Indian Journal of Obstetrics and Gynecology Research

Print ISSN: 2394-2746

Online ISSN: 2394-2754

CODEN : IJOGCS

Indian Journal of Obstetrics and Gynecology Research (IJOGR) open access, peer-reviewed quarterly journal publishing since 2014 and is published under auspices of the Innovative Education and Scientific Research Foundation (IESRF), aim to uplift researchers, scholars, academicians, and professionals in all academic and scientific disciplines. IESRF is dedicated to the transfer of technology and research by publishing scientific more...


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Sonny and Kurniawati: Vault prolapse cases in Dr. Soetomo general hospital Surabaya


Introduction

Based on epidemiology data, vault prolapse is often occurred after hysterectomy procedure, and sometimes need a surgical repair. The prevalence of post-hysterectomy vault prolapse ranges from 0.2 to 43%. 1

However, not all women with vault prolapse require surgery. A large-scale study in Austria reported that out of 7,645 hysterectomy procedures, 577 cases of vault prolapse were found, those who were estimated to require surgical repair were 6-8%. 2

Materials and Methods

The data in this case report were obtained through medical records and register books from Urogynecology Division of Obstetrics and Gynecology Department, Soetomo General Hospital during 2015-2019. From these data, an assessment of patient characteristics, factors that were associated with the incidence of vault prolapse, and an overview of the operating modalities for vault prolapse repair performed at our teaching hospital, Dr. Soetomo General Hospital were carried out.

Results and Discussion

Characteristics of vault prolapse patients at RSUD Dr. Soetomo in 2015-2019

Most of the patients who come to the urogynecology clinic and are diagnosed with vaginal stomp prolapse or cervical stomp prolapse or vault prolapse are patients from another hospital.

Table 1

Patient data with vault prolapse at Dr. Soetomo General Hospital

No.

Case

(Complain)

(Physical examination)

Assessment

Procedures

1.

Mrs. ALM

52 y.o

Parity 2102

Youngest child: 22 y.o

Lump from the vagina

Inspekulo (Gynecologic Examination):

A slippery portio, good stomp suture, mass came out from anterior vaginal wall

Cervical stomp prolapse + Grade III Cystocele + Post SVH for uterine prolapse + Euthyroid phase hyperthyroidism

Transvaginal Trachelectomy + anterior and posterior colporrhaphy

Operation History: Post SVH for uterine prolapse indication in 3 years previously

Vaginal toucher

Mass came out from anterior vagina which was 4x4 cm, closed - smooth portio

Married 1x à 38 years

Aa +3 Ba +2 C +3

Contraception history: 3 months injection

GH 4 Pb 3 TVL 6

Sexual activity: active

AP -3 Bp -3 D -3

2

Mrs. HAS

58 y.o

Parity 7005

Youngest child: 14 years

Lump from the vagina

Inspekulo (Gynecologic Examination):

mass came out from posterior vaginal wall + vaginal stomp, good stomp suture

Grade III vaginal stomp prolapse + Post TAH-BSO for vaginal grade IV uterine prolaps + Grade III rectocele + Grade I cystocele + Nonsexual active

Colpocleisis

Operation History: Post TAH BSO for grade IV uterine prolapse in 1 year previously

Vaginal toucher:

Married 1x: 32 years

Mass came out from the vagina – which was about 5x5 cm

POP Q:

Contraception history: -

Aa -1 Ba -2 C +5

GH 4 Pb 3 TVL 8

Sexual activity: not active

AP +2 Bp +3 D ​​-

3

Mrs. HAR

50 y.o

Parity 2002

Youngest child: 20 y.o

Lump from the vagina

Inspekulo (Gynecologic Examination):

Mass came out from the vagina, good stomp suture

Grade III vaginal stomp prolapse + Post TAH-BSO for uterine prolapse + grade III cystocele + grade III rectocele

Sacrospinous fixation + anterior and posterior colporrhaphy

Operation History: Post TAH-BSO for uterine prolapse in 1 year previously

Vaginal toucher:

Mass came out from the vaginal stomp, anterior + posterior wall of the vagina

Married 1x à 25 years

POP Q:

Contraception history: 3 months injection

Aa +3 Ba +3 C + 3

GH 4 Pb 3 TVL 6

Sexual activity: active

AP +3 Bp +3 D ​​-

4

Mrs. NAI

53 y.o

Parity 6006

Youngest child: 14 y.o

Lump from the vagina

Inspekulo (Gynecologic Examination):

Mass came out from the vagina, good stomp suture

Grade III vaginal stomp prolaps + Post TAH for uterine prolapse + Grade III cystocele + Grade IV rectocele

Sacrospinous fixation + anterior and posterior colporrhaphy

Vaginal toucher:

Married: 1x à 16 years

Operation History: Post TAH for uterine prolapse in 2 years previously

Mass came out from the vaginal stomp, anterior + posterior wall of the vagina

POP Q:

Contraception history:

Aa +3 Ba +4 C +4

GH 5 Pb 3 TVL 7

Sexual activity: active

AP +3 Bp +6 D -

5

Mrs. NIK

58 y.o

Parity 4004

Youngest child: 22 y.o

Lump came out of the vagina

Inspekulo (Gynecologic Examination):

Pessary attached, good stomp suture

Vaginal stomp prolapse + Post TAH-BSO for uterine prolapse + Grade III cystocele + Grade II rectocele

Sacrospinous fixation + anterior and posterior colporrhaphy

Vaginal toucher:

Married: 1x à 42 years

Operation History: Post TAH-BSO for uterine prolapse in 3 years previously

Mass came out from the vaginal stomp, anterior + posterior wall of the vagina

POP Q:

Contraception: injection 3 monthly

Aa +3 Ba +3 C +2

GH 4,5 Pb 2,5 TVL 6

Sexual activity: active

AP +1 Bp +1 D -

6

Mrs. ROS

51 y.o

Parity 2002

Youngest chield: 17 years

Lump from the vagina

Inspekulo (Gynecologic Examination):

Mass came out from the vagina, vaginal stomp was good

Grade III vaginal stomp prolapse + Post TAH-BSO for uterine prolapse + Grade IV cystocele + Grade III rectocele

Colpocleisis

Vaginal toucher:

Married 2x:

Operation History: TAH-BSO for uterine prolapse in 7 years previously

Mass came out from the vagina

1. 1990-1991

2. 1990-2013

POP-Q:

Contraception history: Pills

Aa +3 Ba +5 C +4

GH 3 Pb 2 TVL 7

Sexual activity: not active

AP +3 Bp +4 D -

7

Mrs. TUM

61 y.o

Parity 5015

Youngest child : 29 y.o

Lump from the vagina, difficult urinating (dysuria)

Inspekulo (Gynecologic Examination):

a slippery portio, a mass came out fromr the anterior vagina

Grade I cervical stomp prolapse + Post SVH for uterine prolapse + Grade IV cystocele

Sacrospinous fixation + anterior and posterior colporrhaphy

Vaginal toucher:

Married 1x à 47 years

Operation History: Post SVH for uterine prolapse in 2 years previously

Mass came out from the anterior of the vagina

POP-Q:

Contraception history: Injection 3 monthly

Aa +3 Ba +5 C –2

GH 5 Pb 2 TVL 7

Sexual activity: Not active

AP -3 Bp -3 D -3

8

Mrs. UMU

59 y.o

Parity 2002

Youngest child: 27 y.o

Unsatisfied and incomplete urination (Urinary retention)

Inspekulo (Gynecologic Examination):

a mas came out from the vagina, good stomp suture

Grade IV vaginal stomp prolapse + Post TAH BSO for uterine prolapse + grade IV cystocele + grade III rectocele

Sacrospinous fixation + anterior and posterior colporrhaphy

Vaginal toucher:

Married 1x à 47 years

Operation History: Post TAH-BSO for uterine prolapse in 4 years previously

A mass came out from the anterior vagina + vaginal stomp

POP-Q:

Contraception history: 3 months injection

Aa +3 Ba +4 C +5

GH 5 Pb 3 TVL 6

Sexual activity: active

AP +3 Bp +3 D ​​-

9

Mrs. PUJ

64 y.o

Parity 4004

Youngest child: 28 y.o

Unsatisfied and incomplete urination (Urinary retention)

Inspekulo (Gynecologic Examination):

A slippery portio, a mass came out from the anterior vagina

Grade II cervical stomp prolapse + Post SVH-BSO for uterine prolapse + Grade III cystocele

Sacrospinous fixation + anterior and posterior colporrhaphy

Vaginal toucher:

Married 1x à 42 years

Operation history: Supravaginal hysterectomy- bilateral salpingo-oophorectomy for uterine prolapse in 5 years previously

A mass came out from the anterior vagina + vaginal stomp

POP-Q:

Contraception history:

Aa +2 Ba +3 C +1

GH 5 Pb 2 TVL 7

Sexual activity:

Not active

AP -3 Bp -3 D -3

10

Mrs. RIA

68 y.o

Parity 8018

Youngest child: 27 years

Lump from the vagina

Inspekulo (Gynecologic Examination):

A sippery portio, a mass came out from the posterior vagina

Servix stomp prolapse + Post SVH-BSO for uterine prolapse + grade III rectocele post

Trachelectomy transvaginal + anterior and posterior colporrhaphy

Vaginal toucher:

Married 1x à 49 years

Operation History: Post SVH-BSO for uterine prolapse + adenomyosis in 1 years previously

A mass came out from posterior vagina, good stomp suture

POP-Q:

Contraception history: -

Aa -3 Ba -3 C +4

GH 5 Pb 3 TVL 7

Sexual activity: Not active

AP +3 Bp +3 D ​​-

11

Mrs. JUL

62 y.o

Parity 2002

Youngest chield: 25 y.o

Lump from the vagina, painful urinating (dysuria)

Inspekulo (Gynecologic Examination):

A mass came out from from the anterior wall of the vagina + vaginal stomp + 7 cm

Prolapse vaginal stomp + Post TVH for uterine prolapse + Grade IV cystocele + Nonsexual active

Partial colpopexy + posterior colporrhaphy

Vaginal toucher:

Married 1x à 25 years

Operation History: Post TVH for uterine prolapse in 1 years previously

A mass came out from the anterior wall + vaginal stomp

POP-Q:

Contraception history: 3 months injection

Aa +3 Ba +5 C +6

GH 6 Pb 2 TVL 6

Sexual activity: Not active

AP +3 Bp +5 D -

12

Mrs. TRA

83 y.o

Parity 16-009

Youngest chield: 43 years

Lump from the vagina

Operation History: Transvaginal hysterectomy for uterine prolapse in 6 years previously

Inspekulo (Gynecologic Examination):

A mass came out from the anterior + posterior wall of the vagina, and vaginal stomp, good stomp suture

Grade IV vaginal stomp prolapse + Post TVH for uterine prolapse + Grade IV cystocele + Grade IV rectocele

Colpocleisis

Vaginal toucher:

Married 1x à 43 years

Married 1x à 43 years

A mass came out from the anterior wall + the posterior wall of the vagina, vaginal stomp

POP-Q:

Contraception history: -

Aa +3 Ba +4 C +4

GH 4 Pb 3,5 TVL 5

Sexual activity: not active

AP +3 Bp +4 D -

13

Mrs. JUW

63 y.o

Parity 6006

Youngest chield: 33 years

Lump from the vagina, difficult urinating (dysuria)

Inspekulo (Gynecologic Examination):

A mass came out from the anterior wall of the vagina + vaginal stomp, good stomp suture

Prolapse vaginal stomp + Post TVH for uterine prolapse + Grade III cystocele

Sacrospinous fixation + anterior and posterior colporrhaphy

Vaginal toucher:

Married 1x à 51 years

Operation History: Post TVH for uterine prolapse in 4 years previously

A mass came out from anterior vaginal wall + vaginal stomp

POP-Q:

Contraception history: -

Aa +3 Ba +2 C +3

GH 4 Pb 3 TVL 7

Sexual activity: not active

AP -3 Bp -3 D

14

Mrs. SUM

52 y.o

Parity 6015

Youngest chield: 22 y.o

Lump from the vagina

Operation History: Post TVH for uterine prolapse in 1 year previously

Inspekulo (Gynecologic Examination):

A mass came from anterior and posterior vaginal wall, the vaginal stomp comes out of the vaginal introitus

Grade IV vaginal stomp prolapse + Post TVH for uterine prolapse + Grade II cystocele + Grade III rectocele

Le Fort Colpocleisis

Vaginal toucher:

Married 2x:

A mass came out from the anterior and posterior vaginal wall, the vaginal stomp comes out of the vaginal introitus

1.1985-2012

2. 2012-3 years (husband died

POP-Q:

Contraception history: -

Aa +1 Ba 0 C +5

GH 4 Pb 3 TVL 6

Sexual activity: Not active

AP +3 Bp +2 D -

15

Mrs. SUN

62 y.o

Parity 2002

Youngest chield: 34 years

Lump from the vagina

Inspekulo (Gynecologic Examination):

A mass came out from the anterior + posterior vaginal wall, vaginal stomp, good stomp suture

Prolapse vaginal stomp + Post TVH for uterine prolapse + Grade IV cystocele + Grade III rectocele

Anterior and posterior colporrhaphy

Vaginal toucher:

Married 1x à 1980-1997 (husband died)

Operation History: Post TVH for uterine prolapse in 2 years previously

A mass came out from the anterior + posterior vaginal wall + vaginal stomp

POP-Q:

Contraception: injection 3 monthly

Aa +3 Ba +3 C +1

GH 5 Pb 3 TVL 7

Sexual activity: Not active

AP +3 Bp +3 D ​​-

16

Mrs. AMA

60 y.o

Parity 4004

Youngest child: 34 y.o

Lump from the vagina

Inspekulo (Gynecologic Examination):

A mass came out from anterior + posterior vaginal wall, vaginal stomp, good stomp suture

Grade IV vaginal stomp prolapse + Post TVH for uterine prolapse + Grade IV cystocele + Grade III rectocele

Sacrospinous fixation + anterior and posterior colporrhaphy

Vaginal toucher:

Operation History: Post TVH for uterine prolapse in 1 year previously

A mass came out from anterior + posterior vaginal wall, vaginal stomp

Married 1x à 45 years

POP-Q:

Contraception: -

Aa +3 Ba +4 C +4

GH 5 Pb 2 TVL 6

Sexual activity: Not active

AP +3 Bp +2 D -

Most patients have complaints of recurrent lumps and complaints of urinary disorders. In 2015-2019, the total number of cases of transvaginal hysterectomy (TVH) surgery in Dr. Soetomo General Hospital were 187 cases. In 2015-2019 there were 16 patients diagnosed with vault prolapse with a preoperative diagnosis of uterine prolapse (16 cases). Of the 16 cases of vault prolapse, 10 cases (62.50%) were post transabdominal hysterectomy procedure, and 6 cases (37.5%) were post transvaginal hysterectomy procedure, the distribution of cases in some hospital such as Dr. Soetomo General Hospital (3 cases), another cases performed outside Dr. Soetomo General Hospital. Describe in Table 1.

Of the 10 cases that were performed transabdominal surgery, 4 patients (40%) had suffered vault prolapse in the same year as the surgery, while the mean time of recurrence was 3.5 years. Of the 6 cases that were performed transvaginal surgery, 3 patients (50%) had suffered vault prolapse in the same year as the surgery and the mean time of vault prolapse insidence was 1 years.

From the patient characteristics that were suspected to be associated with risk factors for recurrence, it was found that the post-transabdominal hysterectomy vault prolapse case had an average age of 52.3 years, an average parity of 4, and an average BMI of 32. From the characteristics of post-transvaginal hysterectomy vault prolapse patients, they had an average age of 63.66 years, an average parity of 6, and an average BMI of 27.48.

Vault prolapse diagnosis

The assessment of women with symptoms of prolapse after hysterectomy should include a physical examination and a fundamental prior history. Current recommendations for objective assessment of vaginal support include the use of the Pelvic Organ Prolapse Quantification (POP-Q) system. Determination of apical prolapse or vault prolapse is done by measuring the location, relative to hymen with hysterectomy scar (point C) during maximal valsalva maneuver and/or traction during examination. As described, apical prolapse is often associated with more severe anterior or posterior compartment prolapse, so it is important to identify this in order to formulate an appropriate reparations strategy. 3

In our urogynecology outpatient clinic, we diagnosed vault prolapse based on history taking dan physical examination. The most important from history taking are about chief complaint such as lump came out from her vagina and any complaint related cystocele and rectocele, and her sexual activity. In physical examination, we used inspekulo, vaginal toucher and POP-Q to evaluate vault prolapse’s grade or severity and evaluate if the vault prolapse including anterior or posterior compartment. As a noted, in our hospital we used terminology vault prolapse with “stomp prolaps” or “apical prolapse”. After diagnosed the patient, this data was discussed in urogynecology department of obstetrics and gynecology to make consideration about the preparation of the second operation and what technique that appropriate for the patient.

Table 2

Characteristics of postoperative patients with vault prolapse repair at Dr. Soetomo General Hospital 2015-2019

Characteristics

%

Age

< 60 years-old

6

37.5

> 60 years-old

10

62.5

Parity

0

0

0

1-2

5

31.25

≥ 3

11

68.75

Number of Vaginal Deliveries

0

0

0

1-2

5

31.25

≥ 3

11

68.75

Body Mass Index

Underweight (< 18.5)

0

0

Normal (18.5-24.99)

7

43.75

Overweight (> 25-29.99)

8

50

Obesity (> 30)

1

6.25

Refferal Status

By reference

16

100

Come on their own accord (w/o reference)

0

0

Race

Javanese

13

81.25

Madurese

3

18.75

Others

0

0

Education

Elementary/Primary School

7

43.75

Junior High

3

18.75

High school

5

31.25

University

1

6.25

Profession/Occupation

Housewife

12

70.58

Traders

4

13.53

Previous Operation Techniques

Supravaginal hysterectomy

4

37.50

Total abdominal hysterectomy

6

9.59

Transvaginal hysterectomy

6

37.50

Recurrence After Post Vault Prolapse Correction (second reccurence)

Yes

2

5.88

No

15

88.23

Vault Prolapse Management

Procedure of vault prolapse is broadly divided into conservative and operative procedures. Conservative procedure includes pelvic floor exercises, stamping and pessaries placement. The role of this conservative procedure is unclear and there is still no evidence that pelvic floor muscle training is useful.4 However, pessaries may have limited benefits in patients who fear surgery and in very old women – where surgery is not an option.

Guidelines for determining surgery in cases of vault prolapse have almost the same principles in cases of genital organ prolapse which are planned for vaginal surgery. It is important to ask whether the woman (patient) is sexually active before considering vaginal surgery, as this can change surgery options. Another factor that influences the choice of surgery is patient suitability and surgeon preference.5

In our hospital, we performed various procedure for vault prolaps correction procedure such as transvaginal trachelectomy, colpoclesis, sacrospinous fixation. We gave information to the patient about the procedure, advantage and disadvantage and the chance of after the procedure.

Of the 10 cases of post-transabdominal hysterectomy vault prolapse, reoperation was performed at Dr. Soetomo General Hospital with various procedures; transvaginal trachelectomy + anterior and posterior colporrhaphy (2 cases), colpocleisis (2 cases), and sacrospinous fixation + anterior and posterior colporrhaphy (6 cases). There was 1 case after got vault prolaps correction preocedure with sacrospinous fixation + anterior and posterior colporrhaphy procedure had reccured again and then reoperated with trachelectomy + anterior and posterior colporrhaphy + sacrospinous fixation procedure in Dr. Soetomo General Hospital.

Of the 6 cases of post transvaginal hysterecromy vault prolapse, reoperation was performed with various procedures; colpocleisis (2 cases), Partial colpopexy + posterior colporrhaphy (1 case), sacrospinous fixation + anterior and posterior colporrhaphy (2 case), and anterior and posterior colporrhaphy (1 case). There was 1 case of post sacrospinous fixation + anterior and posterior colporrhaphy had reccured again recurred again and was performed correction with another sacrospinous fixation + anterior and posterior colporrhaphy operation in Dr. Soetomo General Hospital.

After the operation, patients are communicated, informed, and educated to avoid risk factors associated with 'relapse' such as to avoid heavy lifting activities and sexual intercourse for 6-8 weeks. From a total of 16 cases of vault prolapse that were reoperated with various procedures, the surgery success rate was 87.5%.

Conclusion

At Dr. Soetomo General Hospital, the number of cases vault prolapse post transabdominal and transvaginal surgeries has a similar percentage of cases. Various corrective action procedures were re-performed by the Urogynecology Division of Obstetrics and Gynecology, Dr. Soetomo General Hospital with good result.

Source of Funding

None.

Conflict of Interest

The authors declare that there is no conflict of interest.

References

1 

JW Barrington G Edwards Review Article Posthysterectomy Vault ProlapseInt Urogynecol J20001142415

2 

T Aigmueller A Dungl S Hinterholzer I Geiss P Riss An estimation of the frequency of surgery for posthysterectomy vault prolapseInt Urogynecol J201021329930210.1007/s00192-009-1033-4

3 

J L Lowder The role of apical vaginal support in the appearance of anterior and posterior vaginal prolapseObstet Gynecol200811111527

4 

S Hagen Conservative management of pelvic organ prolapse in womenCochrane Database Syst Rev200610.1002/14651858.CD003882.pub3

5 

AK Wiskind SM Creighton SL Stanton The incidence of genital prolapse after the Burch colposuspensionAm J Obstet Gynecol1992167239940510.1016/s0002-9378(11)91419-7



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© This is an open access article distributed under the terms of the Creative Commons Attribution License - Attribution 4.0 International (CC BY 4.0). which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.


Article type

Case Report


Article page

117-126


Authors Details

Fadli Sonny, E M Kurniawati


Article History

Received : 21-10-2020

Accepted : 05-11-2020

Available online : 13-03-2021


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