Post hysterectomy vaginal vault prolapse (PHVVP) occurs in up to 40% of women following hysterectomy with 6-8% of cases requiring surgery (1). PHVVP often has a significantly negative impact on a woman's quality of life by causing vaginal discomfort as well as bowel, bladder and sexual dysfunction. Therefore, many authorities recommend a procedure such as uterosacral ligament vault suspension (ULVS) is performed alongside hysterectomy to prevent future PHVVP. However, there is a concern that performing ULVS increases the risk of ureteric injury. The incidence of ureteric injury during ULVS is unknown but may be underestimated by studies which do not employ a reliable technique to detect ureteric complications. In this study we aim to investigate the incidence of ureteric  injury as well as other outcomes following ULVS procedures. Here we present a large case series detailing surgical outcomes from transvaginal ULVS with the use of intra-operative cystoscopy with indigocarmine to accurately detect ureteric injury.

A retrospective observational study was performed detailing outcomes from vaginal surgical procedures with transvaginal ULVS performed routinely during vaginal vault closure. All procedures were carried out in a single UK hospital by the senior author.   
In all cases ULVS was performed alongside a primary procedure of a vaginal hysterectomy.  

Data collection involved review of the case notes for all ULVS procedures performed  over a 4 year period. 142 women initially met inclusion criteria. Exclusion criteria were women with incomplete data available after case note review (n = 15). Data was collected on patient age, body mass index (BMI), co-morbidity, previous pelvic surgery, parity, menopausal status and indication for surgery. The primary outcome measure was the incidence of ureteric injury or obstruction. Secondary outcome measures included duration of operation, length of hospital stay, change in haemoglobin concentration between the preoperative value and the first post-operative day, surgical complications and histology. 

Intra-operative cystoscopy with indigocarmine (Indigotridisulfonate sodium) dye was used in all cases as it increases detection rates of ureteric injury  from 50% to 80-90% and bladder injury from 25% to 80% (2). Statistical analysis was performed using standard statistical techniques. Statistical significance was determined using the two tailed t-test. P < 0.05 was considered statistically significant for all comparisons. Ethical approval was not required for this study as it was a retrospective case series.

142 consecutive cases of ULVS met initial inclusion criteria. 127 (90%) had complete data sets available and were analysed.  The majority of patients were multiparous (96.1%), post-menopausal (55.9%) and had undergone previous pelvic surgery (52.8%). The mean body mass index was 29.4 and the mean age was 54.2. The most common indication for surgery was uterovaginal prolapse (71.7%). The overall complication rate was 7.1%. There was a single case of direct ureteric injury giving a ureteric complication rate of 0.8%. The ureteric injury was identified intra-operatively using cystoscopy with indigocarmine dye allowing prompt repair with minimal additional morbidity. The most common complication in this series was blood loss requiring transfusion which accounted for 50% (4 cases) of complications. However, in 3 out of these 4 patients the pre-operative haemoglobin was sub-optimal, being less than 10.5g/l, meaning these patients were more susceptible to post-operative anaemia even without excessive blood loss. There was a single patient who returned to theatre in the post operative period due to inadequate haemostasis from the uterine vascular pedicle which required resuturing. There were no bowel or bladder injuries, no intensive care admissions and no deaths. 99.2% of procedures were successfully completed vaginally with 1 case requiring conversion to laparotomy to complete the procedure.

The results of this study suggest ULVS is a safe additional procedure to perform at the time of vaginal hysterectomy to prevent PHVVP. The single ureteric injury that occurred in this series was unrelated to the ULVS part of the procedure (occurring during the vaginal hysterectomy stage of the operation), but if included gives an injury rate of 0.8%. The use of cystoscopy with indigocarmine dye represents a robust method for identifying ureteric injury intra-operatively. Intra-operative diagnosis is desirable as early recognition and repair of ureteric injury reduces post-operative complications, overall morbidity and the need for repeat operations. Limitations of this study include its retrospective nature as well as the fact that all operations were performed in a single unit by the same experienced surgeon.

In conclusion, ULVS represents a feasible and safe procedure for the prevention of PHVVP with a low rate of ureteric obstruction or injury. However, given the anatomical proximity of the ureter to the uterosacral ligament the authors recommend that intra-operative cystoscopy with indigocarmine dye should be used routinely as a simple method to identify ureteric injury or obstruction allowing immediate correction.

Aigmueller T, Dungl A, Hinterholzer S et al. An estimation of the frequency of surgery for post hysterectomy vault prolapse. Int Urogynaecol J 2010; 21: 299–302.
AAGL Practice Report: Practice Guidelines on the Prevention of Apical Prolapse at the Time of Benign Hysterectomy AAGL Advancing Minimally Invasive Gynecology Worldwide. J Minimally Invasive Gynecol. 2014; 21: 715–722.