Anterior, Posterior, and Apical Vaginal Vault Reconstruction Using Dermal Grafts
Drs. Michael J. Bonidie, Stacey South
Western Pennsylvania Hospital
Pittsburgh, Pennsylvania

Objectives: The objectives of this study are (1) identify a patient population with symptomatic pelvic organ prolapse quantified using the POP-Q system, (2) describe and perform an innovative operative technique for pelvic floor reconstruction utilizing dermal graft material, (3) determine the morbidity associated with this procedure, and (4) assess the efficacy of this repair.

Study design: A prospective cohort study evaluating 16 patients from June 2000 to July 2001 with pelvic organ prolapse before and after surgery using the POP-Q system. All patients under went transvaginal pelvic reconstruction using dermal grafts. The anterior vaginal graft was sutured at the lateral margin to the arcus tendineus fascia pelvis bilaterally. The posterior graft was sutured to the pelvic sidewall bilaterally and to the perineal body distally. Both grafts were sutured at the apex to the sacrospinous ligaments bilaterally. The grafts were also sutured together at the apex. All patients returned for at least one follow up visit, with the mean time of follow up being 11 wks. Factors considered for morbidity included receiving a transfusion of pRBCs, visceral injury, and post-operative fever.

Results: Using the POP-Q system, the mean values of Aa, Ba, C, Bp, and Ap for all patients prior to surgery were -0.7, +0.8, +0.6, +0.8, and +0.3, respectively. Post-operatively, the values improved to -2.63, -2.63, -7.13, -2.5, and -2.5, respectively. Only one patient had recurrence requiring revision. Morbidity consisted of one patient requiring transfusion of 2 units of pRBCs. Two patients had post-operative fever. Two patients sustained a cystotomy during a concurrent suburethral sling procedure, and one patient had a rectal injury. The mean EBL was 348 ± 144 cc. The mean operating room time was 157 ± 35 minutes. The mean hospital stay was 3.1 ± 0.7 days.

Conclusion: Preliminary data indicate that the use of dermal grafts for anterior and posterior vaginal vault reconstruction with bilateral sacrospinous ligament fixation for apical suspension is a viable alternative to currently accepted procedures. Early follow up has shown a resolution of pelvic floor prolapse in 93.7% of patients. Longer follow up and additional patients will be needed to prove the efficacy of this procedure.

Keywords: Vaginal vault prolapse, vaginal vault reconstruction, dermal grafts.