Posthysterectomy vault prolapse of vaginal walls: Choice of operating procedure

Post-hysterectomy vaginal vault prolapse is a common complication following different types of hysterectomy with a negative impact on the woman's quality of life due to associated urinary, anorectal and sexual dysfunction. A clear understanding of the supporting mechanisms for the uterus and vagina is important in order to make the right choice of the corrective procedure and also to minimize the risk of posthysterectomy occurrence of vault prolapse. Preexisting pelvic floor defect prior to hysterectomy is the single most important risk factor for vault prolapse. Various surgical techniques have been advanced in hysterectomy to prevent vault prolapse. Vaginal vault repair can be carried out abdominally or vaginally. Sacrospinous fixation and abdominal sacrocolpopexy are the commonly performed procedures. The vaginal approach for vault prolapse is superior to the abdominal approach in terms of complication rates, blood loss, postoperative discomfort, length of hospital stay and cost-effectiveness. Moreover, it allows the simultaneous repair of all coexistent pelvic floor defects, such as cystocele, enterocele and rectocele. Abdominal sacrocolpopexy is associated with a lower rate of recurrent vault prolapse and dyspareunia than the vaginal sacrospinous colpopexy. Other less commonly performed procedures include uterosacral ligament suspension and illeococcygeal fixation with a high risk of ureteric injury. Surgical mesh of non-absorbent material is gaining in popularity and preliminary data from vaginal mesh procedures is encouraging.