Previous Surgery

Reoperation rates for recurrent prolapse have been estimated to be approximately 30%. The time interval between repeat procedures for recurrent prolapse has been shown to decrease with each successive repair.5 Theoretically, previous surgical treatment will cause further damage to the nerves and surrounding support systems and is thus increasing potential risks for recurrent prolapse. Vaginal vault prolapse is a late and common complication after an abdominal or vaginal hysterectomy (Table 2-3.1), with a reported incidence as high as 43%.8 Marchionni and colleagues9 found that vault prolapse was higher when a hysterectomy had been performed for relaxation compared with a hysterectomy for benign disease (11.6% vs. 1.8%). For patients who underwent previous abdominal hysterectomy for benign disease, the incidence of vault prolapse was 2%, and, for those with a previous vaginal hysterectomy, the incidence was essentially zero.

Development of prolapse after retropubic urethropexy has been described in the literature with a reported occurrence rate of anywhere from 4% to 26%, depending on the surgical technique used, severity of prolapse, and duration of follow-up.10 In theory, prolapse occurs after a ure-thropexy because of the anterior displacement of the infe-

Table 2-3.1. Common sites for genital prolapse

Before Hysterectomy

After Hysterectomy

Cystocele

Vault prolapse

Uterine prolapse

Enterocele

Rectocele

Cystocele

Enterocele

Rectocele

Vault prolapse

rior portion of the vagina, which creates a change in vector forces, therefore making the upper portion of the posterior vaginal wall susceptible to increases in intraabdominal pressure.

The vaginal retroversion that is seen after sacrospinous fixation of the vaginal vault has been suggested to be a predisposing factor for the development of anterior vaginal wall defects. This is the result of excess intraabdominal pressure on the anterior vaginal wall from the exaggeration in the posterior vaginal wall axis deviation. Studies have indicated that the risk of development of a cystocele after sacrospinous ligament fixation is up to 20%.11,12

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