I read with interest the review article1 (Vol 105 January 1998) and would certainly agree that the management of prolapse, particularly vaginal vault prolapse, is a difficult, challenging and interesting condition. This review article does well in highlighting the different approaches to this problem. The authors raise several points however that I feel could be highlighted.
Many women with this condition are by its very nature overweight (sometimes grossly), elderly and not always in the best of health. In my experience ring pessaries for vault prolapse and accompanying large cystocele or enterocele are not particularly successful. This can be secondary to a deficient perineum. There is also the potential however for the prolapse to come through the ring. In these women shelf pessaries can offer a much more effective solution and their obvious drawbacks frequently do not worry this group of women. I feel that shelf pessaries do have a specific role in this condition allowing the vault to rest on the shelf itself and deserve wider mention.
I would agree with the author's comments regarding the inad-visability of using vaginal repairs for these problems. I am far from certain, however, that sacrospinous fixation and sacro-colpopexy are interchangeable operations for this condition. The author expressed surprise that an asymptomatic cystocele was found to occur in a significant number of women after sacrospinous fixation, but in many ways the situation is analogous to the occurrence of posterior and uterine prolapse after col-posuspension: distorting the anatomy of the vault posterior and to the right appears to put additional pressure on the anterior wall of the vagina which then prolapses further. If one believes in classifying cystocele as either being due to lateral, central or transverse defects in the supporting tissues then it is difficult to provide good support of the anterior wall of the vagina when the vault has been pulled in the opposite direction by a sacrospinous fixation. One is left with a traditional anterior repair as the only way of dealing with this problem and this does have a wellknown recurrence rate. Colposuspension is usually considered the most effective treatment for stress incontinence and it is almost impossible to combine this with a sacrospinous fixation. I would therefore suggest that when the anterior wall of the vagina and particularly the bladder neck is reasonably well supported and the main problem relates to vault prolapse with enterocele sacrospinous fixation may be the best and least traumatic approach. If, however, there is considerable loss of anterior support with a large cystocele due to lateral wall defects then it is better and more anatomically correct to combine sacrocolpopexy with a colposuspension or paravaginal repair. The latter does not add a great deal of time to sacrocolpopexy and may be less troublesome than vaginal suspension operations to provide bladder neck support at the time of sacrospinous fmation.
I would agree therefore that accurate assessment of the patient's symptoms and degree of prolapse in each compartment is vital in the treatment of vaginal vault prolapse. I would suggest however that a randomised trial between the two approaches may not be appropriate as each may have a role in different situations I would also conclude that in women unfit for surgery with this distressing condition shelf pessaries are well worth considering.