We thank Mr Constantine for his thoughtful letter which highlights the increasing interest in improving the management of vaginal vault prolapse. Our article has tried to cover all aspects of the management of vault prolapse albeit rather briefly. We note the comments about the use of shelf pessaries. In our experience the use of all pessaries, including shelf pessaries, in this condition have been disappointing, and we prefer surgical treatment wherever possible. As Mr Constantine mentions, many of the women with vault prolapse are a challenge surgically due to their weight and other health issues which may compromise the outcome. We have tried to give a balanced view to both sacrospinous ligament fixation and sacrocolpopexy which are, to a large degree used interchangeably for similar circumstances, depending on the expertise and preference of the surgeons. To date the limitations or specific indications have not been fully identified.

We tend to favour a sacrocolpopexy since this appears to have a slightly better success rate and we may perform a concurrent colposuspension in cases of genuine stress incontinence. If there is a significant rectocele this is repaired as an interval procedure three months later. In the absence of stress incontinence the choice may be biased by the presence of other vaginal prolapse when the vaginal approach may be superior. Excessive previous surgery may make the vaginal approach more difficult than an abdominal procedure.

We agree with the idea that we need to select the right operation for the patient rather than adopt one operation for everyone. However, in order to establish which procedure is best and under which circumstances requires comparative studies before we can refine the indications for each procedure.