Vaginal Length Adjustments of the Michigan Modification Sacrospinous Suspension: Does the Size of the Prolapse Influence the Amount of Vagina Excised?

Drs. Rohna Kearney, John O. L. DeLancey

University of Michigan
Ann Arbor, Michigan

Objective : To quantify the amount of vaginal wall that exists between the anterior and posterior vaginal wall points selected to reach the sacrospinous ligament and to evaluate the size and location of this excised tissue relative to the size of the prolapse and location of the hysterectomy scar.
Materials and Methods : A prospective study of 62 women with post hysterectomy vaginal vault eversion who had the Michigan Modification of the sacrospinous suspension between 1998 and 2001 was performed.  The mean age of the women was 65.9 + 8.8 sd and mean parity 3.6 + 1.8.  The mean distance below the hymen of the most dependent POP-Q point was 4.8 cm + 2.7  (range 1.0 to 18 cm). During surgery, the distance from the hymeneal ring to the sacrospinous ligament where the vagina is to be suspended was assessed.  This distance was then measured along the posterior vaginal wall and this point on the vaginal wall was grasped with an Allis clamp.  The tip of the clamp was used to elevate this point to the sacrospinous ligament to confirm that this length of vagina comfortably reaches the ligament and eliminates any sagging of the wall. This process was repeated on the anterior vaginal wall.  The intervening vagina between these two points was measured. The distance from the center of vaginal wall to be excised and the hysterectomy scar was recorded. This vaginal length was then removed establishing a new apex that was to be suspended. 
Results : The size of the prolapse as determined by the distance below the hymen of the most dependent POP-Q point was strongly correlated with the amount removed (r = 0.71 p<0.0001). The length of the excised tissue was also correlated with preoperative vaginal length (r = 0.825 p < 0.0001).  The mean amount of vagina excised was 4.4cm + 2.6cm.  In 14 women (22.5%) the vagina reached the ligament without sagging and no vaginal wall was excised. Of the remaining 48 women who had vaginal wall removed the mean length excised was 5 cm. Seventeen women (27.4%) had 6 cm or more excised and one woman had 14 cm of vagina excised. The new apex was most often centered on the posterior vaginal wall (33 women, 53%).  Only in 19 (31%) women was the new apex centered on the hysterectomy scar while it was anterior in only 10 women (16%) women.  In 31 (50%) the scar was not included in the excised tissue, in 11 (18%) it was at the edge and in 20 (32%) within the excised area.
Conclusions : In women with post hysterectomy vaginal prolapse, the larger the prolapse, the more excess vagina is present.
Key Words : Sacrospinous suspension, vaginal length.