Is a 70-year-old patient with a history of grade 4 prolapse in all compartments, who recently underwent repair of cystocele (bladder prolapse) and rectocele (rectal prolapse), also indicated for total vault construction?

Total Vault Construction is Indicated for This Patient with Grade 4 Vault Prolapse

For this 70-year-old patient with grade 4 prolapse in all compartments who has already undergone cystocele and rectocele repair, total vault construction is strongly indicated to address the remaining vault prolapse and prevent recurrence of symptoms.

Rationale for Total Vault Construction

The patient presents with a complex pelvic floor defect including:

• Grade 4 prolapse in all compartments (complete procidentia)
• Already completed cystocele and rectocele repair
• Persistent vault prolapse (grade 4)
• Significant symptoms affecting quality of life (pain, pressure, inability to walk, urinary symptoms)
• History of hysterectomy 20 years ago

Evidence Supporting Vault Construction

Patients with symptomatic grade 3-4 prolapse require surgical intervention to address all compartments involved 1. The patient has already had repair of the anterior (cystocele) and posterior (rectocele) compartments, but still requires management of the vault prolapse component.

When vault prolapse exists with cystocele and rectocele (as in this case), a comprehensive approach addressing all compartments is necessary for optimal outcomes 1. Failure to address the vault component can lead to recurrence of prolapse in the previously repaired compartments.

Surgical Options for Vault Prolapse

For this patient with grade 4 vault prolapse, several options exist:

1. Total vault construction/suspension - Indicated for this patient
2. Sacrocolpopexy with mesh interposition
3. Iliococcygeus fascia suspension
4. Sacrospinous ligament fixation

Why Total Vault Construction is Preferred for This Patient

Total vault construction is particularly appropriate because:

1. The patient has already undergone repair of cystocele and rectocele, but still has grade 4 vault prolapse
2. The patient has severe symptoms affecting quality of life
3. The patient has a history of prior hysterectomy (20 years ago)
4. All compartments were initially affected (grade 4 prolapse in all compartments)

Studies have shown that addressing vault prolapse is critical when multiple compartments are involved. Research by Shull et al. 2 demonstrated excellent long-term results with suspension of the vagina to support structures, with only 4 recurrences in 110 patients after 3 years of follow-up.

Expected Outcomes and Benefits

With total vault construction, the patient can expect:

• Restoration of normal vaginal axis and depth
• Resolution of symptoms including pain, pressure, and difficulty walking
• Improvement in urinary symptoms (both urgency and SUI)
• Prevention of recurrence in the anterior and posterior compartments

Sacrocolpopexy with mesh interposition has shown significant reduction in vault prolapse and rectocele with improvement in symptoms 3. In one study, all women with Stage II and III vault prolapse were successfully corrected with this approach.

Potential Complications and Considerations

• Age (70 years) is not a contraindication for vault construction
• Prior hysterectomy makes vault suspension particularly important
• Urinary symptoms (urgency, UUI, SUI) may improve with proper vault support
• Failure to address the vault component could lead to recurrence of cystocele or rectocele

Alternative if Surgery Contraindicated

If for any reason surgery becomes contraindicated, pessary management could be considered. For severe prolapse (grade 4), a double pessary technique might be required 4, though this would be less optimal than surgical correction given the patient's symptoms and activity limitations.

In conclusion, this patient with grade 4 vault prolapse who has already undergone cystocele and rectocele repair clearly requires total vault construction to address her remaining prolapse and provide complete resolution of her symptoms.