Vault prolapse after hysterectomy treatment. Post-Hysterectomy Vaginal Vault Prolapse: Causes, Treatments, and Prevention

31.07.202309.07.2023 by alexxlab

What are the risk factors for post-hysterectomy vaginal vault prolapse. How can vaginal vault prolapse be treated surgically. Which surgical approaches are most effective for repairing vaginal vault prolapse. What preventive measures can reduce the risk of vault prolapse after hysterectomy.

Содержание

Understanding Post-Hysterectomy Vaginal Vault Prolapse

Post-hysterectomy vaginal vault prolapse is a condition that can occur following a hysterectomy procedure. It involves the descent of the upper part of the vagina into the vaginal canal or outside the vagina. This prolapse can significantly impact a woman’s quality of life, causing urinary, anorectal, and sexual dysfunction.

Why does vaginal vault prolapse occur after hysterectomy? The primary reason is the disruption of the normal supportive structures of the pelvic floor during the hysterectomy procedure. When the uterus is removed, it can weaken the attachments that normally hold the top of the vagina in place.

Prevalence and Risk Factors

The prevalence of post-hysterectomy vaginal vault prolapse varies, but studies suggest it affects a significant number of women who undergo hysterectomy. The single most important risk factor is a pre-existing pelvic floor defect prior to the hysterectomy. Other risk factors may include:

Age
Obesity
Chronic cough
Constipation
Heavy lifting
Genetic factors affecting connective tissue strength

Surgical Techniques for Preventing Vault Prolapse

Can vault prolapse be prevented during hysterectomy? While it’s not always possible to prevent vault prolapse, certain surgical techniques during hysterectomy may reduce the risk:

McCall culdoplasty: This involves suturing the uterosacral ligaments to the vaginal cuff
Sacrospinous ligament fixation: The vaginal cuff is attached to the sacrospinous ligament
Uterosacral ligament suspension: The vaginal cuff is suspended using the uterosacral ligaments
Prophylactic mesh placement: A synthetic mesh is used to reinforce the vaginal support

These techniques aim to provide additional support to the vaginal vault, potentially reducing the risk of future prolapse.

Surgical Approaches for Vault Prolapse Repair

When vault prolapse occurs, surgical repair is often necessary. The choice of surgical approach depends on various factors, including the severity of the prolapse, the patient’s overall health, and the surgeon’s expertise. The two main approaches are vaginal and abdominal.

Vaginal Approach

The vaginal approach for vault prolapse repair offers several advantages:

Lower complication rates
Reduced blood loss
Less postoperative discomfort
Shorter hospital stay
Cost-effectiveness
Ability to repair coexisting pelvic floor defects simultaneously

The most common vaginal procedures include:

Sacrospinous fixation: The vaginal vault is attached to the sacrospinous ligament
Iliococcygeus fixation: The vault is fixed to the iliococcygeus muscle
Uterosacral ligament suspension: The vault is suspended using the uterosacral ligaments

Abdominal Approach

The abdominal approach, specifically abdominal sacrocolpopexy, is associated with a lower rate of recurrent vault prolapse and dyspareunia compared to vaginal sacrospinous colpopexy. This procedure involves attaching a synthetic mesh from the vaginal vault to the sacrum.

Is abdominal sacrocolpopexy always superior to vaginal approaches? Not necessarily. While it may have some advantages in terms of long-term outcomes, it also has potential drawbacks:

Longer operating time
Increased postoperative pain
Longer recovery period
Higher cost

Emerging Trends in Vault Prolapse Repair

Recent developments in surgical techniques for vault prolapse repair have focused on minimizing invasiveness while maximizing effectiveness. Some emerging trends include:

Laparoscopic and Robotic Approaches

Laparoscopic and robotic-assisted sacrocolpopexy procedures are gaining popularity. These minimally invasive techniques offer the benefits of the abdominal approach with reduced postoperative pain and faster recovery times.

Mesh Augmentation

The use of surgical mesh in vaginal prolapse repair has been a topic of much discussion and research. While mesh can provide additional support and potentially reduce recurrence rates, it also carries risks such as mesh erosion and pain.

Are mesh augmentation procedures safe for vault prolapse repair? The safety and efficacy of mesh procedures continue to be studied. Current guidelines suggest that mesh should be used judiciously, considering the potential benefits and risks for each individual patient.

Comprehensive Management of Vault Prolapse

Effective management of vault prolapse extends beyond surgical repair. A comprehensive approach may include:

Preoperative Evaluation

Thorough preoperative assessment is crucial for successful treatment. This may involve:

Physical examination to assess the extent of prolapse
Urodynamic studies to evaluate bladder function
Imaging studies such as MRI or ultrasound to visualize pelvic floor anatomy

Pelvic Floor Rehabilitation

Pelvic floor muscle training, supervised by a specialized physiotherapist, can be beneficial both before and after surgical repair. This can help strengthen the pelvic floor muscles and improve overall pelvic organ support.

Lifestyle Modifications

Certain lifestyle changes can help manage symptoms and reduce the risk of prolapse progression:

Weight management
Avoiding heavy lifting
Treating chronic cough
Managing constipation

Long-term Outcomes and Follow-up

What can patients expect in terms of long-term outcomes after vault prolapse repair? While success rates are generally high, recurrence is possible. Factors influencing long-term outcomes include:

The specific surgical technique used
The surgeon’s experience
Patient factors such as age, weight, and tissue quality
Adherence to postoperative instructions and lifestyle modifications

Regular follow-up is essential to monitor for recurrence and address any complications promptly. Follow-up care may include:

Physical examinations to assess the repair
Symptom assessment
Quality of life evaluations
Pelvic floor muscle assessments

Future Directions in Vault Prolapse Management

The field of pelvic floor surgery continues to evolve, with ongoing research aimed at improving outcomes and reducing complications. Some areas of active investigation include:

Tissue Engineering

Researchers are exploring the use of bioengineered materials to create more compatible and durable surgical grafts for prolapse repair. These materials may offer the support of synthetic mesh with reduced risk of complications.

Regenerative Medicine

Stem cell therapies and growth factors are being studied for their potential to enhance tissue healing and strengthen pelvic floor support structures.

Advanced Imaging Techniques

Improved imaging modalities may allow for more precise preoperative planning and intraoperative guidance, potentially improving surgical outcomes.

Patient Education and Shared Decision Making

Effective management of vault prolapse requires active patient involvement. Healthcare providers play a crucial role in educating patients about their condition, treatment options, and long-term management strategies.

Informed Consent

Patients should be fully informed about the potential risks and benefits of different treatment options. This includes discussing:

The natural history of untreated prolapse
Conservative management options
Surgical approaches and their respective risks and benefits
Potential impact on sexual function and quality of life

Personalized Treatment Plans

Treatment decisions should be tailored to each patient’s individual needs, preferences, and health status. Factors to consider include:

Age and overall health
Severity of symptoms
Impact on quality of life
Desire for future pregnancies
Sexual activity

By engaging patients in shared decision-making, healthcare providers can ensure that treatment plans align with patients’ goals and values, potentially improving satisfaction and outcomes.

Psychosocial Aspects of Vault Prolapse

The impact of vault prolapse extends beyond physical symptoms, often affecting patients’ emotional well-being and social interactions. Healthcare providers should be attentive to these psychosocial aspects of the condition.

Emotional Support

Many women with vault prolapse experience feelings of embarrassment, anxiety, or depression. Providing emotional support and referrals to mental health professionals when necessary can be an important part of comprehensive care.

Sexual Counseling

Vault prolapse can significantly impact sexual function and intimacy. Open discussions about sexual concerns and appropriate counseling or referrals can help patients navigate these challenges.

Support Groups

Connecting patients with support groups or peer counseling programs can provide valuable emotional support and practical advice for living with vault prolapse.

In conclusion, post-hysterectomy vaginal vault prolapse is a complex condition that requires a multifaceted approach to management. From preventive strategies during hysterectomy to advanced surgical techniques for repair, the field continues to evolve. By combining surgical expertise with comprehensive patient care, including attention to lifestyle factors and psychosocial support, healthcare providers can help women affected by vault prolapse achieve improved quality of life and pelvic floor health.

[Posthysterectomy vault prolapse of vaginal walls: choice of operating procedure]

. 2012 Sep-Oct;140(9-10):666-72.

doi: 10.2298/sarh2210666a.

[Article in

Serbian]

Rajka Argirović

PMID:
23289289
DOI:
10.2298/sarh2210666a

Free article

[Article in

Serbian]

Rajka Argirović.

Srp Arh Celok Lek.

2012 Sep-Oct.

Free article

. 2012 Sep-Oct;140(9-10):666-72.

doi: 10.2298/sarh2210666a.

Author

Rajka Argirović

PMID:
23289289
DOI:
10. 2298/sarh2210666a

Abstract

Post-hysterectomy vaginal vault prolapse is a common complication following different types of hysterectomy with a negative impact on the woman’s quality of life due to associated urinary, anorectal and sexual dysfunction. A clear understanding of the supporting mechanisms for the uterus and vagina is important in order to make the right choice of the corrective procedure and also to minimize the risk of posthysterectomy occurrence of vault prolapse. Preexisting pelvic floor defect prior to hysterectomy is the single most important risk factor for vault prolapse. Various surgical techniques have been advanced in hysterectomy to prevent vault prolapse. Vaginal vault repair can be carried out abdominally or vaginally. Sacrospinous fixation and abdominal sacrocolpopexy are the commonly performed procedures. The vaginal approach for vault prolapse is superior to the abdominal approach in terms of complication rates, blood loss, postoperative discomfort, length of hospital stay and cost-effectiveness. Moreover, it allows the simultaneous repair of all coexistent pelvic floor defects, such as cystocele, enterocele and rectocele. Abdominal sacrocolpopexy is associated with a lower rate of recurrent vault prolapse and dyspareunia than the vaginal sacrospinous colpopexy. Other less commonly performed procedures include uterosacral ligament suspension and illeococcygeal fixation with a high risk of ureteric injury. Surgical mesh of non-absorbent material is gaining in popularity and preliminary data from vaginal mesh procedures is encouraging.

Cited by

Treatment of vaginal vault prolapse in The Netherlands: a clinical practice survey.
Vermeulen CKM, Coolen ALWM, Spaans WA, Roovers JPWR, Bongers MY.
Vermeulen CKM, et al.
Int Urogynecol J. 2019 Apr;30(4):581-587. doi: 10.1007/s00192-018-3832-y. Epub 2018 Dec 4.
Int Urogynecol J. 2019.
PMID: 30515540

Publication types

MeSH terms

Vaginal Prolapse | Johns Hopkins Medicine

What You Need to Know

Vaginal prolapse, also known as vaginal vault prolapse, occurs when the top of the vagina weakens and collapses into the vaginal canal. In more serious cases of vaginal prolapse, the top of the vagina may bulge outside the vaginal opening.
Symptoms of vaginal prolapse include the feeling of vaginal pressure or fullness — like you’re sitting on a small ball — and the sensation that something has fallen out of your vagina.
A cystocele or rectocele usually occurs with vaginal prolapse.
Mild cases of vaginal prolapse do not require treatment. Moderate to severe symptoms require nonsurgical therapies or minimally invasive surgeries, such as vaginal prolapse repair.

What is vaginal prolapse?

Prolapse occurs when a woman’s pelvic floor muscles, tissues and ligaments weaken and stretch. This can result in organs dropping out of their normal position. Vaginal prolapse refers to when the top of the vagina — also called the vaginal vault — sags and falls into the vaginal canal. In severe cases, the vagina can protrude outside of the body.

What causes vaginal prolapse?

There are no direct causes of vaginal prolapse. However, women are at an increased risk of developing vaginal prolapse if they:

Delivered children vaginally, especially repeat deliveries
Are approaching or experiencing menopause
Have certain lifestyle factors, including being overweight
Were born with a rare condition, such as bladder exstrophy

Vaginal Prolapse After Hysterectomy

Hysterectomy, a surgery to remove a woman’s uterus, is sometimes performed to treat uterine prolapse. However, vaginal prolapse can occur after hysterectomy (regardless of the reason for hysterectomy). This is called “vaginal prolapse after hysterectomy.”

How common is vaginal prolapse?

Vaginal prolapse is relatively common. About one-third of women will experience some degree of prolapse during their lifetime. If you have more than one risk factor, your chances of developing vaginal prolapse increase.

What are the signs and symptoms of vaginal prolapse?

Vaginal Pressure

Women with vaginal prolapse often report feeling pressure in the vaginal area, described as a throbbing pain in the vagina. Women also report:

Vaginal fullness (such as the feeling that something is stuck in the vagina)
The sensation that something is falling out of her vagina

Additional Vaginal Prolapse Symptoms

The pelvic organs are all supported by each other. When one organ prolapses, it can affect the functioning of other nearby organs. Thus, some women also experience:

Changes in bowel function, such as difficulty having a bowel movement
Changes in bladder function, such as inability to empty the bladder
Secondary prolapses, specifically rectocele prolapse (sagging of the connective tissue between the vagina and rectum) or cystocele prolapse (sagging of the connective tissue between the vagina and the bladder).
Pain or discomfort during sexual intercourse
Difficulty using tampons

How is a vaginal prolapse diagnosed?

Your doctor will review your medical and surgical history and complete a physical exam. Additional tests, such as ultrasound or MRI, are rarely needed. In some cases, your doctor may also recommended urodynamics testing, a group of tests that evaluate bladder function.

The Johns Hopkins Women’s Center for Pelvic Health & Reconstructive Surgery

Our team of compassionate urogynecologists uses the latest research and advanced technologies to treat a range of pelvic floor disorders.

Learn how our urogynecology team can help.

How is vaginal prolapse treated?

Treatment for vaginal prolapse varies, depending on the severity of the symptoms. Many cases will not require treatment. In mild cases, your physician may recommend pelvic floor exercises to strengthen the muscles. In moderate cases, your doctor may insert a vaginal pessary to support your vaginal wall. In the most severe cases, you may benefit from surgery, such as colposuspension, a minimally invasive surgical procedure, where the vaginal wall is attached to a stable ligament in the pelvis.

Surgery for apical vaginal prolapse in women

Review question

Which surgical procedures for apical vaginal prolapse lead to the best results?

Relevance

Apical vaginal prolapse is a prolapse of the uterus or (after a hysterectomy) of the upper part of the vagina (fornix). There are various methods of surgical treatment, but there is no recommendation as to which one is best.

Study profile

Thirty randomized controlled trials evaluated 3414 women undergoing surgery for apical vaginal prolapse. The most common comparisons were between vaginal access surgery and sacral colpopexy (an abdominal surgery in which the upper part of the vagina is suspended with a graft at the level of the sacral promontory) (six randomized controlled trials (RCTs)), between vaginal access surgery with with and without mesh (six RCTs), between vaginal hysterectomy and its alternatives (six RCTs), and between different types or modes of sacral colpopexy (eight RCTs). The evidence is current to July 2015.

Main results

Compared with various reconstructive vaginal surgeries, sacral colpopexy was associated with a lower incidence of sensation of prolapse, reoperation for prolapse, detection of prolapse on examination, stress urinary incontinence (SUI), and painful intercourse. While 7% of women experience prolapse (drooping and prolapse) after sacral colpopexy, 14% (7% to 27%) of women are likely to experience it after vaginal surgery. If after sacral colpopexy 4% of women will need a second operation for prolapse, then after vaginal operations it will be required by 5-18% of women.

We did not find convincing evidence that vaginal surgery increases the need for reoperation for SUI. If after sacral colpopexy, 3% of women will need reoperation for SUI, then after vaginal surgery, 2-16% of women will need it.

Limited evidence does not support the use of transvaginal mesh versus native tissue repair. The evidence was inaccurate, but suggests that if 18% of women experience prolapse after non-mesh surgery, 6-59% of women will feel it after mesh surgery. While 4% of women will need re-surgery for prolapse after non-mesh surgery, 1-7% of women will need it after mesh surgery. We did not find clear evidence that mesh surgery reduces the recurrence of prolapse. Most of the transvaginal meshes studied (in studies) are no longer being produced, and there is currently no evidence for the safety of the newer, lighter meshes.

Evidence was inconclusive when comparing uterine-sparing surgery with vaginal hysterectomy, and when comparing different methods of sacral colpopexy.

Quality of evidence

The quality of the evidence ranged from very low to moderate. Limitations included inaccuracies, incomplete reporting of study methods, and lack of consistency.

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Translation notes:

Translation: Anastasia Evgenievna Volozhaninova. Editing: Yudina Ekaterina Viktorovna. Project coordination for translation into Russian: Cochrane Russia – Cochrane Russia (branch of the Northern Cochrane Center on the basis of Kazan Federal University). For questions related to this translation, please contact us at: [email protected]; [email protected]

Genital prolapse.

Pelvic organ prolapse in women.

Prolapse of the cervix, vaginal wall with urinary
bladder and/or rectal wall or bowel loops are combined with the concept of prolapse
pelvic organs. The symptoms of pelvic prolapse affect a woman’s quality of life,
on general well-being and sexual function. This is a serious medical and social
problem.

Types of pelvic organ prolapse in women

Lateral anterior
prolapse – if the leading prolapse point
is the anterior wall of the vagina with the posterior wall of the bladder (cystocele).

Lateral posterior
prolapse – if the posterior wall predominates
vagina or anterior wall of the rectum.

Central or
apical prolapse – predominance of cervical prolapse, sagging
fornix of the vagina.

When the uterus is removed and there is prolapse or
sagging of intestinal loops through the vaginal stump, they speak of enterocele as a variant of the apical or
central prolapse.

These terms are provisional, but the definition of prevailing
compartment is important when choosing the type of treatment.

The border of the exit of organs outside the small pelvis
is the plane of the hymen or hymen. To understand how it goes
prolapse, understand the normal anatomy and mechanisms that hold the vagina
in normal condition.

Anatomy of the pelvic organs in women

Anatomical support of the pelvic organs in women
women is provided by the interaction between the muscles of the pelvic floor and
connective tissue fascia and ligaments connecting the pelvic bones with organs.
Together, these muscles and ligaments provide stable support to the organs.
small pelvis, while maintaining elasticity. Also a powerful stabilizing
the factor is the complex of sacro-uterine and cardinal ligaments of the uterus.

DeLancey pelvic support levels:

sacro-uterine and cardinal ligaments that fix the uterus and upper third
vagina to the sacrum and side wall of the pelvis. They allow the uterus to hold on
vertically. Destruction of these ligaments, for example, as a result of traumatic childbirth,
leads to prolapse of the cervix, and then the entire uterus, along with the upper third
vagina.

Second level
support – a complex of fascial structures
laterally from the vagina or located along the length of the vagina and passing to
levators and the linea alba of the fascia of the pelvis. Damage to these structures leads to
prolapse of the bladder and the anterior wall of the vagina.

Third level – perineal body, including superficial and deep
perineal muscles that support the distal third of the vagina. Damage to these
structures anteriorly leads to hypermobility of the urethra, and posteriorly to a rectocele or
prolapse of the posterior wall of the vagina with the anterior wall of the rectum.

The innervation of the supporting
apparatus at the expense of the spinal cord. Certain nerve fibers form
pudendal or pudendal nerve. The superior bundles of the pudendal nerve supply the levators,
pubic-coccygeal muscle, urogenital diaphragm, and below the genital
nerve innervates the anal sphincter.

Risk factors for prolapse

Risk factors for pelvic organ prolapse in women
include natural childbirth and its number, age and obesity. Risk factors
recurrence of prolapse after surgical correction include muscle damage,
raising the anus, treatment of advanced forms of prolapse and family forms
diseases.

Number of deliveries

The risk of prolapse increases with the number of deliveries
through the natural birth canal in history.

Oxford Family Planning study, which
covered more than 17,000 women who were followed for 17 years, showed
that compared with nulliparous, the risk of hospitalization for prolapse is markedly
increased after the first (4 times) and second (8 times) births, and then increased
slower: after third birth at 9times, fourth – 10 times and so on.

Factors associated with childbirth and the development of prolapse,
include high birth weight, long second stage of labor, and
maternal age less than 25 years at first birth. However, vaginal prolapse can
occur in nulliparous women.

Old age

The risk of prolapse increases with age.

women” (more than 27,000 women) there was a small but statistically significant
progressive increase in the prevalence of rectocele with age (from 50 to 59compared with 60 to 69 and from 70 to 79 years).

Obesity

Overweight women (BMI ≥25–29.9 kg/
m2) and obese (BMI ≥30 kg/m2) have an increased risk of prolapse
compared with peers with normal weight. At the same time, the question of whether
whether weight loss leads to regression of prolapse remains debatable, but there are reports of
regression of prolapse in women after bariatric surgery.

Hysterectomy

Role of hysterectomy in subsequent prolapse
pelvic organs is controversial. Risk may depend on age, presence of prolapse
before hysterectomy and surgical access.

Retrosymphysial urethropexy or suspension procedure

(fixation of the uterus to
posterior surface of the symphysis pubis) can lead to a greater deviation
anterior wall of the vagina anteriorly, which changes the distribution of force over all
the walls of the vagina. As a result, the apex and posterior wall of the vagina may become
prone to developing support defects, including enterocele or rectocele.

Increased
intra-abdominal pressure

Chronic constipation and other conditions causing
recurring increase in intra-abdominal pressure, such as chronic
obstructive pulmonary disease, can cause stretching and damage to the genital
nerve.

Currently no reliable data
regarding whether the risk of prolapse is increased in women involved in lifting
weights. One study of over 1,000 women found that women
those who perform physically strenuous work have significantly more severe prolapses,
than other categories of women.

Connective tissue pathology

Certain connective tissue diseases
(eg, Ehlers-Danlos syndrome) or congenital anomalies (eg, exstrophy
bladder) contribute to the development of prolapse. In women with hypermobility
joints have a higher prevalence of prolapse than women with
normal joint mobility.

Family history

Potential genes and inheritance patterns
unknown. Most likely, we are talking about connective tissue dysplasia as
cause of the prolapse.

Symptoms of pelvic organ prolapse in women

foreign body sensation and heaviness in the area
perineum, vaginal discomfort
urinary disorders (cystocele and urethrocele):
frequent urination, lack of satisfaction with the act
urination, urge to urinate, urinary incontinence when coughing, and any
load and so on.
defecation and stool disorders (rectocele,
enterocele, sigmoidocele, perineocele, rectal prolapse): fecal incontinence,
rectal bleeding.
sexual dysfunction.

Lower back or pelvic pain is often associated with prolapse,
but this relationship has not been confirmed in studies.

Prolapse symptoms are often associated with body position: less
noticeable in the morning or when lying on the back and worse during the day when
women are active and upright.

Many women with prolapse have no symptoms,
treatment in this case is usually not indicated. Some women see for themselves
protrusion of organs outside the genital slit.

Complications of pelvic organ prolapse

chronic vaginitis and persistent pathological discharge. Mucosal contact
with the external environment gradually leads to the formation of ulcers and bleeding.

Treatment

Treatment indicated for women with symptoms of prolapse or
symptoms associated with prolapse (impaired urination and emptying
bowel or sexual dysfunction).

Establishing the patient’s goals is central to setting
treatment tactics. The method is selected individually according to the symptoms and
their impact on quality of life. It is important to set realistic expectations with
taking into account comorbid somatic diseases that affect the perception of symptoms.

The choice of therapy depends on the preference of the woman and
also on the ability to comply with recommended conservative therapy (as
usually exercise) or undergo surgery.

Expectant management – suitable for
women who are not very concerned about their symptoms and can tolerate it for the time being, do not
deciding to have surgery. However, patients with grade 3 or 4 prolapse are at risk
accession of additional problems with urination and defecation, due to
than regular monitoring is recommended.

Vaginal pessaries

The main alternative to prolapse surgery is
use of vaginal pessaries.

Pessaries are silicone devices of various
shapes and sizes that support the pelvic organs. Pessaries needed
remove and clean regularly.

Pelvic floor training (Kegel exercises).

Randomized trials have shown
the benefits of such exercises, especially when taught individually and/or under
observation. Therefore, biofeedback therapy has become widespread. The less
the degree of prolapse, the more effective the exercise program.

Estrogen therapy

No evidence to support systemic or local
the use of estrogen as the main therapy for prolapse. At the same time, introduction
estrogen in the vagina in the perioperative period increases the production of mature
collagen, increases the thickness of the vaginal wall and reduces the activity
degrading enzymes.

Surgery

Candidates for surgery are women
with symptoms of prolapse who cannot perform conservative measures
or refuse them deliberately.

Operations for pelvic organ prolapse are performed vaginally
and abdominal accesses using local tissues and synthetic
materials.

The choice of surgical tactics depends on the severity
symptoms, degree of prolapse, experience of the surgeon, and expectations of the patient. One of
problems of prolapse surgery is the recurrence rate. Risk of repeat surgery
when using local fabrics, according to various sources, it reaches 30%. That’s why
technologies with the use of synthetic prostheses are widely used

Sacrocolpopexy and strengthening of the middle third of the urethra
– methods that have proven effective when using mesh materials. Rest
technology, especially the use of synthetic materials for vaginal
access are debatable and even “forbidden” in different countries.

Thus, the use of local fabrics and
suburethral sling with vaginal access, as well as sacrocolpopexy and
Birch operation (fixation of the anterior wall of the vagina to the Cooper ligament of the pubic
bones through access to the Retzian space) with abdominal access
are considered today as operations that have proven their
consistency in accordance with international clinical guidelines.

Prevention of prolapse

Strategies for the prevention of prolapse and its progression are not well understood.