Posthysterectomy vault prolapse and uterovaginal prolapse has remained a challenging problem for the pelvic reconstructive surgeon. Various approaches are available for repair, including vaginal, laparoscopic, and abdominal, the last in the form of an abdominal sacral colpopexy. Success rates for maintenance of apical support for abdominal sacral colpopexy range from 78–100% over a follow-up period of 6 months to 3 years.1 One study with a mean follow-up of 13.7 years showed a 74% success rate and a 10.5% reoperation rate.2 However, abdominal approaches require extensive dissection, which may result specifically in venous bleeding from presacral veins. In addition, abdominal surgery has higher rates of morbidity and longer convalescent times than vaginal or laparoscopic surgery. The laparoscopic approach to vaginal vault prolapse is new and has not received widespread acceptance in the gynecologic arena due to the inherent technical difficulties in performing the procedure laparoscopically.
The vaginal approach to the uterosacral vault suspension is the preferred method at our center. Compared with sacrospinous ligament vault fixation, the uterosacral vault suspension and similar procedures such as the Mayo culdoplasty preserves the orientation of the vaginal axis in its natural position, thus potentially preventing the recurrence rate of prolapse in other vaginal segments, especially the anterior segment.3,4 Sacrospinous ligament suspension, although successful in suspending the prolapsed vaginal cuff, has been associated with postoperative rates of cystocele formation in 18–92%.4 Another technique, the iliococcygeus fixation, has the advantage of providing a more anatomic vaginal orientation but may result in vaginal foreshortening due to the fact that the point of apical fixation is distal to the ischial spines.4 Various authors purport that specific breaks in the uterosacral ligaments occur rather than become attenuated in the setting of advanced prolapse.5–8 These authors have contended that in the presence of vaginal prolapse, the uterosacral ligaments can be identified when tension is applied to their distal margins, to which the vaginal vault can be anchored in a secure, durable manner.
We have previously described our 6 months to 3 years (mean 21.6 months) results of the high intraperitoneal suspension of the vaginal vault to the uterosacral ligaments in conjunction with reconstruction of the continuity of the superior aspects of the anterior pubocervical fascia and posterior rectovaginal fascia.
The rate of symptomatic recurrence of apical prolapse was 1% (2 women), whereas a further nine (4.5%) patients required additional treatment due to the development of recurrent symptomatic anterior or posterior segment prolapse.8 This current study reports the 5-year anatomic and functional outcome of this procedure.
MATERIALS AND METHODS
The target population consisted of women with at least prolapse of the apex to the level of the hymen who had a uterosacral vault suspension (vaginal approach) from January 1997 to January 2000 performed at Good Samaritan Hospital and Bethesda North Hospital. Patients were excluded if surgery was performed at three other outlying hospitals where hospital privileges were no longer in place for the senior author (M.K.). One hundred ten patients with advanced symptomatic uterovaginal or posthysterectomy prolapse that were treated in the local hospital system were identified. Between July 2003 and April 2005, 72 of the 110 eligible patients consented to participate in the study.
The 72 patients all underwent a preoperative history that included an inquiry regarding symptoms of urinary dysfunction, dyspareunia, and bowel dysfunction. A through physical examination was performed, including a site-specific defect analysis of the pelvic floor segments utilizing the Baden-Walker halfway system.9 Postvoid residual volumes were obtained, and office filling cystometry was performed to evaluate the presence of the sign of stress (overt or occult) incontinence. Patients subsequently underwent multichannel urodynamic testing if incontinence was observed. The women were asked to complete the short forms of the Incontinence Impact Questionnaire and Urogenital Distress Inventory during their first visit.10
Patients underwent surgery under general or regional anesthesia by or under the direct supervision of the senior author (M.K.). A vaginal hysterectomy was performed in patients who had a uterus. For those with posthysterectomy apical prolapse, the vaginal apex was grasped with two Allis clamps and incised with a scalpel. The vaginal epithelium was dissected off the enterocele sac up to the neck of the hernia. After entering the enterocele, the hernia sac was excised. Moist tail sponges were placed in the posterior cul de sac and hollow of the sacrum, after which a wide retractor was used to elevate the intestines and packing out of the operative field. The ischial spines were palpated transperitoneally, and the remnants of the uterosacral ligaments were noted posterior and medial to the ischial spines. The ureters were palpated along the pelvic sidewall 1 to 5 cm ventral and lateral to the ischial spine. Traction applied to an Allis clamp at the 5 o’clock and 7 o’clock positions (with one end of the clamp in the vagina and the other end intraperitoneally) allowed palpation of the connective tissue condensations along the pelvic sidewall. Numerous nonabsorbable sutures (usually 2–4 sutures) were passed through the uterosacral ligaments on each side, incorporating intervening peritoneum. If indicated, an anterior colporrhaphy or sling procedure was then performed. Delayed absorbable sutures (usually 4–6 sutures) were used to suspend the anterior and posterior vaginal walls to the plicated uterosacral ligaments. Tying of these sutures resulted in suspension of the prolapsed apex. All other vaginal procedures were performed as indicated.8
Postoperative evaluation consisted of a thorough history, specifically regarding urinary function, sexual function, and defecatory function. Functional results were obtained with standardized questionnaires, including the short form Incontinence Impact Questionnaire (IIQ) and Urogenital Distress Inventory (UDI), and Female Sexual Function Index administered by a trained research nurse.10,11
A value of less than 3.6 for each sexual domain and a value of less than 26.55 for the total score was considered abnormal, values that were based on previous published results from Wiegel et al,12 which determined optimal cutoff scores on the basis of sensitivity and specificity analysis and the Classification and Regression Trees procedure. Anatomic outcomes were obtained by either the senior author or three fellows using the Pelvic Organ Prolapse Quantification (POPQ) system.13 Maximal descent of the prolapse was noted with the patient in the supine position during maximal Valsalva with an empty bladder. To appreciate any further extent of apical prolapse, the patients were then examined in the standing position during maximal Valsalva.
Demographic data for consenting and nonconsenting patients was compared using the independent samples t test for continuous variables and the χ2 test for nominal variables. Preoperative and postoperative quality-of-life scores (UDI/IIQ) were compared using the paired samples t test. Visceral function and rates of dyspareunia before and after the operation were compared using the χ2 test. The study was approved by the institutional review board of Good Samaritan Hospital.
One hundred ten patients were eligible to participate in the study, and 72 (65.5%) gave consent and agreed to return for a follow-up assessment. The 38 (34.%) patients who did not consent to participate in the study were deceased (8.2%), could not be contacted (17.2%), or refused to enter the study due to inconvenience or social issues (9.1%). The mean follow-up period was 5.1 years (range 3.5–7.5 years). Mean age was 61.0 years, and median parity was 3.0. Demographic data of the consenting and nonconsenting groups are presented and compared in Table 1.
Previous surgeries included hysterectomy (62.5%), retropubic urethropexy (11.1%), pubovaginal sling (2.8%), needle suspension (1.4%), anterior repair (11.1%), and posterior repair (9.7%). The prolapse repair was a primary procedure in 49 (68.1%) of the women and was performed for recurrence or persistence in 23 (31.9%) of the women.
Vaginal hysterectomy was performed in 37.5% of the patients while anterior colporrhaphy, posterior colporrhaphy, and suburethral slings were performed in 58.3%, 87.5%, and 31.9%, respectively. Posthysterectomy patients comprised 62.5% (45/72) of the study group. Mean postoperative POPQ results were as follows: Aa (anteriorly at anterior segment) −2.3, Ba (anteriorly at posterior segment) −2.1, C (cervix or apex) −6.4, Gh (genital hiatus) 3.5, Pb (perineal body) 3.9, TVL (total vaginal length) 6.8, Ap (posteriorly at anterior segment) −2.4, and Bp (posteriorly at posterior segment) −2.3.
Surgical failure, when defined as symptomatic recurrent prolapse of stage 2 or greater in one or more segments was 11 of 72 (15.3%). These included prolapse involving the following: recurrent stage 2 anterior segment (three patients who originally had grade 3 cystoceles), recurrent stage 2 posterior segment (five patients, three of whom originally had grade 2 rectoceles and three with grade 1–2 rectoceles), recurrent stage 3 posterior segment (one patient who originally had a grade 2 rectocele), and recurrent stage 2 posterior and apical segment (two patients, one of whom originally had grade 3 vaginal vault and posterior prolapse, and another with grade 3 vaginal vault and grade 2 posterior segment prolapse). Four cases of de novo prolapse (stage 2) were noted, two in the anterior segment and two in the posterior segment. When failure is defined as symptomatic recurrence of apical (vault) prolapse of stage 2 or greater, 2 of 78 (2.8%) had apical failure.
Baseline prolapse grades and postoperative prolapse stages are noted in Table 2. Only two patients underwent further surgery due to recurrent prolapse during the study period. One patient required a subsequent posterior colporrhaphy with the use of allograft material for recurrent stage 2 posterior segment prolapse after initially undergoing anterior colporrhaphy, uterosacral vault suspension, and posterior colpoperineorrhaphy. A second patient presented with a recurrent apical and posterior vaginal wall prolapse after failure of two separate sets of surgeries (set 1 was abdominal hysterectomy, Burch colposuspension, enterocele repair, and posterior colporrhaphy; set 2 was abdominal sacrocolpopexy with cadaveric fascia lata, repeat Burch colposuspension, enterocele repair, anterior colporrhaphy, and posterior colporrhaphy). After failure of vaginal repair at our center in the form of an enterocele repair, uterosacral vault suspension, and posterior colporrhaphy, the patient subsequently underwent a repeat abdominal sacrocolpopexy with synthetic mesh, enterocele repair, and posterior colporrhaphy.
Forty-eight (66.2%) were sexually active preoperatively, whereas 39 (54.2%) were sexually active postoperatively. Thirty-four (47.2%) were sexually active both preoperatively and postoperatively, whereas 5 (6.9%) became sexually active postoperatively despite not being active preoperatively. Of the 14 patients who were no longer sexually active postoperatively, the reasons cited were as follows: recurrent prolapse (stage 2 of apical and posterior segments) (one patient), prevented by atrophy (one patient), decreased desire (two patients), no partner (one patient), partner’s medical conditions (six patients), patient and partner’s medical condition (two patients), patient choice but no abnormality (one patient).
Analysis of the 34 people that were sexually active both preoperatively and postoperatively yielded the following results (Table 3): seven (20.6%) people complained of dyspareunia preoperatively who improved or were cured after surgery. However, seven cases of postoperative dyspareunia occurred de novo. The reasons cited were as follows: vaginal atrophy (one patient), vaginal atrophy with decreased libido (one patient), tight introitus (one patient), vaginal constriction (two patients), vaginal atrophy and tight introitus (one patient), and vaginal atrophy and recurrent stage 2 cystocele (one patient). Of the 31 who responded to the satisfaction domain of the Female Sexual Function Index, 94% (29/31) reported normal satisfaction. One of the patients with dyspareunia did not respond to the satisfaction domain, whereas two of the patients with dyspareunia reported abnormal satisfaction. However, four patients with de novo dyspareunia reported normal satisfaction.
Short-form IIQ/UDI scores showed a statistically significant improvement in all aspects of daily living except for the complaint of “small amounts of leakage” (P=.10) (Table 4). Postoperative IIQ/UDI scores were statistically significantly improved in all three domains (irritative, P=.01; obstructive, P<.001; stress, P=.03); and overall (IIQ-7, P<.001; UDI, P<.001) compared with the preoperative scores. Bowel dysfunction was reported 33.3% preoperatively (15/72 or 20.8% constipation, 9/72 or 12.5% fecal incontinence) compared with 27.8% postoperatively (15/72 or 20.8% constipation, 5/72 or 6.9% fecal incontinence) (P=.24). Three patients had fecal incontinence preoperatively that persisted postoperatively. Six had resolution of fecal incontinence after prolapse repair, whereas two developed de novo fecal incontinence.
Table 5 summarizes the preoperative and postoperative subjective functional results. There was a statistically significant perceived improvement in urinary function; however, no difference in bowel function or rates of dyspareunia were noted.
Understanding the anatomy of pelvic support is crucial for surgical restoration in the setting of pelvic prolapse. DeLancey14 described three levels of vaginal support corresponding to the upper, mid, and lower portions of the vagina. Level I support of the upper quarter of the vagina is established by the uterosacral–cardinal ligament complex. The paracolpium’s vertical fibers in level I are postulated to prevent prolapse of the vaginal apex and vaginal eversion. Richardson et al15 introduced the concept that discrete breaks in the vaginal endopelvic fascia leads to vaginal prolapse rather than attenuation of the supportive tissue. Richardson16 described that an apical enterocele occurs secondary to a defect in the endopelvic fascia at the apex of the vagina.
There are few reports in the literature that evaluate the effectiveness and complication rate of uterosacral ligament vaginal vault suspension (Table 6). Anatomic cure rates have been reported to range from 82–96% over a mean follow-up period of 6.3–33 months. The risk of ureteric entrapment or injury has been attributed to the proximity of the ureter to the uterosacral ligaments. This rate has been reported to range from 0 to 11% in previous studies.5–8,17,18 In the study by Karram et al8 five (2.4%) cases of ureteric injury or kinking occurred, four of which resolved after removal of the sutures in the affected side. In one case, a ureterotomy occurred that required ureteral reimplantation. Barber et al6 reported five (11%) cases of ureteric occlusion, three of which resolved after suture removal, and two of which required reimplantation. In all these reported cases, ureteric injury was discovered intraoperatively, therefore underscoring the importance of cystoscopy after uterosacral ligament vault fixation. No ureteric injuries were noted in the particular patient group in the present study. Direct palpation of the ureters is an important step in prevention of ureteric injury. However, it is not possible in all cases to palpate the ureter transperitoneally. In our experience, ureteral anatomy is far from consistent, and the distance of the ureter to the lateral edge of the uterosacral ligament can be unpredictable. When passing the needle through the uterosacral ligament, it is important to go from a lateral to medial direction, exiting away from the ureter.5 We also strongly recommend routine cystoscopy after this procedure to confirm ureteral patency.
The low risk of blood transfusion (1–3%), bowel injury (0.6%), and pelvic infection (0.6%) has been previously described.5,8,17
The term “high” uterosacral ligament vault suspension refers to the cephalad placement of sutures along the uterosacral ligament. McCall, in his description of the New Orleans culdoplasty, stated that these sutures were to be “…inserted, each one higher than the last…”.19 In our patient population, nonabsorbable sutures were placed at the level of the ischial spines.
We acknowledge that our technique is in slight variation to others. For instance, Shull et al5 passed the same sutures from the uterosacral ligament pedicles through the superior aspect of the transverse portion of the pubocervical and rectovaginal fascia. In our technique two to four nonabsorbable sutures, usually 0 polypropylene (Prolene, Ethicon, Somerville, NJ) are passed through the uterosacral ligaments on each side, incorporating intervening peritoneum. We believe that complete obliteration of the cul-de-sac contributes to the high success rate of the procedure. In addition, by directly suspending the vaginal vault in the hollow of the sacrum, the vaginal axis does not significantly alter, which may also theoretically increase the success rates of repair of the apical and anterior vaginal segments. An 18–92% postoperative rate of cystocele has been reported after sacrospinous ligament suspension, because this procedure deviates the vaginal axis in a posterior orientation. A second, separate set of four to six delayed absorbable sutures, usually polyglactin 910 (Vicryl, Ethicon) are then used to suspend the anterior and posterior vaginal walls to the plicated uterosacral ligaments. The use of a nonabsorbable suture initially may theoretically lead to a stronger repair of the enterocele, and it is safe to use, because the knot is intraperitoneal at this site. However, delayed absorbable sutures are used for the second set of sutures because the knot is tied in the lumen of the vagina.
More than one half (61%) of the apical suspension procedures were performed on posthysterectomy patients. In our experience, were are able to enter the cul-de-sac the majority of times to perform the procedure for vaginal vault prolapse. Karram et al8 reported in a separate study that uterosacral vaginal vault suspension could not be performed in 6 of 202 women because of difficulty in identifying or exposing the cul de sac. In the present study, the two symptomatic apical recurrences were seen in patients who previously underwent a hysterectomy; these numbers are too small to determine definitively whether previous hysterectomy is a risk factor for recurrent vault prolapse. However, the good long-term results illustrate that uterosacral ligament suspension may be appropriate not only for cases in which a hysterectomy is being performed, but also for cases of posthysterectomy vaginal vault prolapse.
In previous studies, the duration of follow-up times on patients treated with uterosacral ligament vault suspension have been relatively short. Furthermore, all of the above studies (excluding Karram et al8) did not compare preoperative and postoperative quality-of-life scores using a standardized, validated questionnaire. Our study examined longer outcomes at a mean of 5.1 years (range 5–6 years) of patients who received a uterosacral vault suspension. Furthermore, objective outcomes were obtained in the form of pelvic organ prolapse grading and standardized quality-of-life questionnaires.
The previous study by Karram et al8 that evaluated anatomic and functional results at a mean of 21.6 months differed from the current one in that the patient population in the current study excluded those women treated at outlying hospital systems where the senior author no longer had privileges. However, patient evaluation and treatment would not be expected to differ by hospital site. This exclusion did decrease the patient pool from which patients were recruited to the study. In this earlier study, the rate of symptomatic recurrence of apical prolapse was 1% (two women) while a further nine (4.5%) patients required additional treatment due to the development of recurrent symptomatic anterior or posterior segment prolapse, yielding a 94% success rate. This current study yielded an 85% success rate, with two women (2.8%) that developed recurrent apical vaginal prolapse and a further nine patients with symptomatic recurrent prolapse of stage 2 or greater in the anterior, posterior, or both segments. However, unlike the earlier study, only two patients required reoperation, the rest complaining of only mild symptoms. In addition, only three patients in this study developed recurrence of symptomatic anterior vaginal prolapse (all stage 2), underlying the fact that a vaginal axis in the mid position may be associated with less anterior pelvic support defects. The eight (11.1%) cases of recurrent posterior vaginal wall prolapse seen in this study are within the literature reported anatomic cure rates of 82–100% after a mean follow-up period of 3–18 months.20–24
The results of urinary, bowel, and rates of dyspareunia are also similar to that reported by Karram et al.8 Significant improvement is noted in both studies in rates of urinary dysfunction, which is also supported by results of the validated UDI/IIQ questionnaire when comparing the preoperative and postoperative states. Similarly, there were no statistically significant differences in rates of bowel dysfunction. There were no differences in the net frequencies of dyspareunia (seven subjects preoperatively and seven postoperatively). However, the seven postoperative cases occurred de novo. The reasons cited were as follows: vaginal atrophy (one patient), vaginal atrophy with decreased libido (one patient), tight introitus (one patient), vaginal constriction (two patients), vaginal atrophy and tight introitus (one patient), and vaginal atrophy and recurrent stage 2 cystocele (one patient). Three of these cases were as a direct result of iatrogenic vaginal or introital constriction, two of whom were being treated conservatively with vaginal dilators. A single case of dyspareunia was attributed to a combination of recurrent stage 2 cystocele and vaginal atrophy and the remaining two cases due to vaginal atrophy; these patients have reported improvement in their symptoms with local estrogen therapy. These observations underscore the importance of careful excision of vaginal mucosa and perineal tissue at time of repair and aggressive treatment of vaginal atrophy in those women that are sexually active after surgery. In the group of 34 patients that were sexually active before and after surgery, it is noteworthy that mean postoperative Female Sexual Function Index scores are in the normal range for all the domains except for the desire domain.
The National Health and Social Life Survey in 1992, based on a National probability sample of 1,749 women and 1,410 men aged 18–59 years, reported that decreased libido was the most common complaint (30%), followed by problems with orgasm (25%), difficulty lubricating (21%), and pain disorders (14%). In addition, sexual dysfunction was shown to occur more often in females (43%) than men (31%).25 It is interesting to observe in our study that the rate of sexual dissatisfaction was 6% in this cohort of patients, despite the presence of a rate of sexual dysfunction of 54.8%, which is mainly attributed to the abnormal desire scores seen in 50% of the patients. Clearly, the issue of sexual activity has many confounding variables and is a multifactorial process with psychological, social, and organic roots. This higher rate of postoperative sexual dysfunction differs from that seen in the earlier study of Karram et al,8 perhaps due to the fact the earlier study did not use a validated sexual function questionnaire, or specific questions related to desire-phase disorder may not have been addressed.
The study has several limitations. Much of the data were collected retrospectively and relied on historical information from chart review and patient interviews. Additionally, the study lacked the use of a validated bowel questionnaire in the setting of pelvic organ prolapse because one was not in wide use in the last decade. Similarly, a validated sexual quality-of-life questionnaire was not used preoperatively, although we attempted to obtain some objective information with the use of the validated Female Sexual Function Index in the postoperative phase. We relied on the use of the Baden-Walker system when reporting preoperative prolapse severity because the use of the POPQ system was not in routine use at our center until the last part of the previous decade. The POPQ evaluation was performed by several physicians in the postoperative phase. However, the issue of interobserver variability has been addressed by several studies in the past. Two separate reports have shown good reproducibility of the POPQ measurements.26,27
For example, in a study by Hall et al,26 seven examiners (including two attending faculty members, three urogynecology fellows, and two third-year residents) were randomly paired to perform POPQ examinations on 48 subjects, each blinded to the results of the other examination. Their study showed that correlations for each of the POPQ measurements were highly significant and staging was highly reproducible.27 Another limitation included the inability to enroll 34.5% of the patients due to the inherent difficulty in locating patients after a 5-year period and the lack of interest of several patients in returning for follow-up examination, likely due to factors related to age, medical illness, or inconvenience. Also, our study was not designed to find any immediate failures that occurred in patients with less than a 4–5 year follow-up time. Finally, due to the extensive surgical experience with this technique by the senior author, the generalization of the study results may be limited. However, many of the procedures were performed by a urogynecology fellow under direct supervision of the senior author. In our experience, the technique can be taught by a preceptor to various learners.
Over a 5-year follow-up period, a high uterosacral ligament suspension seems to be a durable, long-lasting procedure for repair of apical vault and uterovaginal prolapse. In many patients the goals of vaginal reconstruction can be achieved through a vaginal approach that offers the advantages of decreased morbidity and decreased operative discomfort compared with an abdominal approach.
1. Nygaard IE, McCreery R, Brubaker L, Connolly A, Cundiff G, Weber AM, et al. Abdominal sacrocolpopexy: a comprehensive review. Obstet Gynecol 2004;104:805–23.
2. Hilger WS, Poulson M, Norton PA. Long-term results of abdominal sacrocolpopexy. Am J Obstet Gynecol 2003;189:1606–10.
3. Webb MJ, Aronson MP, Ferguson LK, Lee RA. Posthysterectomy vaginal vault prolapse: primary repair in 693 patients. Obstet Gynecol 1998;92:281–5.
4. Sze EH, Karram MM. Transvaginal repair of vault prolapse: a review. Obstet Gynecol 1997;89:466–75.
5. Shull BL, Bachofen C, Coates KW, Kuehl TJ. A transvaginal approach to repair of apical and other associated sites of pelvic organ prolapse with uterosacral ligaments. Am J Obstet Gynecol 2000;183:1365–73.
6. Barber MD, Visco AG, Weidner AC, Amundsen CL, Bump RC. Bilateral uterosacral ligament vaginal vault suspension with site-specific endopelvic fascia defect repair for treatment of pelvic organ prolapse. Am J Obstet Gynecol 2000;183:1402–10.
7. Jenkins VR 2nd. Uterosacral ligament fixation for vaginal vault suspension in uterine and vaginal vault prolapse. Am J Obstet Gynecol 1997;177:1337–43.
8. Karram M, Goldwasser S, Kleeman S, Steele A, Vassallo B, Walsh P. High uterosacral vaginal vault suspension with fascial reconstruction for vaginal repair of enterocele and vaginal vault prolapse. Am J Obstet Gynecol 2001;185:1339–42.
9. Baden WF, Walker TA, Lindsey JH. The vaginal profile. Tex Med 1968;64:56–8.
10. Uebersax JS, Wyman JF, Shumaker SA, McClish DK, Fantl JA. Short forms to assess life quality and symptom distress for urinary incontinence in women: the Incontinence Impact Questionnaire and the Urogenital Distress Inventory. Continence Program for Women Research Group. Neurourol Urodyn 1995;14:131–9.
11. Rosen R, Brown C, Heiman J, Leiblum S, Meston C, Shabsigh R, et al. The Female Sexual Function Index (FSFI): a multidimensional self-report instrument for the assessment of female sexual function. J Sex Marital Ther 2000;26:191–208.
12. Wiegel M, Meston C, Rosen R. The female sexual function index (FSFI): cross-validation and development of clinical cutoff scores. J Sex Marital Ther 2005;31:1–20.
13. Bump RC, Mattiasson A, Bo K, Brubaker LP, DeLancey JO, Klarskov P, et al. The standardization of terminology of female pelvic organ prolapse and pelvic floor dysfunction. Am J Obstet Gynecol 1996;175:10–7.
14. DeLancey JO. Anatomic aspects of vaginal eversion after hysterectomy. Am J Obstet Gynecol 1992;166:1717–24.
15. Richardson AC, Lyon JB, Williams NL. A new look at pelvic relaxation. Am J Obstet Gynecol 1976;126:568–73.
16. Richardson AC. The anatomic defects in rectocele and enterocele. J Pelvic Surg 1995;1:214–21.
17. Amundsen CL, Flynn BJ, Webster GD. Anatomical correction of vaginal vault prolapse by uterosacral ligament fixation in women who also require a pubovaginal sling. J Urol 2003;169:1770–4.
18. Milkos JR, Kohli N, Lucente V, Saye WB. Site-specific fascial defects in the diagnosis and surgical management of enterocele. Am J Obstet Gynecol 1998;179:1418–22.
19. McCall ML. Posterior culdeplasty; surgical correction of enterocele during vaginal hysterectomy; a preliminary report Obstet Gynecol 1957;10:595–602.
20. Cundiff GW, Weidner AC, Visco AG, Addison WA, Bump RC. An anatomic and functional assessment of the discrete defect rectocele repair. Am J Obstet Gynecol 1998;179:1451–6.
21. Porter WE, Steele A, Walsh P, Kohli N, Karram MM. The anatomic and functional outcomes of defect- specific rectocele repairs. Am J Obstet Gynecol 1999;181:1353–8.
22. Kenton K, Shott S, Brubaker L. Outcome after rectovaginal fascia reattachment for rectocele repair. Am J Obstet Gynecol 1999;181:1360–3.
23. Glavind K, Madsen H. A prospective study of the discrete fascial defect rectocele repair. Acta Obstet Gynecol Scand 2000;79:145–7.
24. Singh K, Cortes E, Reid WM. Evaluation of the fascial technique for surgical repair of isolated posterior vaginal wall prolapse. Obstet Gynecol 2003;101:320–4.
25. Laumann EO, Paik A, Rosen RC. Sexual dysfunction in the United States: prevalence and predictors. JAMA 1999;281:537–44.
26. Hall AF, Theofrastous JP, Cundiff GW, Harris RL, Hamilton LF, Swift SE, et al. Interobserver and intraobserver reliability of the proposed International Continence Society, Society of Gynecologic Surgeons, and American Urogynecologic Society pelvic organ prolapse classification system. Am J Obstet Gynecol 1996;175:1467–70.
27. Kobak WH, Rosenberger K, Walters MD. Interobserver variation in the assessment of pelvic organ prolapse. Int Urogynecol J Pelvic Floor Dysfunct 1996;7:121–4.
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