Vaginal surgical approach to vaginal vault prolapse: considerations of anatomic correction and safety

Pelvic organ prolapse is a common problem in women and often requires surgical management. Vaginal vault prolapse requires significant expertise. The pelvic reconstructive surgeon should be familiar with various methods of repair, including the vaginal approach, in order to provide appropriate individualized patient care. The safety of procedures should be balanced against the need for anatomic correction. Vaginal surgical approaches such as sacrospinous suspension, although shown in the past to have slightly less success than abdominal approaches such as sacral colpopexy, continue to have good safety and efficacy profiles, and may be used in appropriately selected patients. Randomized clinical trials are still required to compare different vaginal procedures such as sacrospinous and uterosacral ligament suspension. A new minimally invasive transperineal approach, posterior intravaginal slingplasty, requires further evaluation before being used in routine clinical practice. Posthysterectomy prolapse of the apical vaginal compartment frequently requires a surgical solution. This may be approached via the abdominal, vaginal or combined route. A vaginal approach, being less invasive, may be the safer option if carefully performed. The gynecologic surgeon must balance the advantages of anatomic correction (e.g. with sacrospinous vault suspension) against the advantages of a potentially safer yet less anatomically correct procedure (e.g. colpocleisis). The surgical approach must be individualized for every patient.