Accurate repair of the prolapsed vagina by use of measured lateral flaps

Objective: We report our experience with a technique for planning the final vaginal caliber and location of the vaginal apex in patients with severe vaginal prolapse. Study Design: During the 2-year period ending April 1998, the technique was used in all 27 patients who were undergoing vaginal repair of prolapse performed by Mitchel S. Hoffman, MD, and who desired to retain the vagina but required at least partial excision. The major steps included determination of sites for lateral apical support, definition of the desired introital caliber, marking of the measured lateral vaginal flaps, excision of the intervening epithelium (and uterus if present, N = 14), high peritoneal closure, closure of the anterior vaginal wall, placement of apical supporting sutures, and completion of closure with tying of supporting sutures. Small flaps were designed for the 8 patients who did not anticipate further sexual intercourse. Results: The only intraoperative complication was hemorrhage >1000 mL in 3 patients. Immediate anatomic results were considered excellent for 26 patients. The only early postoperative complication was hemorrhage in a patient being treated with an anticoagulant; she responded to conservative management. Follow-up was available for 24 patients (21-42 months of follow-up; mean, 29 months). All patients had complete relief of prolapse symptoms. Anatomic results remained excellent for 21 of the 24 patients; in the remaining 3 patients asymptomatic grade 2 cystoceles developed at 6 to 12 months. Three patients had new urinary symptoms that persisted. Nine patients resumed sexual intercourse, with no difficulties noted. Conclusion: Defining the vaginal apex and designing lateral vaginal flaps facilitate the precise creation of an anatomically and functionally appropriate vagina, with reasonable morbidity, good symptomatic relief, and mild alteration of surrounding organ function. (Am J Obstet Gynecol 2000;183:286-90.)