Sacrospinous ligament fixation at the time of transvaginal hysterectomy Stephen H. Cruikshank, MD, and Donald W. Cox, MD Minneapolis, Minnesota, and Morgantown, West Virginia Sacrospinous ligament fixation of the vagina was performed on 48 of 135 patients at the time of transvaginal hysterectomy. All 48 patients in the group had at least moderate or severe uterovaginal prolapse and symptomatic pelvic relaxation, which is described herein. In five patients cystoceles developed, in two patients rectoceles developed, and one patient has had vault prolapse subsequent to surgery. Morbidity was minimal. Postoperative results indicate that sacrospinous ligament fixation of the vagina can be a useful adjunctive procedure when performed at the time of vaginal hysterectomy. (AM J OBSTET GVNECOL 1990;162:1611-9.)
Key words: Sacrospinous ligament fixation, uterovaginal prolapse
Vaginal vault prolapse is considered an infrequent yet tragic (by the patient) complication after hysterectomy. Estimates in recent literature of its incidence range from 0.2%' to 1.0%.2 The literature is replete with methods of repairing vault prolapse. Largely because of the work of Randall and Nichols," 4 the use of sacrospinous ligament fixation to correct this condition has had a resurgence in the United States. Consistent with the consensus in the literature, Morley and DeLanceyS have characterized this procedure as being for therapeutic purposes only. This article recommends that sacrospinous fixation be performed at the time of transvaginal hysterectomy as an adjunctive measure to be used with patients at risk for vaginal vault prolapse. We recount the results of such surgery on 48 patients and offer this article as a complement to a previously published report. 6 We hope the readers will read the discussions and our closing statement to get the full flavor of this presentation.
Material and methods Sacrospinous fixation of the vagina was performed on 48 of 135 patients undergoing vaginal hysterectomy for benign disease. Besides the indications for operation listed in Table I, all 48 patients had moderate to severe uterovaginal prolapse with or without symptomatic pelvic relaxation. Moderate uterovaginal prolapse From the Department of Obstetrics and Gynecology, Hennepin County Medical Center, University of Minnesota, and the Department of Obstetrics and Gynecology, West Virginia University School of Medicine. Presented at the Fifty-seventh Annual Meeting of the Central Association of Obstetricians and Gynecologists, Scottsdale, Arizona, October 12-14,1989. Reprint requests: S. H. Cruikshank, MD, Chairman, Department of Obstetrics and Gynecology, Hennepin County Medical Center, 701 Park Ave. South, Minneapolis, MN 55415.
was defined as the presentation of the cervix past the mid portion of the vagina or to the introitus as a result of Valsalva's ma~euver (Fig. 1). Severe uterovaginal prolapse was defined as presentation of the cervix past the introitus with or without Valsalva's maneuver (Fig. 2). The uterosacral-cardinal ligament complex was totally lax (surgically weak) or nonexistent in all 48 patients at the time of operation. These structures were unavailable to shorten or attach for support, although an attempt was made. Only the material relevant to the use of the sacrospinous fixation at the time hysterectomy is discussed. Other important details of this operation have been presented by Nichols and Randall,. Miyazaki,' and, most recently, Morley and DeLancey.' The ages of the patients ranged from 33 to 81 years with a mean of 50 years. These patient characteristics were noted: age, weight, surgical indications, parity, and secondary diagnoses. All patients were screened with Papanicolaou smears and colposcopy when indicated. Patients gave informed consent for all procedures. The surgeons included one faculty member (S. H. C.), a gynecology resident, and at all times the referring physician, who was present to learn the procedure. One hundred thirty-five patients underwent transvaginal hysterectomy as described in two standard texts. 4 ,8 Forty-eight of these patients fulfilled criteria as defined above to have a sacrospinous fixation performed as well. A previously reported method 6 of attaching the uterosacral-cardinal ligament complex to the vaginal membrane for prevention of posthysterectomy vault prolapse was attempted in all cases (Fig. 3). In all 48 cases the laxity or lack of the uterosacralcardinal ligament complex made it difficult to shorten or attach these for support. Therefore, after the hysterectomy was completed, the sacrospinous ligament 1611
1612 Cruikshank and Cox
June 1990 Am J Obstet Gynecol
Fig. 1. Moderate uterovaginal prolapse.
Fig. 2. Severe uterovaginal prolapse.
Table I. Indications for operation
Primary indication Stress urinary incontinence Grade 2 or 3* Refractory dysmenorrhea Recurrent postmenopausal bleeding Dysfunctional uterine bleeding TOTAL
No. of patients
No. of patients with concurrent uterovaginal prolapse (only)
4
9 14 5 16 48
No. of patients with concurrent symptomatic relaxed vaginal outlet and uterovaginal prolapse
1 6 10 5
3 3 4
10
6
o
*Includes patients desiring sterilization with biopsy-proved grade 2 or 3 cervical intraepithelial neoplasia.
was identified. The ligament fixation procedure was performed as follows: (1) The posterior vaginal wall was opened to the apex and the rectovaginal space entered. (2) This was dissected with the operator's finger to the level of the ischial spines. (3) At that time the descending rectal septum (pillar) was perforated, opening the pararectal space (Fig. 4). With additional blunt dissection, the ischial spine and the coccygeus musclesacrospinous ligament were palpated and identified. (4) No.2 Vicryl sutures were placed through the ligament (Fig. 5). These were held and left untied until any additional reconstructive procedures were completed. (5) Last, the sacrospinous ligament fixation was carried out with the use of both safety and pulley stitches' (Fig. 6).
Results
Transvaginal hysterectomy was accomplished in all 135 patients. Forty-eight adjunctive sacrospinous fixations of the vagina were carried out in these same patients. There were no injuries to the rectum, nerves, or bladder. In two cases, significant bleeding occurred from the perirectal veins, necessitating transfusion. The bleeding was stopped and there were no adverse sequelae as a result of injury to these vessels. The morbidity and complications were low. All patients received prophylactic cephalosporin antibiotic therapy. Forty-four (92%) of the 48 patients remained afebrile throughout the postoperative course. Of the four patients with febrile morbidity (oral temperature of ~37.9° C), three had a urinary tract infection and
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~, "
1 ,
'
Fig. 3. Uterosacral and cardinal ligaments sutured to vaginal membrane. (From Cruikshank SH. AM] OBSTET GYNECOL 1987;156:1433-40.)
rectal.pi~r
. C()Ccygem rnusqe .& 5a£ro$pinous·fig;t~i!flt
Fig. 4. Opening pararectal space (arrow) to identify coccygeus muscle.
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1614 Cruikshank and Cox
June 1990 Am J Obstet Gynecol
Fig. 5. Use of Miya hook to place sacrospinous ligament sutures.
Fig. 6. Demonstration of safety and pulley stitches.
one had no demonstrable cause. The average blood loss was 290 ml for all procedures; average blood loss for sacrospinous ligament fixation was 100 ml. The average time for the entire operation was 2 hours 20 minutes (in a teaching setting), and the average time of the sacrospinous fixation procedure was 18.5 minutes. The average hospital stay was 6.2 days. Four patients with concomitant anterior colporrhaphY'were unable to urinate before discharge from the hospital. All were sent home with Foley catheters in
place. All four patients have urinated since then. Two patients had transient stress incontinence from the sacrospinous procedure, but this complication resolved in both cases. Twenty patients complained of right buttock pain. All had spontaneous resolution by their 6week postoperative checkup. All patients have been followed up from 8 months to 3.2 years without evidence of posthysterectomy vaginal prolapse, except in one patient. All patients were examined 6 weeks postoperatively. In both the supine and the standing position the patients were asked to elicit a Valsalva maneuver. The mean follow-up time has been 2 years. Subsequent minor complications were without sequelae. In five patients anterior wall relaxation developed postoperatively without evidence of stress urinary incontinence. None of these had anterior colporrhaphy with our initial procedures. In two patients rectocele developed postoperatively. Neither had a posterior colporrhaphy with the initial operation; they elected not to have this complication repaired. Twenty-five patients had anterior colporrhaphy for urinary stress incontinence and/or symptomatic anterior vaginal wall relaxation. Eighteen patients had posterior colporrhaphy in addition to anterior repair. Five patients had an enterocele repaired, and seven additional patients had posterior colporrhaphy only. To date there has been one reported case of posthysterectomy vaginal vault prolapse.
Comment Traditionally, sacrospinous fixation has been regarded as a therapeutic tool to be used only for repair
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of vaginal vault prolapse." 5 However, I feel that this procedure also may be used as a prophylaxis (as defined herein) against posthysterectomy vault prolapse. Not every vaginal hysterectomy patient is a candidate. If there is a loss of pelvic supportive structures (uterosacral-cardinal ligament complex) noted at the time of hysterectomy, an attempt to use their remnants should be made. However, sacrospinous fixation as an adjunct will prevent further vault prolapse. Nichols and RandalI,9 in their most recent textbook, state that without strong pelvic support a sacrospinous colpopexy is easy to perform after vaginal hysterectomy. The 48 patients in this study represent only 35% of the vaginal hysterectomies performed during this time period. I stress again the point that the adjunctive sacrospinous fixation is not to be used universally in all vaginal hysterectomies. In these other 87 patients the uterosacral-cardinal ligament complex was attached only, and a sacrospinous ligament fixation was not required. Previously a method was described that uses the pelvic supportive structures (the cardinal-uterosacral ligament complex) to help prevent subsequent prolapse. 6 These steps hold the vagina in its almost horizontal position above the levator ani; however, if these supportive structures are not present, the vaginal apex is still at risk for prolapse. In all 48 patients the apex was drawn past the introitus after the hysterectomy and any plastic repair. We feel it is appropriate during transvaginal hysterectomy to attempt support of the vagina in its normal anatomic position. Moreover, if moderate or severe uterovaginal prolapse exists as well, either as the main indication or as a secondary diagnosis, the pelvic surgeon should use the sacrospinous fixation to correct this, thus preventing future complications and sparing the patient from further procedures. Sacrospinous ligament fixation is not to be performed universally at the time of hysterectomy. Out of 135 patients undergoing vaginal hysterectomy, only 48 fulfilled the prerequisites for sacrospinous fixation of the vaginal vault. We feel this is an appropriate adjunctiveprophylactic procedure if strict criteria are met: (1) total laxity of the uterosacral-cardinal ligament complex, (2) moderate to severe laxity of the supportive structures and the ability to pull the vaginal apex to or past the introitus after hysterectomy and other plastic procedures, and (3) total procidentia at the time of hysterectomy. Various principles of vaginal fixation during hysterectomy are recognized today. At all times the surgeon should note the laxity of the supporting structures and attempt to repair this at the initial operation. Transvaginal hysterectomy offers a good opportunity to prevent future vaginal prolapse. Considering the results of this study, it seems feasible to add the sacrospinous fixation as a procedure in cases of vagi-
1615
nal hysterectomy presenting with moderate to severe uterovaginal descensus and loss of pelvic support. The procedure carries minimal morbidity, supports the vaginal apex, and provides the pelvic surgeon with an additional prophylactic measure against posthysterectomy vaginal prolapse. REFERENCES 1. Symmonds RE, Williams TJ, Lee RA, Webb MJ. Posthysterectomy enterocele and vaginal vault prolapse. AM J OBSTET GYNECOL 1981;140:852-9. 2. Kaser 0, Ikle FA, Hirsch HA. Atlas of gynecological surgery. 2nd ed. New York: Thieme-Stratton, 1985: 12.58. 3. Randall CL, Nichols DH. Surgical treatment of vaginal inversion. Obstet Gynecol 1971;38:327-32. 4. Nichols DH, Randall CL. Vaginal surgery. 2nd ed. Baltimore: Williams & Wilkins, 1983:284-303. 5. Morley GW, DeLancey JOL. Sacrospinous ligament fixation for eversion of the vagina. AM J OBSTET GYNECOL 1988; 158:872-81. 6. Cruikshank SH. Preventing posthysterectomy vaginal vault prolapse and enterocele during vaginal hysterectomy. AM J OBSTET GYNECOL 1987;156:1433-40. 7. Miyazaki FS. Miya hook ligature carrier for sacrospinous ligament suspension. Obstet Gynecol 1987;70:286-8. 8. Mattingly RF, Thompson JD. TeLinde's operative gynecology. 6th ed. Philadelphia: JB Lippincott, 1983:548-60. 9. Nichols DH, Randall CL. Vaginal surgery. 3rd ed. Baltimore: Williams & Wilkins, 1989:328-9.
Editors' note: This manuscript was revised after these discussions were presented.
Discussion DR. GEORGE W. MORLEY, Ann Arbor, Michigan. At the outset, I wish to compliment the authors on their well-presented thesis and on their endeavor to put forth an additional surgical procedure to prevent' vaginal vault prolapse after vaginal hysterectomy. In the interest of time, however, whereas I strongly believe sacrospinous ligament fixation as a treatment of vaginal vault prolapse is a significant step forward in our therapeutic armamentarium, I must respectfully challenge their recommendation of it at the time of vaginal hysterectomy as a prophylactic measure against vaginal prolapse in the future. With the possible exception of a total procidentia, I must question the indication for this operation as an adjunct to vaginal hysterectomy. In the manuscript it is stated that all 48 patients on whom the prophylactic procedure was performed, had moderate to severe uterovaginal prolapse with or without symptomatic pelvic relaxation. I personally think the more traditional definitions of uterine prolapse could have been used rather than the terms moderate and severe since most textbooks of gynecology describe uterine prolapse by degrees. In the authors' terms, however, how many cases were classified as moderate and how many as severe? Also were there any thirddegree procidentias in their series? It is also stated that the uterosacral and cardinalligament complex was totally lax or nonexistent in all 48 patients. One wonders what method was used to ascertain this impression since in my experience attach-
1616 Cruikshank and Cox
ment of the sacrouterine and cardinal ligaments to the vaginal apex (even though these ligaments may be markedly attenuated), high closure of the peritoneum, and the McCall-type culdoplasty have worked most satisfactorily as a preventive procedure. In this study the authors performed a sacrospinous ligament fixation prophylactically on 48 of 135 patients undergong vaginal hysterectomy, giving a frequency of performance of 35.5%. And yet in their own introduction they quote from a review of the literature an actual incidence of vaginal prolapse after both abdominal .and vaginal hysterectomy (with almost an equal distribution) a range of only 0.2% to 1%. Given then a 0.5% incidence of vaginal prolapse after vaginal hysterectomy alone, 200 patients would have to undergo this prophylactic procedure to prevent one prolapse instead of one patient undergoing it therapeutically at a later date. In a further effort to compare the infrequency of vaginal vault prolapse with the frequency of hysterectomy, the most common major gynecologic procedure we do, I reference one report from the literature. A number of years ago, Symmonds and Prate from the Mayo Clinic reported that over a 15-year period, when > 15,000 hysterectomies were performed in their institution, only 24 of these patients were treated for vaginal prolapse there during the same time period. They stated in their article, "Even if we allow for the possibility that an equal number of patients with vaginal prolapse may have obtained treatment of prolapse elsewhere, the incidence of prolapse following hysterectomy performed at this clinic has not been great.'" Finally, the risk/benefit ratio must be considered since this procedure is not without complication; i.e., excess bleeding requiring blood transfusions, sciatic or pudendal nerve inpingement, and postoperative sepsis. There have been at least two deaths probably related to this procedure. In closing, the role of the discussant is first to anticipate the questions of the profession and second to represent the welfare of the patients who are possible candidates for any procedure that might be recommended. With apologies to the authors but in feeling a responsibility as the discussant, I must state that I consider the sacrospinous ligament fixation as a prophylactic procedure unwarranted in most situations! I challenge the prophylactic procedure as adjunctive treatment after vaginal hysterectomy for these reasons: (1) because of the infrequency of vaginal prolapse when compared with the frequency of hysterectomy, (2) because of the operative risks and postoperative complications, which when encountered may be significant, (3) because of the additional cost (should there be a charge) of the procedure to the patient or payor, and (4) because of the potential failure of the prophylactic procedure in the future. Sixty-six percent or two thirds of our patients treated therapeutically at Michigan 2 ex-
June 1990 Am J Obstet Gynecol
perienced their initial symptoms of prolapse longer than 5 years after hysterectomy. The short-term followup of the patients treated prophylactically in the authors' series had a mean of only 21 months. I have for Dr. Cruikshank one additional question out of curiosity. What was the incidence of prophylactic bilateral oophorectomy in your overall series? I thank you for the invitation to discuss this manuscript, and again my apologies to the essayist. REFERENCES 1. Symmonds RE, Pratt JH. Vaginal prolapse following hysterectomy. AM J OBSTET GVNECOL 1960;79:899-909. 2. Morley GW, DeLancey JOL. Sacrospinous ligament fixation for eversion of the vagina. AM J OBSTET GVNECOL 1988; 158:872-81.
DR. LEsTER A. BALLARD,JR., Cleveland, Ohio. At the Central Association meeting in 1986, Dr. Cruikshank presented a paper entitled, "Preventing Posthysterectomy Vaginal Vault Prolapse and Enterocele During Vaginal Hysterectomy," in which he described 112 consecutive vaginal hysterectomies where there were identifiable uterosacral cardinal ligaments. He described his technique of shortening and attaching these ligaments to the vaginal vault for vault support, as well as a technique for enterocele prevention with the use of high peritoneal ligation incorporating the anterior wall of the rectum to close the posterior cul-de-sac. These 112 operations were done from July 1983 to March 1986, and the patients had a mean age of 30, ranging from 23 to 69 years. In my discussion of his paper, I asked what he did when the uterosacral cardinal ligaments were nonexistent or stringlike and not strong enough to support the vaginal vault, as in the older postmenopausal patient with severe prolapse. I mentioned that 38 (34.5%) of our 110 sacrospinous ligament fixations where there was third-degree uterine prolapse (mean patient age 63.5 years) were required as a primary adjunct to vaginal hysterectomy to maintain adequate vaginal depth and axis. In their article the authors described a subsequent series of 135 vaginal hysterectomies where 48 patients required a sacrospinous fixation for vault suspension. This group of patients had a mean age of 50 (range 33 to 81 years) with the longest follow-up being 3.2 years. The authors have found sacrospinous ligament fixation to be a "useful adjunct" as a primary procedure done at the time of vaginal hysterectomy. The indications for Dr. Cruikshank's vaginal hysterectomies in 1986 were dysfunctional uterine bleeding, grade 2 and grade 3 cervical epithelial neoplasia, refractory dysmenorrhea, stress urinary incontinence, recurrent postmenopausal bleeding, and symptomatic pelvic relaxation. In this report the indications were the same as in 1986, except there was no separate symptomatic pelvic relaxation group. The authors included 32 cases of vaginal prolapse and 16 cases of relaxed vaginal outlet with symptomatic uterovaginal prolapse
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in these original five categories. I would have expected these patients to present with symptomatic pelvic pressure, bearing-down discomfort, protrusion, bleeding as a result of irritation, and urine irritability. The authors illustrated and described patients with moderate degrees of prolapse, defined as the presentation of the cervix past the midline portion of the vagina or to the introitus, and severe prolapse, defined as presentation of the cervix past the introitus but showing the body of the uterus in the vagina. It is interesting that Drs. Morley and DeLancey2 refer to the criteria of Wilson and Carrington, which describe a first-degree prolapse as the cervix being between the level of ischial spine and vaginal introitus, seconddegree prolapse as the cervix protruding through the introitus while the corpus remains in the vagina, and third-degree prolapse as complete prolapse of both the cervix and body of the uterus past the introitus and the entire vaginal canal everted. Therefore Dr. Cruikshank's moderate prolapse is Drs. Morley and DeLancey's first-degree, and Dr. Cruikshank's severe is Drs. Morley and DeLancey's second-degree and questionably third-degree together. Can the authors tell us how many cases were in the moderate and severe categories and did they include complete procidentia in the severe group? The authors described uterosacral cardinal ligaments as totally lax or nonexistent in all 48 patients. Their structures were unavailable to shorten and attach for support although an attempt was made. They presented three criteria for adjunctive prophylactic use of the sacrospinous ligament fixation at vaginal hysterectomy: (1) total laxity of the uterosacral cardinal complex, (2) moderate to severe laxity of the supportive structures and the ability to pull the vaginal apex past the introitus after hysterectomy and other plastic procedures, and (3) total procidentia. Being able to pull the vaginal apex past the introitus after removal is a new criterion. I certainly concur with the third criterion of total procidentia. Does one have to have all three criteria or just one or two? As a result of the authors' follow-up (mean 2 years), five anterior wall relaxations and two rectoceles were found; none of these patients had associated anterior and posterior colporrhaphy at the time of the sacrospinous ligament fixation. It is interesting that 37.5% of their patients had anterior-posterior repairs, 14.6% had anterior repairs only, 14.6% had posterior repairs only, and 33.3% had neither anterior nor posterior repair. Five patients had enterocele repairs, and one had vault recurrence. In our current series of 268 sacrospinous ligament fixations, 233 (87%) of our patients had anteriorposterior repairs, 29 (l O. 7%) had posterior repairs only, 3 (1.1 %) had anterior repairs only and 3 (1.1 %) had no repair. Six had vault recurrences. Because of our original anterior wall recurrences and anterior enterocele with vault recurrence, I have increased the percentage of anterior-posterior wall repairs, even if only
1617
minor degrees of weakness are evident, to attempt to prevent these recurrences. In Dr. Nichols' series of 163 patients, 59 (27.6%) cases were primary. In our own series of 268 sacrospinous fixations, 79 (29.5%) cases were primary. Dr. Nichols and I feel that primary sacrospinous fixation should be done at the time of vaginal hysterectomy when there are no surgically useful uterosacral cardinal ligaments for support of the vaginal vault. When cardinal uterosacral strength is lacking, an alternate method for vault suspension should be found. I would prefer not to rely on inadequate uterosacral cardinal ligaments for support or to have to depend on flimsy perirectal fascia and supralevator fascia support, for which one sacrifices depth and caliber. The latter procedure is good in the patient who does not want to maintain coital capacity. I concur with Drs. Morley and DeLancey that prophylactic use of sacrospinous ligament fixation for "usual" or mild to moderate degrees of uterine prolapse is not usually needed and is an additional unnecessary financial burden. Hoerr's law, as used at the Cleveland Clinic, states, "It is difficult to make the asymptomatic patient feel better with surgery." In patients with good uterosacral cardinal ligaments that can be shortened for vault suspension, there is no need to perform a sacrospinous ligament fixation. However, in the patient with severe and complete uterine prolapse without surgically usable or identifiable ligaments, I would prefer to use sacrospinous ligament fixation. Drs. Morley and DeLancey also state that" ... sacrospinous ligament fixation should be classified as a therapeutic procedure with the only reservation possibly being in patients with complete uterine prolapse as defined by Wilson and Carrington." I will look forward to follow-up reports of Dr. Cruikshank's 1986 and present series regarding the prevention of vaginal vault prolapse. REFERENCES 1. Cruikshank SH. Preventing posthysterectomy vaginal vault prolapse and enterocele during vaginal hysterectomy. AM J OBSTET GYNECOL 1987;156:1433-40. 2. Morley GW, DeLancey JOL. Sacrospinous ligament fixation for eversion of the vagina. AM J OBSTET GYNECOL 1988; 158:872-81. 3. Nichols DH. Sacrospinous fixation for massive eversion of the vagina. AM J OBSTET GYNECOL 1982;142: 901-4. 4. Nichols DH, Randall CL. Vaginal surgery. 3rd ed. Baltimore: Williams & Wilkins, 1989:321. DR. SCO'IT SNYDER, Columbia, Missouri. I would like to know how many of the 138 patients had retropubic urethropexies and how this influenced the decision to do the sacrospinous ligament fixation. DR S. ROBERT KOVAC, St. Louis, Missouri. I have a question to ask both Dr. Cruikshank and Dr. Morley. I'm a little bit confused, and maybe they can help me understand this better. Are we really quite sure what
1618 Cruikshank and Cox
the uterosacral-cardinal complex does anatomically to prevent vault prolapse? We need to decide whether this ligament complex supports the vagina or simply directs the vagina over the levator plate for support. Vault prolapse may be the result of a problem at a much higher pelvic level; therefore I think it is probably folly to rely on that particular complex as the sole definitive support of the vagina. We must decide what anatomically we are attempting to accomplish with any type of plication procedures involving these ligaments. If we believe that these ligaments can prevent vault prolapse, then I think we must accept the consequences that we are going to have vault prolapse after some hysterectomies whether they are performed abdominally or vaginally. However, sacrospinous fixation does not anatomically correct the cause of vault prolapse, but it does indirectly direct the vagina over the levator plate, perhaps better than plication procedures. It appears to me that "the horse is out of the barn, and we forgot to close the gate"; now we're trying to catch up with the problem of preventing future vault prolapse. I think the most important issue is to actually determine and agree on what anatomic structures cause vault and uterine prolapse. Then we as gynecologic surgeons can design a specific surgical procedure to correct this problem and not rely on whatever we have used in the past to prevent this condition now and in the future. DR. ALAN G. WAXMAN, Gallup, New Mexico. I wonder if, as Dr. Cruikshank expands his series, it might not be useful to introduce a comparison group, perhaps of the same patient population, randomized and operated on by the same surgeons so we can see if there really is efficacy from this procedure in the long run. DR. BRUCE C. RICHARDS, Lakewood, Colorado. In the appropriate case-and not to get into the controversy-for those that are interested in doing this procedure, I would endorse the notion of using the Mia hook. It is very facilitative. DR L. RUSSELL MALINAK, Houston, Texas. Was the cuff left open or was it closed in your patients with sacrospinous fixation? Does it matter? DR. CRUIKSHANK (Closing). I am humbled. First of all, I would like to thank the discussants. I'm reading the book Final Flight. A quotation from it goes like this: "Confront the enemy with the tip of your sword against his face," and that's what I'm going to do in this debate. The first thing I would like to say in respect to taking care of pelvic floor relaxation is that each aspect must be addressed to obtain optimal results. I think we need to keep that in mind when we're evaluating the patient in the office. I think the history and physical examination are probably the most important things, with the patient in the erect and the supine positions, not under anesthesia. Once you make your surgical decision and find out in which quadrant or which anterior-posterior area you have a defect, then you can plan your repair; then a
June 1990 Am J Obstet Gynecol
good pelvic examination with the patient under anesthesia should be done as well. I anticipated this discussion so I brought one certain article to help me. This is Dr. Morley'S article on sacrospinous fixation. He questions my indications and asked how many patients had procidentia. Procidentia was found in 8 patients. Severe prolapse as I defined it occurred in 24, moderate prolapse was found in 16. To back my manuscript further, the abstract of Dr. Morley and Dr. DeLancey says that while 57 patients had a posthysterectomy complete vaginal prolapse, 38 patients had an incomplete vaginal prolapse. Again on page 873 it is stated: "The indication for operation was total vaginal prolapse in 57 patients (vaginal apex below the introitus), incomplete vaginal prolapse in 38 (vaginal apex at or above the introitus), and enterocele in five." Now, if you recall my illustrations, the only differences between my criteria and his criteria is that the uterus is in situ in our patients. Once it's out, I then reexamine the patient and I've obtained his criteria. If I've done plastic repairs and I can still get the apex past the introitus or down to the introitus, then I've got the same problem as he does; that's why we have to take each defect and look at it individually and not just do a hysterectomy and say we solved it. Uterine prolapse is not the cause of genital prolapse. It's a result. So if we have anterior wall relaxation, posterior wall relaxation, or enterocele, that's the result of genital prolapse; do we really know what causes it? Well, we're trying to find out, but we all have techniques that we're trying to use to cure it, and that's what I'm doing. I would also like to read from Dr. Morley's article something else that parallels my manuscript (remember that the only difference is that the uterus is in situ in my patients until the hysterectomy is done): "Simply stated, all relaxations should not be treated as cystocelerectocele." I have the feeling that that's what he wanted me to do as long as the uterus was in situ. This in my opinion would result in posthysterectomy degrees of prolapse. Now, on page 878 of the article, I read: "An incomplete prolapse is present when any pathologic descensus down to the introitus exists. Any degree of descensus beyond this point is classified as a total vaginal prolapse. If further description of the prolapse is required, mensuration from the introitus as a reference point could be used." I think I attempted to define that, and I tried to do that in the office when the patients came in; if they could perform a Val salva maneuver of the uterus down to the introitus or past the introitus, there was more abnormality than just uterine prolapse. So I didn't want to do a hysterectomy and just say, "See you back after a while." The complications in Dr. Morley's patient population were no different from the complications in mine or the complications of Dr. Nichols, and they're not as bad as the complications we see from episiotomies and ce-
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sarean sections. We've got to do something about these routine-what we call therapeutic-operations that wreak a lot of havoc and have more morbidity than a sacrospinous fixation. Now, 0.2% to 1% as the incidence of vault prolapse is in the recent literature. Gynecology is very interesting. What is old literature? In the 1960s reports say vault prolapse occurs in 1% to 43%; is that the old literature? And in obstetrics "current" means "5 years old." In gynecology though, what's old? So the 0.2% to 1% figure represents the literature of the late 1970s
1619
and 1980s. But in the older literature, in the 1960s, it was as high as 43%. I spent some time in the Third World just this summer, and I can guarantee that some things are different. I was in Portugal. We had a whole ward of women who were seen with uterovaginal and vaginal prolapses, and there was close to if not more than 43% incidence. It may be their life-style or that the hysterectomy was performed wrong the first time. I don't know. It was very impressive.
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Key words: Sacrospinous ligament fixation, uterovaginal prolapse
Vaginal vault prolapse is considered an infrequent yet tragic (by the patient) complication after hysterectomy. Estimates in recent literature of its incidence range from 0.2%' to 1.0%.2 The literature is replete with methods of repairing vault prolapse. Largely because of the work of Randall and Nichols," 4 the use of sacrospinous ligament fixation to correct this condition has had a resurgence in the United States. Consistent with the consensus in the literature, Morley and DeLanceyS have characterized this procedure as being for therapeutic purposes only. This article recommends that sacrospinous fixation be performed at the time of transvaginal hysterectomy as an adjunctive measure to be used with patients at risk for vaginal vault prolapse. We recount the results of such surgery on 48 patients and offer this article as a complement to a previously published report. 6 We hope the readers will read the discussions and our closing statement to get the full flavor of this presentation.
Material and methods Sacrospinous fixation of the vagina was performed on 48 of 135 patients undergoing vaginal hysterectomy for benign disease. Besides the indications for operation listed in Table I, all 48 patients had moderate to severe uterovaginal prolapse with or without symptomatic pelvic relaxation. Moderate uterovaginal prolapse From the Department of Obstetrics and Gynecology, Hennepin County Medical Center, University of Minnesota, and the Department of Obstetrics and Gynecology, West Virginia University School of Medicine. Presented at the Fifty-seventh Annual Meeting of the Central Association of Obstetricians and Gynecologists, Scottsdale, Arizona, October 12-14,1989. Reprint requests: S. H. Cruikshank, MD, Chairman, Department of Obstetrics and Gynecology, Hennepin County Medical Center, 701 Park Ave. South, Minneapolis, MN 55415.
was defined as the presentation of the cervix past the mid portion of the vagina or to the introitus as a result of Valsalva's ma~euver (Fig. 1). Severe uterovaginal prolapse was defined as presentation of the cervix past the introitus with or without Valsalva's maneuver (Fig. 2). The uterosacral-cardinal ligament complex was totally lax (surgically weak) or nonexistent in all 48 patients at the time of operation. These structures were unavailable to shorten or attach for support, although an attempt was made. Only the material relevant to the use of the sacrospinous fixation at the time hysterectomy is discussed. Other important details of this operation have been presented by Nichols and Randall,. Miyazaki,' and, most recently, Morley and DeLancey.' The ages of the patients ranged from 33 to 81 years with a mean of 50 years. These patient characteristics were noted: age, weight, surgical indications, parity, and secondary diagnoses. All patients were screened with Papanicolaou smears and colposcopy when indicated. Patients gave informed consent for all procedures. The surgeons included one faculty member (S. H. C.), a gynecology resident, and at all times the referring physician, who was present to learn the procedure. One hundred thirty-five patients underwent transvaginal hysterectomy as described in two standard texts. 4 ,8 Forty-eight of these patients fulfilled criteria as defined above to have a sacrospinous fixation performed as well. A previously reported method 6 of attaching the uterosacral-cardinal ligament complex to the vaginal membrane for prevention of posthysterectomy vault prolapse was attempted in all cases (Fig. 3). In all 48 cases the laxity or lack of the uterosacralcardinal ligament complex made it difficult to shorten or attach these for support. Therefore, after the hysterectomy was completed, the sacrospinous ligament 1611
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June 1990 Am J Obstet Gynecol
Fig. 1. Moderate uterovaginal prolapse.
Fig. 2. Severe uterovaginal prolapse.
Table I. Indications for operation
Primary indication Stress urinary incontinence Grade 2 or 3* Refractory dysmenorrhea Recurrent postmenopausal bleeding Dysfunctional uterine bleeding TOTAL
No. of patients
No. of patients with concurrent uterovaginal prolapse (only)
4
9 14 5 16 48
No. of patients with concurrent symptomatic relaxed vaginal outlet and uterovaginal prolapse
1 6 10 5
3 3 4
10
6
o
*Includes patients desiring sterilization with biopsy-proved grade 2 or 3 cervical intraepithelial neoplasia.
was identified. The ligament fixation procedure was performed as follows: (1) The posterior vaginal wall was opened to the apex and the rectovaginal space entered. (2) This was dissected with the operator's finger to the level of the ischial spines. (3) At that time the descending rectal septum (pillar) was perforated, opening the pararectal space (Fig. 4). With additional blunt dissection, the ischial spine and the coccygeus musclesacrospinous ligament were palpated and identified. (4) No.2 Vicryl sutures were placed through the ligament (Fig. 5). These were held and left untied until any additional reconstructive procedures were completed. (5) Last, the sacrospinous ligament fixation was carried out with the use of both safety and pulley stitches' (Fig. 6).
Results
Transvaginal hysterectomy was accomplished in all 135 patients. Forty-eight adjunctive sacrospinous fixations of the vagina were carried out in these same patients. There were no injuries to the rectum, nerves, or bladder. In two cases, significant bleeding occurred from the perirectal veins, necessitating transfusion. The bleeding was stopped and there were no adverse sequelae as a result of injury to these vessels. The morbidity and complications were low. All patients received prophylactic cephalosporin antibiotic therapy. Forty-four (92%) of the 48 patients remained afebrile throughout the postoperative course. Of the four patients with febrile morbidity (oral temperature of ~37.9° C), three had a urinary tract infection and
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~, "
1 ,
'
Fig. 3. Uterosacral and cardinal ligaments sutured to vaginal membrane. (From Cruikshank SH. AM] OBSTET GYNECOL 1987;156:1433-40.)
rectal.pi~r
. C()Ccygem rnusqe .& 5a£ro$pinous·fig;t~i!flt
Fig. 4. Opening pararectal space (arrow) to identify coccygeus muscle.
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1614 Cruikshank and Cox
June 1990 Am J Obstet Gynecol
Fig. 5. Use of Miya hook to place sacrospinous ligament sutures.
Fig. 6. Demonstration of safety and pulley stitches.
one had no demonstrable cause. The average blood loss was 290 ml for all procedures; average blood loss for sacrospinous ligament fixation was 100 ml. The average time for the entire operation was 2 hours 20 minutes (in a teaching setting), and the average time of the sacrospinous fixation procedure was 18.5 minutes. The average hospital stay was 6.2 days. Four patients with concomitant anterior colporrhaphY'were unable to urinate before discharge from the hospital. All were sent home with Foley catheters in
place. All four patients have urinated since then. Two patients had transient stress incontinence from the sacrospinous procedure, but this complication resolved in both cases. Twenty patients complained of right buttock pain. All had spontaneous resolution by their 6week postoperative checkup. All patients have been followed up from 8 months to 3.2 years without evidence of posthysterectomy vaginal prolapse, except in one patient. All patients were examined 6 weeks postoperatively. In both the supine and the standing position the patients were asked to elicit a Valsalva maneuver. The mean follow-up time has been 2 years. Subsequent minor complications were without sequelae. In five patients anterior wall relaxation developed postoperatively without evidence of stress urinary incontinence. None of these had anterior colporrhaphy with our initial procedures. In two patients rectocele developed postoperatively. Neither had a posterior colporrhaphy with the initial operation; they elected not to have this complication repaired. Twenty-five patients had anterior colporrhaphy for urinary stress incontinence and/or symptomatic anterior vaginal wall relaxation. Eighteen patients had posterior colporrhaphy in addition to anterior repair. Five patients had an enterocele repaired, and seven additional patients had posterior colporrhaphy only. To date there has been one reported case of posthysterectomy vaginal vault prolapse.
Comment Traditionally, sacrospinous fixation has been regarded as a therapeutic tool to be used only for repair
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of vaginal vault prolapse." 5 However, I feel that this procedure also may be used as a prophylaxis (as defined herein) against posthysterectomy vault prolapse. Not every vaginal hysterectomy patient is a candidate. If there is a loss of pelvic supportive structures (uterosacral-cardinal ligament complex) noted at the time of hysterectomy, an attempt to use their remnants should be made. However, sacrospinous fixation as an adjunct will prevent further vault prolapse. Nichols and RandalI,9 in their most recent textbook, state that without strong pelvic support a sacrospinous colpopexy is easy to perform after vaginal hysterectomy. The 48 patients in this study represent only 35% of the vaginal hysterectomies performed during this time period. I stress again the point that the adjunctive sacrospinous fixation is not to be used universally in all vaginal hysterectomies. In these other 87 patients the uterosacral-cardinal ligament complex was attached only, and a sacrospinous ligament fixation was not required. Previously a method was described that uses the pelvic supportive structures (the cardinal-uterosacral ligament complex) to help prevent subsequent prolapse. 6 These steps hold the vagina in its almost horizontal position above the levator ani; however, if these supportive structures are not present, the vaginal apex is still at risk for prolapse. In all 48 patients the apex was drawn past the introitus after the hysterectomy and any plastic repair. We feel it is appropriate during transvaginal hysterectomy to attempt support of the vagina in its normal anatomic position. Moreover, if moderate or severe uterovaginal prolapse exists as well, either as the main indication or as a secondary diagnosis, the pelvic surgeon should use the sacrospinous fixation to correct this, thus preventing future complications and sparing the patient from further procedures. Sacrospinous ligament fixation is not to be performed universally at the time of hysterectomy. Out of 135 patients undergoing vaginal hysterectomy, only 48 fulfilled the prerequisites for sacrospinous fixation of the vaginal vault. We feel this is an appropriate adjunctiveprophylactic procedure if strict criteria are met: (1) total laxity of the uterosacral-cardinal ligament complex, (2) moderate to severe laxity of the supportive structures and the ability to pull the vaginal apex to or past the introitus after hysterectomy and other plastic procedures, and (3) total procidentia at the time of hysterectomy. Various principles of vaginal fixation during hysterectomy are recognized today. At all times the surgeon should note the laxity of the supporting structures and attempt to repair this at the initial operation. Transvaginal hysterectomy offers a good opportunity to prevent future vaginal prolapse. Considering the results of this study, it seems feasible to add the sacrospinous fixation as a procedure in cases of vagi-
1615
nal hysterectomy presenting with moderate to severe uterovaginal descensus and loss of pelvic support. The procedure carries minimal morbidity, supports the vaginal apex, and provides the pelvic surgeon with an additional prophylactic measure against posthysterectomy vaginal prolapse. REFERENCES 1. Symmonds RE, Williams TJ, Lee RA, Webb MJ. Posthysterectomy enterocele and vaginal vault prolapse. AM J OBSTET GYNECOL 1981;140:852-9. 2. Kaser 0, Ikle FA, Hirsch HA. Atlas of gynecological surgery. 2nd ed. New York: Thieme-Stratton, 1985: 12.58. 3. Randall CL, Nichols DH. Surgical treatment of vaginal inversion. Obstet Gynecol 1971;38:327-32. 4. Nichols DH, Randall CL. Vaginal surgery. 2nd ed. Baltimore: Williams & Wilkins, 1983:284-303. 5. Morley GW, DeLancey JOL. Sacrospinous ligament fixation for eversion of the vagina. AM J OBSTET GYNECOL 1988; 158:872-81. 6. Cruikshank SH. Preventing posthysterectomy vaginal vault prolapse and enterocele during vaginal hysterectomy. AM J OBSTET GYNECOL 1987;156:1433-40. 7. Miyazaki FS. Miya hook ligature carrier for sacrospinous ligament suspension. Obstet Gynecol 1987;70:286-8. 8. Mattingly RF, Thompson JD. TeLinde's operative gynecology. 6th ed. Philadelphia: JB Lippincott, 1983:548-60. 9. Nichols DH, Randall CL. Vaginal surgery. 3rd ed. Baltimore: Williams & Wilkins, 1989:328-9.
Editors' note: This manuscript was revised after these discussions were presented.
Discussion DR. GEORGE W. MORLEY, Ann Arbor, Michigan. At the outset, I wish to compliment the authors on their well-presented thesis and on their endeavor to put forth an additional surgical procedure to prevent' vaginal vault prolapse after vaginal hysterectomy. In the interest of time, however, whereas I strongly believe sacrospinous ligament fixation as a treatment of vaginal vault prolapse is a significant step forward in our therapeutic armamentarium, I must respectfully challenge their recommendation of it at the time of vaginal hysterectomy as a prophylactic measure against vaginal prolapse in the future. With the possible exception of a total procidentia, I must question the indication for this operation as an adjunct to vaginal hysterectomy. In the manuscript it is stated that all 48 patients on whom the prophylactic procedure was performed, had moderate to severe uterovaginal prolapse with or without symptomatic pelvic relaxation. I personally think the more traditional definitions of uterine prolapse could have been used rather than the terms moderate and severe since most textbooks of gynecology describe uterine prolapse by degrees. In the authors' terms, however, how many cases were classified as moderate and how many as severe? Also were there any thirddegree procidentias in their series? It is also stated that the uterosacral and cardinalligament complex was totally lax or nonexistent in all 48 patients. One wonders what method was used to ascertain this impression since in my experience attach-
1616 Cruikshank and Cox
ment of the sacrouterine and cardinal ligaments to the vaginal apex (even though these ligaments may be markedly attenuated), high closure of the peritoneum, and the McCall-type culdoplasty have worked most satisfactorily as a preventive procedure. In this study the authors performed a sacrospinous ligament fixation prophylactically on 48 of 135 patients undergong vaginal hysterectomy, giving a frequency of performance of 35.5%. And yet in their own introduction they quote from a review of the literature an actual incidence of vaginal prolapse after both abdominal .and vaginal hysterectomy (with almost an equal distribution) a range of only 0.2% to 1%. Given then a 0.5% incidence of vaginal prolapse after vaginal hysterectomy alone, 200 patients would have to undergo this prophylactic procedure to prevent one prolapse instead of one patient undergoing it therapeutically at a later date. In a further effort to compare the infrequency of vaginal vault prolapse with the frequency of hysterectomy, the most common major gynecologic procedure we do, I reference one report from the literature. A number of years ago, Symmonds and Prate from the Mayo Clinic reported that over a 15-year period, when > 15,000 hysterectomies were performed in their institution, only 24 of these patients were treated for vaginal prolapse there during the same time period. They stated in their article, "Even if we allow for the possibility that an equal number of patients with vaginal prolapse may have obtained treatment of prolapse elsewhere, the incidence of prolapse following hysterectomy performed at this clinic has not been great.'" Finally, the risk/benefit ratio must be considered since this procedure is not without complication; i.e., excess bleeding requiring blood transfusions, sciatic or pudendal nerve inpingement, and postoperative sepsis. There have been at least two deaths probably related to this procedure. In closing, the role of the discussant is first to anticipate the questions of the profession and second to represent the welfare of the patients who are possible candidates for any procedure that might be recommended. With apologies to the authors but in feeling a responsibility as the discussant, I must state that I consider the sacrospinous ligament fixation as a prophylactic procedure unwarranted in most situations! I challenge the prophylactic procedure as adjunctive treatment after vaginal hysterectomy for these reasons: (1) because of the infrequency of vaginal prolapse when compared with the frequency of hysterectomy, (2) because of the operative risks and postoperative complications, which when encountered may be significant, (3) because of the additional cost (should there be a charge) of the procedure to the patient or payor, and (4) because of the potential failure of the prophylactic procedure in the future. Sixty-six percent or two thirds of our patients treated therapeutically at Michigan 2 ex-
June 1990 Am J Obstet Gynecol
perienced their initial symptoms of prolapse longer than 5 years after hysterectomy. The short-term followup of the patients treated prophylactically in the authors' series had a mean of only 21 months. I have for Dr. Cruikshank one additional question out of curiosity. What was the incidence of prophylactic bilateral oophorectomy in your overall series? I thank you for the invitation to discuss this manuscript, and again my apologies to the essayist. REFERENCES 1. Symmonds RE, Pratt JH. Vaginal prolapse following hysterectomy. AM J OBSTET GVNECOL 1960;79:899-909. 2. Morley GW, DeLancey JOL. Sacrospinous ligament fixation for eversion of the vagina. AM J OBSTET GVNECOL 1988; 158:872-81.
DR. LEsTER A. BALLARD,JR., Cleveland, Ohio. At the Central Association meeting in 1986, Dr. Cruikshank presented a paper entitled, "Preventing Posthysterectomy Vaginal Vault Prolapse and Enterocele During Vaginal Hysterectomy," in which he described 112 consecutive vaginal hysterectomies where there were identifiable uterosacral cardinal ligaments. He described his technique of shortening and attaching these ligaments to the vaginal vault for vault support, as well as a technique for enterocele prevention with the use of high peritoneal ligation incorporating the anterior wall of the rectum to close the posterior cul-de-sac. These 112 operations were done from July 1983 to March 1986, and the patients had a mean age of 30, ranging from 23 to 69 years. In my discussion of his paper, I asked what he did when the uterosacral cardinal ligaments were nonexistent or stringlike and not strong enough to support the vaginal vault, as in the older postmenopausal patient with severe prolapse. I mentioned that 38 (34.5%) of our 110 sacrospinous ligament fixations where there was third-degree uterine prolapse (mean patient age 63.5 years) were required as a primary adjunct to vaginal hysterectomy to maintain adequate vaginal depth and axis. In their article the authors described a subsequent series of 135 vaginal hysterectomies where 48 patients required a sacrospinous fixation for vault suspension. This group of patients had a mean age of 50 (range 33 to 81 years) with the longest follow-up being 3.2 years. The authors have found sacrospinous ligament fixation to be a "useful adjunct" as a primary procedure done at the time of vaginal hysterectomy. The indications for Dr. Cruikshank's vaginal hysterectomies in 1986 were dysfunctional uterine bleeding, grade 2 and grade 3 cervical epithelial neoplasia, refractory dysmenorrhea, stress urinary incontinence, recurrent postmenopausal bleeding, and symptomatic pelvic relaxation. In this report the indications were the same as in 1986, except there was no separate symptomatic pelvic relaxation group. The authors included 32 cases of vaginal prolapse and 16 cases of relaxed vaginal outlet with symptomatic uterovaginal prolapse
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in these original five categories. I would have expected these patients to present with symptomatic pelvic pressure, bearing-down discomfort, protrusion, bleeding as a result of irritation, and urine irritability. The authors illustrated and described patients with moderate degrees of prolapse, defined as the presentation of the cervix past the midline portion of the vagina or to the introitus, and severe prolapse, defined as presentation of the cervix past the introitus but showing the body of the uterus in the vagina. It is interesting that Drs. Morley and DeLancey2 refer to the criteria of Wilson and Carrington, which describe a first-degree prolapse as the cervix being between the level of ischial spine and vaginal introitus, seconddegree prolapse as the cervix protruding through the introitus while the corpus remains in the vagina, and third-degree prolapse as complete prolapse of both the cervix and body of the uterus past the introitus and the entire vaginal canal everted. Therefore Dr. Cruikshank's moderate prolapse is Drs. Morley and DeLancey's first-degree, and Dr. Cruikshank's severe is Drs. Morley and DeLancey's second-degree and questionably third-degree together. Can the authors tell us how many cases were in the moderate and severe categories and did they include complete procidentia in the severe group? The authors described uterosacral cardinal ligaments as totally lax or nonexistent in all 48 patients. Their structures were unavailable to shorten and attach for support although an attempt was made. They presented three criteria for adjunctive prophylactic use of the sacrospinous ligament fixation at vaginal hysterectomy: (1) total laxity of the uterosacral cardinal complex, (2) moderate to severe laxity of the supportive structures and the ability to pull the vaginal apex past the introitus after hysterectomy and other plastic procedures, and (3) total procidentia. Being able to pull the vaginal apex past the introitus after removal is a new criterion. I certainly concur with the third criterion of total procidentia. Does one have to have all three criteria or just one or two? As a result of the authors' follow-up (mean 2 years), five anterior wall relaxations and two rectoceles were found; none of these patients had associated anterior and posterior colporrhaphy at the time of the sacrospinous ligament fixation. It is interesting that 37.5% of their patients had anterior-posterior repairs, 14.6% had anterior repairs only, 14.6% had posterior repairs only, and 33.3% had neither anterior nor posterior repair. Five patients had enterocele repairs, and one had vault recurrence. In our current series of 268 sacrospinous ligament fixations, 233 (87%) of our patients had anteriorposterior repairs, 29 (l O. 7%) had posterior repairs only, 3 (1.1 %) had anterior repairs only and 3 (1.1 %) had no repair. Six had vault recurrences. Because of our original anterior wall recurrences and anterior enterocele with vault recurrence, I have increased the percentage of anterior-posterior wall repairs, even if only
1617
minor degrees of weakness are evident, to attempt to prevent these recurrences. In Dr. Nichols' series of 163 patients, 59 (27.6%) cases were primary. In our own series of 268 sacrospinous fixations, 79 (29.5%) cases were primary. Dr. Nichols and I feel that primary sacrospinous fixation should be done at the time of vaginal hysterectomy when there are no surgically useful uterosacral cardinal ligaments for support of the vaginal vault. When cardinal uterosacral strength is lacking, an alternate method for vault suspension should be found. I would prefer not to rely on inadequate uterosacral cardinal ligaments for support or to have to depend on flimsy perirectal fascia and supralevator fascia support, for which one sacrifices depth and caliber. The latter procedure is good in the patient who does not want to maintain coital capacity. I concur with Drs. Morley and DeLancey that prophylactic use of sacrospinous ligament fixation for "usual" or mild to moderate degrees of uterine prolapse is not usually needed and is an additional unnecessary financial burden. Hoerr's law, as used at the Cleveland Clinic, states, "It is difficult to make the asymptomatic patient feel better with surgery." In patients with good uterosacral cardinal ligaments that can be shortened for vault suspension, there is no need to perform a sacrospinous ligament fixation. However, in the patient with severe and complete uterine prolapse without surgically usable or identifiable ligaments, I would prefer to use sacrospinous ligament fixation. Drs. Morley and DeLancey also state that" ... sacrospinous ligament fixation should be classified as a therapeutic procedure with the only reservation possibly being in patients with complete uterine prolapse as defined by Wilson and Carrington." I will look forward to follow-up reports of Dr. Cruikshank's 1986 and present series regarding the prevention of vaginal vault prolapse. REFERENCES 1. Cruikshank SH. Preventing posthysterectomy vaginal vault prolapse and enterocele during vaginal hysterectomy. AM J OBSTET GYNECOL 1987;156:1433-40. 2. Morley GW, DeLancey JOL. Sacrospinous ligament fixation for eversion of the vagina. AM J OBSTET GYNECOL 1988; 158:872-81. 3. Nichols DH. Sacrospinous fixation for massive eversion of the vagina. AM J OBSTET GYNECOL 1982;142: 901-4. 4. Nichols DH, Randall CL. Vaginal surgery. 3rd ed. Baltimore: Williams & Wilkins, 1989:321. DR. SCO'IT SNYDER, Columbia, Missouri. I would like to know how many of the 138 patients had retropubic urethropexies and how this influenced the decision to do the sacrospinous ligament fixation. DR S. ROBERT KOVAC, St. Louis, Missouri. I have a question to ask both Dr. Cruikshank and Dr. Morley. I'm a little bit confused, and maybe they can help me understand this better. Are we really quite sure what
1618 Cruikshank and Cox
the uterosacral-cardinal complex does anatomically to prevent vault prolapse? We need to decide whether this ligament complex supports the vagina or simply directs the vagina over the levator plate for support. Vault prolapse may be the result of a problem at a much higher pelvic level; therefore I think it is probably folly to rely on that particular complex as the sole definitive support of the vagina. We must decide what anatomically we are attempting to accomplish with any type of plication procedures involving these ligaments. If we believe that these ligaments can prevent vault prolapse, then I think we must accept the consequences that we are going to have vault prolapse after some hysterectomies whether they are performed abdominally or vaginally. However, sacrospinous fixation does not anatomically correct the cause of vault prolapse, but it does indirectly direct the vagina over the levator plate, perhaps better than plication procedures. It appears to me that "the horse is out of the barn, and we forgot to close the gate"; now we're trying to catch up with the problem of preventing future vault prolapse. I think the most important issue is to actually determine and agree on what anatomic structures cause vault and uterine prolapse. Then we as gynecologic surgeons can design a specific surgical procedure to correct this problem and not rely on whatever we have used in the past to prevent this condition now and in the future. DR. ALAN G. WAXMAN, Gallup, New Mexico. I wonder if, as Dr. Cruikshank expands his series, it might not be useful to introduce a comparison group, perhaps of the same patient population, randomized and operated on by the same surgeons so we can see if there really is efficacy from this procedure in the long run. DR. BRUCE C. RICHARDS, Lakewood, Colorado. In the appropriate case-and not to get into the controversy-for those that are interested in doing this procedure, I would endorse the notion of using the Mia hook. It is very facilitative. DR L. RUSSELL MALINAK, Houston, Texas. Was the cuff left open or was it closed in your patients with sacrospinous fixation? Does it matter? DR. CRUIKSHANK (Closing). I am humbled. First of all, I would like to thank the discussants. I'm reading the book Final Flight. A quotation from it goes like this: "Confront the enemy with the tip of your sword against his face," and that's what I'm going to do in this debate. The first thing I would like to say in respect to taking care of pelvic floor relaxation is that each aspect must be addressed to obtain optimal results. I think we need to keep that in mind when we're evaluating the patient in the office. I think the history and physical examination are probably the most important things, with the patient in the erect and the supine positions, not under anesthesia. Once you make your surgical decision and find out in which quadrant or which anterior-posterior area you have a defect, then you can plan your repair; then a
June 1990 Am J Obstet Gynecol
good pelvic examination with the patient under anesthesia should be done as well. I anticipated this discussion so I brought one certain article to help me. This is Dr. Morley'S article on sacrospinous fixation. He questions my indications and asked how many patients had procidentia. Procidentia was found in 8 patients. Severe prolapse as I defined it occurred in 24, moderate prolapse was found in 16. To back my manuscript further, the abstract of Dr. Morley and Dr. DeLancey says that while 57 patients had a posthysterectomy complete vaginal prolapse, 38 patients had an incomplete vaginal prolapse. Again on page 873 it is stated: "The indication for operation was total vaginal prolapse in 57 patients (vaginal apex below the introitus), incomplete vaginal prolapse in 38 (vaginal apex at or above the introitus), and enterocele in five." Now, if you recall my illustrations, the only differences between my criteria and his criteria is that the uterus is in situ in our patients. Once it's out, I then reexamine the patient and I've obtained his criteria. If I've done plastic repairs and I can still get the apex past the introitus or down to the introitus, then I've got the same problem as he does; that's why we have to take each defect and look at it individually and not just do a hysterectomy and say we solved it. Uterine prolapse is not the cause of genital prolapse. It's a result. So if we have anterior wall relaxation, posterior wall relaxation, or enterocele, that's the result of genital prolapse; do we really know what causes it? Well, we're trying to find out, but we all have techniques that we're trying to use to cure it, and that's what I'm doing. I would also like to read from Dr. Morley's article something else that parallels my manuscript (remember that the only difference is that the uterus is in situ in my patients until the hysterectomy is done): "Simply stated, all relaxations should not be treated as cystocelerectocele." I have the feeling that that's what he wanted me to do as long as the uterus was in situ. This in my opinion would result in posthysterectomy degrees of prolapse. Now, on page 878 of the article, I read: "An incomplete prolapse is present when any pathologic descensus down to the introitus exists. Any degree of descensus beyond this point is classified as a total vaginal prolapse. If further description of the prolapse is required, mensuration from the introitus as a reference point could be used." I think I attempted to define that, and I tried to do that in the office when the patients came in; if they could perform a Val salva maneuver of the uterus down to the introitus or past the introitus, there was more abnormality than just uterine prolapse. So I didn't want to do a hysterectomy and just say, "See you back after a while." The complications in Dr. Morley's patient population were no different from the complications in mine or the complications of Dr. Nichols, and they're not as bad as the complications we see from episiotomies and ce-
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sarean sections. We've got to do something about these routine-what we call therapeutic-operations that wreak a lot of havoc and have more morbidity than a sacrospinous fixation. Now, 0.2% to 1% as the incidence of vault prolapse is in the recent literature. Gynecology is very interesting. What is old literature? In the 1960s reports say vault prolapse occurs in 1% to 43%; is that the old literature? And in obstetrics "current" means "5 years old." In gynecology though, what's old? So the 0.2% to 1% figure represents the literature of the late 1970s
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and 1980s. But in the older literature, in the 1960s, it was as high as 43%. I spent some time in the Third World just this summer, and I can guarantee that some things are different. I was in Portugal. We had a whole ward of women who were seen with uterovaginal and vaginal prolapses, and there was close to if not more than 43% incidence. It may be their life-style or that the hysterectomy was performed wrong the first time. I don't know. It was very impressive.
Make researching easier with the Ten-Year Cumulative Index (1978-1987) to the AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY The Ten-Year Cumulative Index is a complete guide to more than 30,000 pages of original articles, case reports, letters, and editorials published in the AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY from 1978 through 1987 (volumes 130 to 157). Numbering more than 800 pages, the Cumulative Index includes both a subject and an author index. This hard-cover volume is $64.50 ($69.00 international). Prices include shipping. Payment must accompany all orders and must be in U.S. funds, drawn on a U.S. bank. Contact Mosby-Year Book, Inc., Circulation Department, 11830 Westline Industrial Drive, St. Louis, Missouri 63146-3318 USA; phone (314) 872-8370, ext. 7394. In the U.S., call toll-free: 1-800-325-4177, ext. 7394. Please allow six weeks for delivery.
