vault steadied by a surgical assistant. This served to stabilize the vaginal vault. The surgeon then placed anterior traction perpendicular to the middle of the posterior vaginal wall using Gillies forceps to determine MVL vault undisplaced, determined by the length (cm) of the anteriorly displaced midvagina over the lateral vagina. Figure 3a demonstrates this measurement technique. Further measurement of the MVL was performed with the vaginal vault in traction, as in Fig. 2b. This was termed MVL vault displaced). 4 Rectovaginal fascial laxity (level II) This potential defect was assessed once posterior vaginal surgery was commenced. Once the PG had been excised, the posterior vaginal wall was opened in the midline up to the Moynihan forceps. Artery forceps were used to support both sides of the incision. The forceps at the apex

Int Urogynecol J (2016) 27:741 745 743 Fig. 2 a, b Posterior vaginal-vault descent (PVVD): subtract distance from inferiorly displaced vaginal vault and perineal gap (PG) (b) from total posterior vaginal length (TPVL) (a) of the incision was again held under slight tension toward the vaginal vault for stabilization. RVFL was measured in a similar way to MVL. A gentle anterior traction on the fascia was applied, and fascia laxity was measured from the midvagina level. Figure 3b demonstrates measurement technique (artery forceps not shown). Baseline demographic and surgical factors assessed were age, parity, weight, height, body mass index (BMI), menopause status, and prior hysterectomy. Surgical initiatives in response to defects were excision of the perineal defect (PG), vaginal-vault suspension with sacrospinous colpopexy (SSC), excision of excess posterior vaginal skin, and rectovaginal fascial plications. These initiatives were performed as per the previous study [6]: 1. Excision of the entire PG 2. SSC if PVVD >5 cm Fig. 3 Midvaginal laxity (MVL) vault undisplaced (a) Vault is held in undisplaced position by Moynihan forceps while anterior traction on the midpoint of the vaginal superoinferiorly is used to demonstrate MVL (cm). Rectovaginal fascial laxity (RVFL): Similar to a, though measurement of the RVFL occurs once the posterior vaginal wall has been opened to the apical Moynihan forceps (b ) 3. Vaginal skin excision under half MVL vault undisplaced 4. Rectovaginal fascial plication if RVFL >0.5 cm Surgical materials and techniques used were identical for all 300 patients. The posterior vaginal skin was sutured down to the surgical marks for the PG using a 1/0 Vicryl suture. For perineorrhaphy, 2/0 Vicryl rapide was used, with 0/0 Vicryl used for rectovaginal fascial plication, if indicated. Dissection in the rectovaginal space was minimalized. Levator or levator fascial plication was not used in this study as a result of the minimalized dissection. A Capio device (Boston Scientific) was used to insert the size 0 Ethibond sacrospinous colpopexy sutures. Institutional ethical approval was received for the study. All patients gave informed consent as part of this audit of surgical practice. Methods, definitions, and units conform to standards jointly recommended by the

744 Int Urogynecol J (2016) 27:741 745 International Continence Society and the International Urogynecological Society, except where specifically noted [9]. Statistical analysis was conducted with Stata version 13.1 (College Station, TX, USA). Results Table 1 shows the parameter distribution summary. Of the 300 women, 39 (13.0 %) were premenopausal and 261 (87.0 %) were menopausal; (ii) 139 (46.3 %) had a prior hysterectomy, 128 (42.7 %) had a concomitant hysterectomy, and in 33 (11.0 %) the uterus was in situ. 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. Mean preoperative MVL vault displaced was 2.8 cm and mean preoperative MVL vault undisplaced was 1.3 cm. From this finding, it can be interpreted that 1.5 cm (55 %) of preoperative MVL vault displaced was due to vaginal-vault laxity. SSC was required in 84 % of cases to restore level I support. Vaginal skin excision occurred in 96 % cases, with 67 % requiring only up to 0.5-cm bilateral excision. Fascial suturing occurred in 76 %. Table 1 Preoperative baseline patient characteristics and the two sets of posterior prolapse markers: (i) PR-Q; (ii) POP-Q Variable Mean SD Min Max Age (years) 63.6 11.8 31 91 Weight (kg) 71.1 14.6 44 141 Height (cm) 162.9 7.1 142 187 BMI (kg/m 2 ) 26.7 5.0 18.6 46.3 Parity 2.6 1.2 0 8 PR-Q posterior prolapse markers PG (cm) 2.9 1.0 0.3 6.0 PVVD (cm) 6.0 2.0 0.3 15.0 MVL vault undisplaced (cm) 1.3 0.6 0 3.5 RVFL (cm) 1.1 0.7 0 4.0 POP-Q posterior prolapse markers Preop point C (cm) 0.9 2.3 8.0 8.0 Preop point Ap (cm) 1.0 1.4 3.0 5.0 Preop point Bp (cm) 1.0 1.5 3.0 6.0 Genital hiatus preop (cm) 3.7 0.9 1.5 6.5 PR-Q Posterior Repair Quantification, POP-Q Pelvic Organ Prolapse Quantification, BMI body mass index, PG perineal gap, PVVD posterior vaginal-vault descent, MVL midvaginal laxity, RVFL rectovaginal fascial laxity, SD standard deviation Discussion This study confirmed and strengthened our preliminary findings [6] that the anatomical defects found at surgery for posterior vaginal compartment prolapse were more at the vaginal vault (level I) and vaginal introitus (level III) rather than at the midvagina (level II). A majority (55 %) of midvaginal laxity was due to vaginal-vault descent. These results indicate the presence of significant posterior vaginal-vault laxity in the majority of the women undergoing PR. The majority of vaginal-vault support obtained during hysterectomy (prior or concomitant) by using the two supportive uterine ligaments uterosacral and cardinal is directed toward the anterior vaginal vault and wall with very little influence on the posterior vaginal vault and wall [10 12]. Additional posterior vaginalvault support provided by SSC was required in 84 % of cases. We acknowledge that an SSC is not the only vaginal-vault supportive procedure [13, 14]. We adopted a cutoff of 5.0 cm for PVVD level, requiring posterior vaginal-vault fixation, e.g., by a SSC. Our rationale for this arbitrary figure is that: (i) for PVVD >5.0 cm, an SSC is more anatomically and surgically desirable; (ii) for PVVD <5.0 cm, posterior vaginal-vault support is less in question, and it is much harder for the vaginal vault to reach the sacrospinous ligament via the usual posterior approach. We acknowledge that some surgeons believe it is not necessary for the vaginal vault to be in contact with the SSL at SSC. Our results tend to challenge the traditional concept of a rectocele as a level II defect of rectovaginal fascia (septum) [15 17] and accompanying vaginal skin laxity. Overall mean MVL vault undisplaced was only 1.3 cm and mean RVFL only 1.1 cm (Ap and Bp, both 1.0 cm). These results also highlighted the bigger issues in the posterior vaginal compartment were, in fact, at the perineum (level III overall mean PG 2.9 cm; GH mean 3.7 cm) and vaginal vault (level I overall mean PVVD 6.0 cm; point C mean 0.9 cm). Surgical implication in the traditional posterior repair is that to date, the midvagina (level II) may have received more intervention than required, with the vaginal vault and perineum perhaps receiving less surgical attention than needed. MRI evidence [18] supports the view that there is overall weakening and generalized deformation of pelvic floor tissues rather than specific fascial defects, perhaps indicating a reason for the relatively modest success rates of posterior vaginal repairs [16 18]. Results for GH between this series and our preliminary report were essentially similar: 3.7 cm vs 3.6 cm [6]. GH has a strong correlation with prolapse severity [19]. The different anatomical benefits of PG excision have been previously outlined [20]. These include: 1. A 100 % excision of thinned-out perineal skin 2. A 24 % increase in vaginal length over PR commenced at the hymen

Int Urogynecol J (2016) 27:741 745 745 3. Mean 31 % decrease in GH 4. Mean 28 % increase in perineal length 5. Mean 57 % increase in midperineal thickness Postoperative anatomical results were discussed in the preliminary report [6], though they are not a specific part of this particular report. We believe that the strengths of this study were it focus of attention on the defects present at the different levels of the posterior vaginal compartment. We have shown that defects are different from those traditionally thought to be present. These may then be used to guide appropriate surgical measures on a case-specific basis, rather than employing a onesize-fits-all standardized repair. The latter, by not being individualized to the patient s anatomy, might leave some defects unresolved. It also has the potential to create new defects [3]. A weakness of the study is that it does not, at this stage, include further short- and longer-term follow-up data, including rate of recurrent cystocele with increased use of posterior SSC. Part of the future difficulty in creating follow-up data is the need for PR-Q measurements to be performed under anesthesia. In this study, we did not want to confuse or compromise the key message. Other validation studies, including interobserver reliability studies are planned to determine PR-Q prolapse markers. Acknowledgments The authors thank the theater teams at St. Vincent s and Mater Hospitals, Sydney, for providing support and facilitating this study. We acknowledge surgical assistant Dr. John McNamara as an additional observer to measurements, anesthetists for their support and patience, associate professor Alan Molloy and Drs. Colleen Kane, Simon Adamo, Luke Vyvyan, and Alex Wang, who recorded most measurements. Compliance with ethical standards Conflicts of interest References None. 1. 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