Techniques of laparoscopic repair of total vault eversion after hysterectomy

Abstract Study Objective. To diagnose total pelvic vault eversion and develop surgical techniques for laparoscopic pelvic reconstruction in women after hysterectomy. Design. Prospective study. Setting. Regional hospital. Patients. Nineteen women with total pelvic vault eversion and other pelvic defects after hysterectomy. Interventions. All patients had a complete history and physical examination, and complete multichannel urodynamics. Cystocoele, rectocele, enterocele, and vault eversion were graded on a scale of 1 to 4. Posterior vaginal repair, sacral colpopexy, modified culdoplasty, paravaginal repair, and Burch urethropexy were performed laparoscopically according to the vault defects present. All patients had repeat transperineal ultrasound, cough stress test, urodynamic study, and vault examination 6 weeks and 1 year postoperatively. Measurements and Main Results. Extensive diagnostic and grading criteria were used to determine which surgical repairs would result in the most anatomic outcome. Before surgery, 6 patients had complaints of urinary stress incontinence and 11 others were identified with the pessary test. All 19 patients underwent a sacral colpopexy, modified culdoplasty, and Burch urethropexy. Six paravaginal and 13 posterior vaginal repairs were performed. At 6 weeks, two women had detrusor instability that resolved spontaneously; no patients had stress incontinence or pelvic prolapse. At 1 year, one patient had mild genuine stress incontinence (93% cure rate) and none had vault eversion (100% cure rate). Two patients had grade 1 cystocele; one had grade 1 and two grade 2 rectoceles. Conclusion. Initial results of laparoscopic repair of total pelvic vault eversion are comparable to those of other surgical approaches. Careful anatomic evaluation of the different defects, together with urodynamic studies, are necessary in treating this difficult disorder.