The prevalence of vaginal vault prolapse after hysterectomy was reported to range from 0.2-43% [1]. Hysterectomy due to pelvic organ prolapse and the advanced stage of prolapse before surgery are considered the risk factors developing vaginal vault prolapse [2]. It was reported 5.5 times more than other reasons for hysterectomy [3]. 
	Vaginal bulging mass, pelvic heaviness, urinary dysfunction and defecatory dysfunction are the symptoms that have a negative impact on the quality of life of affected patients.
	Treatment consideration of vaginal vault prolapse has many options from conservative treatment such as avoid the risk that increasing intraabdominal pressure, pelvic floor muscle training and applying the mechanical devices (vaginal pessary) supporting the pelvic organ to surgical procedures [1]. The results and complications of each treatment varied and limited data. Therefore, we conducted the study to evaluate the prevalence of vaginal vault prolapse and the factors associated with treatment consideration.

This was a descriptive study. After the ethics committee was approved, the medical records were reviewed all patients diagnosed vaginal vault prolapse in urogynecology clinic, a tertiary hospital from November 2010 to December 2019. Baseline characteristics, the reasons for hysterectomy, the duration from hysterectomy to vaginal vault prolapse, the stage of prolapse (POP-Q), treatment, and outcomes of treatment were recorded. Statistical analysis was performed using STATA/SE version 10.1. Normality testing was conducted using Kolmogorov-Smirnov testing. The descriptive data were presented as percentages, means, and medians. The Chi-square, Fisher’s exact, ANOVA F-test and Kruskal-Wallis test were used as appropriate to compare between conservative and surgical treatment. Patients with failed pessary use and have undergone surgical intervention were classified in the surgical treatment group. p-values of <0.05 were considered to indicate statistical significance.

The total of pelvic organ prolapsed patients was identified during a nine years period was 803 patients. Among this group, fifty-three patients (6.6%) have undergone hysterectomy with vaginal vault prolapse. The mean age + SD and mean BMI + SD were 65.2 ± 9.3 years and 24 ± 3.7 kg/m², respectively. Almost all patients were menopause (98.1%). Two-third (64.2%) had underlying medical diseases. The most common indication of hysterectomy in vaginal vault prolapsed cases was pelvic organ prolapse (34.0%). However, total abdominal hysterectomy was the most common route of hysterectomy (69.8%) and followed by vaginal hysterectomy (28.3%). The mean duration + SD from hysterectomy to developing vaginal vault prolapse was 10.9 ± 8.9 years.
	Vaginal bulging mass was the most common symptom (96.2%) in vaginal vault prolapsed patients. Urgency urinary incontinence (43.4%) was the most common symptom of lower urinary tract dysfunction (LUTs) and followed by stress urinary incontinence (34.0%), mixed urinary incontinence (22.6%) and voiding difficulty (13.2%). Almost 70% of patients presented in advanced stage prolapse (Table1).
	Initially, forty patients with vaginal vault prolapse opted conservative treatment included pelvic floor muscle training (9 patients) and pessary use (31 patients). While the remaining patients have undergone surgery (9 patients) and will undergo surgery (4 patients). However, in pessary group, 15 patients changed their minds to have undergone surgery. Therefore, the total cases who have undergone surgery were 24 patients. 
	Ring pessary was the most common type supporting the pelvic organ in our study. It was 51.6%. Whereas, Donut (3.2%) and Gellhorn pessaries (6.5%) were considered the second choices after failed support pessaries. Vaginal erosion (16.7%) and abnormal vaginal bleeding (13.3%) were the common complications that we found during the pessary used. No vaginal infection was detected in our study (Table2). 
In surgical cases, the operation was considered as physicians’ discretion. We operated vaginal surgery with sacrospinous ligament fixation (37.5%), sacrocolpopexy (abdominal (4.2%) and laparoscopic route (20.8%)), colpocleisis (29.2%) and vaginal mesh surgery (8.3%) using Elevate mesh kit; anterior and apical fixation. Anti-incontinence procedures were performed in cases of having stress urinary incontinence in 4 cases (16.8%).
	Regarding perioperative outcomes, the median amount of blood loss and the median operative time were 20 ml. and 70 minutes, respectively. The mean duration of hospital stay after surgery was 2.7 days. One case was given blood transfusion. One case had extensive subcutaneous emphysema after laparoscopic sacrocolpopexy and resolved after conservative treatment with oxygen therapy. Other complications were shown in Table2. Recurrent prolapse after surgery was detected in two cases. One case was treated by vaginal pessary and another one had undergone the obliterative procedure.
	When compared between conservative treatment and surgery, we found that advanced stage prolapse had statistically significant to have undergone the operative procedure more than early stage prolapse (p=0.001).

The prevalence of vaginal vault prolapse was low (6.6%) when compared to all pelvic organ prolapse. The advanced stage of vault prolapse was the factor that significantly associated to have undergone operative procedure.

Among pelvic organ prolapsed cases, the prevalence of vaginal vault prolapse was low (6.6%). Most cases of vaginal vault prolapse occurring after hysterectomy of pelvic organ prolapsed cases. The treatment modalities initially from conservative treatment. Surgery was considered in failed conservative treatment. For the treatment consideration, the advanced stage of vault prolapse seems the factor associated with increasing surgical intervention.

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