ABSTRACT

Vaginal vault prolapse is observed with increasing frequency in the era of large aging populations. Various surgical techniques have been established, varying in performance, difficulty and outcome, specifically complications. In order to optimize both aspects, we have developed a refined transperineal bilateral sacrospineous colpofixation technique (TPBCF) and give a detailed, step-by-step description of the technique, with focus on the key differences to the “old” method of Intravaginal Sling (IVS). Importantly, we rely not on a transverse but instead on a longitudinal incision and blunt finger dissection to gain access to the sacrospinous ligament. Introducers for transischiorectal sling placement are guided from bilateral stab incisions lateral and dorsal from the anus (to avoid the rectal arteries and riskof arterial injuries) with the inserted finger, thereby ensuring that no undesired structures,mainly bowel, are injured by the advancing introducers during their passage through the pelvis. Preferably, horizontally oriented sutures are used to attach the sling to the underside of the vaginal apex or the posterior aspect of the cervix. As a minimally invasive approach with the potential for conservation of the uterus, our technique should be applicable to all age groups and the increasingly frequent elderly patient with significant co-morbidities.