Vaginal McCall culdoplasty versus laparoscopic uterosacral plication to prophylactically address vaginal vault prolapse

The International Continence Society defines post-hysterectomy vault prolapse (PHVP) as descent of the vaginal cuff scar below a point that is 2 cm less than the total vaginal length above the plane of the hymen [1]. The incidence of PHVP has been reported to affect up to 43% of hysterectomies. The risk of prolapse following hysterectomy is 5.5 times more common in women whose initial hysterectomy was for pelvic organ prolapse as opposed to other reasons [1].

Preventative techniques can be used at the time of a hysterectomy to prevent PHVP. McCall culdoplasty and sacrospinous fixation can be carried out at vaginal hysterectomy [2]. Suturing the cardinal and uterosacral ligaments to the vaginal cuff at the time of abdominal or laparoscopic hysterectomy is effective in preventing post-hysterectomy vaginal prolapse [3].

Recommended management for PHVP can be largely divided into surgical and non-surgical. Methods of treatment offered depend on severity of prolapse but also takes into consideration patient wishes and expectations and suitability for surgery. Conservative management includes weight loss, treatment of constipation and avoidance of heavy lifting. Patients may also avail of physiotherapy and ring pessaries [4].

Techniques available to manage PHVP aim to ultimately suspend the vaginal vault. Approaches include vaginal, e.g. uterosacral ligament suspension, sacrospinous ligament fixation, open procedures and more recently laparoscopic, e.g. sacrocolpopexy and uterosacral plication [2, 5]. The decision-making process for managing these patients is similar to that of any prolapse, namely the response to conservative management, the effect on the quality of life and fitness for surgery [1].

Patients were identified who underwent ‘laparoscopic hysterectomy with uterosacral plication’ and ‘vaginal hysterectomy with McCall culdoplasty’ for pelvic organ prolapse performed by two consultant gynaecologists in Northern Ireland between January 2008 and January 2014. One surgeon performed each of the described procedures.

All patients had presented with subjective symptoms of pelvic organ prolapse, and objectively, this was confirmed on objective Pelvic Organ Prolapse Quantification (POP-Q) examination.

The technique used for vaginal hysterectomy and McCall culdoplasty is described by Raymond Lee of The Mayo Clinic [6]. Following vaginal hysterectomy, one to two internal McCall sutures are placed using a zero monofilament absorbable suture. Each McCall suture is placed deeply into the left pararectal fascia then across the front of the sigmoid colon and deep into the right pararectal fascia. An external McCall suture is subsequently placed, more cephalad to the internal McCall suture. A 1-0 delayed absorbable suture is passed through the posterior vaginal wall incorporating the peritoneum. The same suture is then placed deep through the left pararectal fascia, across the sigmoid colon and deep through the right pararectal fascia. The same external McCall suture is then placed back through the vaginal wall. Depending on anterior and posterior compartment prolapse, the patients may have also undergone an anterior and/or posterior colporrhaphy. All patients underwent routine cystoscopy with indigo carmine.

In the patients undergoing uterosacral plication, following total laparoscopic hysterectomy, the ureters were re-identified. A non-absorbable, zero monofilament suture was used to place three helical sutures full thickness in each uterosacral ligament, beginning in the distal third of the ligament and incorporating the posterior vagina. The ends of the suture were tied with an extra-corporeal knot-tying technique, thus shortening the uterosacral ligaments.

Both groups of patients had their charts reviewed retrospectively and were followed up on a regional electronic care record to see if they attended anywhere in the province for subsequent pelvic organ prolapse repairs.

A total of 143 patients were identified including 73 who had undergone total laparoscopic hysterectomy and uterosacral plication and 70 who had vaginal hysterectomy and McCall culdoplasty.

Mean follow-up was 36 months (range 5–84) in the uterosacral plication group and 41 months (range 5–71) in the McCall culdoplasty group.

The notes were reviewed for parity, age, BMI, indication for surgery, the surgical procedure performed, perioperative or post-operative complications, duration of inpatient stay and findings at their 6-month post-operative review where a POP-Q was performed along with any subsequent attendances.

The aetiology of PHVP is multifactorial; however, damage to the level one supports of the vagina during hysterectomy are thought to be a major contributing factor. The risk of this is thought to be greatest when the hysterectomy is performed for the indication of pelvic organ prolapse [7].

There are very few studies comparing vaginal McCall culdoplasty to laparoscopic uterosacral plication for prevention of subsequent prolapse.

In 1957, McCall described attaching the uterosacral ligaments to the posterior vaginal cuff and the cul de sac peritoneum in order to close off the cul de sac and prevent subsequent prolapse [8].

Uterosacral plication does not obliterate the cul de sac. It involves placing sutures distally on the uterosacral ligaments and tying them in the midline under tension away from their attachment into the vagina. The support this provides for the vagina has so far been unclear [9]. One of the theoretical advantages of laparoscopic over vaginal technique is the ability to identify the ureters, thus reducing the chance of inadvertent ureteric injury. Our study shows that in trained hands and with the prudent employment of indigo carmine and routine cystoscopy, the rate of ureteric injury is not significantly higher in the vaginal McCall group.

This study has retrospectively evaluated the McCall culdoplasty and the laparoscopic uterosacral plication when performed alongside hysterectomies in order to prevent PHVP. It has found them comparable in terms of complications encountered. Laparoscopic uterosacral plication has a statistically significant shorter hospital admission; however, McCall culdoplasty has proven to be superior to laparoscopic uterosacral plication in terms of patients representing with subsequent pelvic organ prolapse.

While both groups had a low rate of PHVP, in this study, McCall culdoplasty was a more successful operation compared to uterosacral plication with no difference in terms of perioperative complications.