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.
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.
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%.
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.