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OBSTETRICS AND GYNECOLOGY BOARD REVIEW MANUAL
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EDITORIAL PURPOSE
The Hospital Physician Obstetrics and Gynecology
Board Review Manual is a peer-reviewed study
guide for residents and practicing physicians
preparing for board examinations in obstetrics and gynecology. Each quarterly manual
reviews a topic essential to the current practice of obstetrics and gynecology.
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OF OPERATIONS
Diagnosis and Treatment
of Vaginal Apical Prolapse
Editor: Jordan G. Pritzker, MD, MBA, FACOG
Assistant Professor, Albert Einstein College of Medicine, Montefiore
Medical Center, Bronx, NY; Obstetrics and Gynecology Faculty
Practice, Ann and Jules Gottleib Women’s Comprehensive Health
Center, Long Island Jewish Medical Center, Manhasset, NY
Contributors:
Scott W. Smilen, MD
Associate Professor, Associate Director, Division of Female Pelvic
Medicine and Reconstructive Pelvic Surgery, New York University
School of Medicine, New York, NY
B. Star Hampton, MD
Teaching Assistant, Fellow, Division of Female Pelvic Medicine and
Reconstructive Pelvic Surgery, New York University School of Medicine,
New York, NY
Jean M. Gaul
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PRODUCTION ASSOCIATE
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NOTE FROM THE PUBLISHER:
This publication has been developed without
involvement of or review by the American
Board of Obstetrics and Gynecology.
Endorsed by the
Association for Hospital
Medical Education
Table of Contents
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Approach to Diagnosis of Pelvic Support Defects . . . . . . 3
Overview of Treatment Options for Vaginal Apical
Prolapse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Vaginal Sacrospinous Ligament Fixation. . . . . . . . . . . . . . 8
Abdominal Sacral Colpopexy . . . . . . . . . . . . . . . . . . . . . 10
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Cover Illustration by Carole R. Owens
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Obstetrics and Gynecology Volume 9, Part 1 1
OBSTETRICS AND GYNECOLOGY BOARD REVIEW MANUAL
Diagnosis and Treatment of
Vaginal Apical Prolapse
Scott W. Smilen, MD, and B. Star Hampton, MD
INTRODUCTION
As the average life span of the population increases,
problems related to pelvic support defects are seen with
increasing frequency in women. The associated symptoms, although not a cause of mortality, have a significant impact on the quality of a patient’s everyday life
and sexual activity. This review focuses specifically on
vaginal apical defects and the most appropriate correction of these defects. Two case patients are presented to
highlight the approach to the diagnosis of pelvic support defects and the range of treatment options for
management of vaginal apical prolapse.
ANATOMY OF THE PELVIC SUPPORT SYSTEM
Nomenclature
Knowledge of the endopelvic fascia support system
and the 3 support axes is essential for understanding
defects in vaginal wall support. The endopelvic fascia—
a network of connective tissue and smooth muscle—is a
continuous system that provides structural support and
maintains the bladder, urethra, uterus, vagina, and rectum in their respective anatomic relationships. All forms
of vaginal prolapse—anterior, apical, or posterior—are
caused by a breakdown in the continuity of the endopelvic fascia system.
Traditionally, pelvic support defects have been described based on the organ that is prolapsed. Cystocele
denoted a herniation of the bladder as evidenced by an
anterior vaginal wall bulge. Similarly, rectocele signified a
protrusion produced by the rectum abutting the posterior vaginal wall. However, what appears to be a cystocele or
rectocele on physical examination often is later found to
be a peritoneum-lined sac sometimes containing omentum or small intestine, which is more appropriately
termed an enterocele. Conversely, a large apparently apical
protrusion clinically consistent with an enterocele in a
posthysterectomy patient will sometimes be found to contain bladder or rectum (or sigmoid colon).
As the anatomy and histology of the pelvis has become better understood, convention has shifted toward
2 Hospital Physician Board Review Manual
nomenclature describing the affected site, and presumably then, the structures lacking in provision of support
(Table).
Levels of Pelvic Support
DeLancey has described 3 levels of pelvic support
(Figure 1).1 The clinical and anatomic correlates of this
support mechanism are summarized in the Table.
Level I consists of the upper 2 to 3 cm of the vagina,
with supporting fibers of the paracolpium spanning
broadly from the lateral pelvic walls to the centrally located pelvic organs. Level I structures are primarily responsible for maintaining the upper vagina, cervix, and uterus
in place over an intact levator ani muscle (Figure 2). At
the lateral aspect of the vagina, the connective tissue fibers
diverge to surround the anterior and posterior vaginal
walls. The upper vagina in vivo is situated in a horizontal
fashion over the posterior half of the levator ani muscle
plexus.2 When intra-abdominal pressure is increased, the
upper vagina is forced against this levator plate and prolapse is prevented. This valve mechanism, along with intact level I fibers, is responsible for prevention of apical
defects.3 Anatomically, level I fibers correspond to the
cardinal-uterosacral ligament complex. Deficiencies in
the level I support complex (ie, connective tissue attachments and valve mechanism) may lead to uterine and/or
vaginal apical prolapse.
Level II fibers (Figure 3) envelop the mid-vagina
anteriorly and posteriorly and attach the lateral aspects
of the vagina to the pelvic sidewall. No true fascia directly envelops the bladder.4 Instead, the bladder muscularis rests on the connective tissue comprising anterior
level II support, attaching the vagina to the arcus
tendineus fasciae pelvis. Anatomically, this supportive
layer is termed the pubocervical fascia. Similarly, the connective tissue posteriorly attaches to the fascia of the levator ani muscle and is termed rectovaginal fascia. Defects
in this connective tissue layer may lead to cystoceles
(pubocervical connective tissue defects) or rectoceles
(rectovaginal connective tissue defects).
Level III (Figure 3) is the distal portion of the vagina, from the introitus to 2 to 3 cm above the hymenal
D i a g n o s i s a n d Tr e a t m e n t o f Va g i n a l A p i c a l P r o l a p s e
Table. Clinical Findings Correlating with Specific
Pelvic Support Defects
Clinical Finding
Defect
Apical prolapse
Upper paracolpium: cardinaluterosacral ligament complex
Anterior wall
prolapse
Lower paracolpium: proximal
pubocervical connective tissue
Urethral
hypermobility
Lower paracolpium: distal
pubocervical connective tissue
Posterior wall
prolapse
Lower paracolpium: rectovaginal
connective tissue
Widened introitus/
weak perineum
Perineal body detachment
III
II
I
Ischial spine and
sacrospinous
ligament
Levator ani
Pubocervical fascia
ring. This region is densely adherent to surrounding
structures. Anteriorly, the distal vagina is attached to the
urethra, within the urogenital diaphragm. Laterally, it is
merged with the fibers of the levator ani muscle.
Posteriorly, it is fused with the perineal body.
APPROACH TO DIAGNOSIS OF PELVIC
SUPPORT DEFECTS
CASE 1: PRESENTATION
Patient 1 is a 76-year-old woman, para 4, who had a
total abdominal hysterectomy for symptomatic leiomyomatous uterus at age 45 years. She has felt a noticeable
bulge from her vagina for approximately 1 year before
presentation. She denies urinary incontinence or other
symptoms.
• What further historical details are important to pursue
in the workup of suspected pelvic organ prolapse?
PERTINENT HISTORY
Symptom History
A thorough symptom history is essential to the
workup of a patient with suspected pelvic organ prolapse, because it helps to direct the form of management (medical versus surgical) and to elucidate causative factors. Some patients may tolerate even severe
degrees of prolapse with no symptoms. Others may
experience symptoms ranging from pelvic pressure to
a pulling or dragging sensation in the vagina to low
backache or groin pain. The need for and type of intervention will vary depending on the patient’s desired
Rectovaginal fascia
Figure 1. Diagram showing the 3 levels of pelvic support (inset),
with a more detailed illustration of levels I and II (upper and midvagina). In level I (suspension), endopelvic fascia suspends the
vagina from the lateral pelvic walls. Level I fibers extend both
vertically and posteriorly toward the sacrum. In level II (attachment), the vagina is attached to the arcus tendineus fasciae pelvis
and to the superior fascia of the levator ani muscles. (Adapted
from DeLancey JO. Anatomic aspects of vaginal eversion after
hysterectomy. Am J Obstet Gynecol 1992;166:1719. Reprinted
with permission from Elsevier Science.)
level of sexual activity. Surgical planning for a sexually
active woman with prolapse requires attention to maintenance of coital capacity; however, a sexually inactive
patient may benefit from nonsurgical management
(eg, pessary) or alternative surgical techniques (eg,
vaginal obliterative procedures for an elderly, medically compromised patient).
Often, patients with marked degrees of prolapse will
not complain of urinary loss. A thorough history, however, often reveals stress incontinence that occurred
before progression of the defect. With a significant
anterior vaginal wall defect, kinking of the urethrovesical junction ultimately prevents incontinence, and
some effort on the patient’s part (eg, digitally replacing
the anterior vaginal wall) is required in order to void.
This information should be pursued because correcting this type of defect without attention to urethral support may unmask stress incontinence after surgery.
Posterior vaginal wall defects also can be associated
with difficulties defecating. Constipation, although often
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D i a g n o s i s a n d Tr e a t m e n t o f Va g i n a l A p i c a l P r o l a p s e
Level I
I
Pubocervical fascia
Paracolpium
Rectovaginal fascia
Rectum
Arcus tendineus
fasciae pelvis
Top of perineal body
Levator plate
Figure 2. The normal vaginal axis, showing almost horizontal
upper vagina and rectum lying on and parallel to the levator
plate. (Adapted from Nichols DH, Milley PS, Rundall CI. Significance of restoration of normal vaginal depth and axis. Obstet
Gynecol 1970;36:251. Reprinted with permission from the
American College of Obstetricians and Gynecologists.)
present in patients with pelvic organ prolapse, may cause
progression of a rectocele (due to straining) but does
not result from it. Typical symptoms of a posterior rectovaginal defect are incomplete defecation and the need
to complete defecation by placing pressure on the posterior vaginal wall or perineum, which is accomplished
by splinting.
Finally, vaginal bleeding or spotting may occur with
prolapsed organs because of mucosal surface erosion.
Ulcerations may lead to symptoms of abnormal vaginal
discharge.
Risk Factors for Pelvic Organ Prolapse
Factors associated with chronic increases in intraabdominal pressure should be sought and corrected.
Such risk factors include chronic respiratory disease
(and/or a history of smoking), constipation, intraabdominal processes (eg, masses, ascites), strenuous
physical activity, and obesity. The presence or history of
other connective tissue problems (eg, hernias, hyperelastosis) may indicate an inherent collagen disorder.
Neurologic disease (eg, spina bifida occulta) also may
predispose to pelvic organ prolapse.
Pregnancy, labor, and vaginal childbirth are the primary causes of pelvic neuromuscular damage.5,6 For
women who have been pregnant, the obstetrical history
should include the number and route of deliveries,
weight of infants delivered, and any complications (eg,
4 Hospital Physician Board Review Manual
Urethra
Levator
ani
Figure 3. Details of level II and level III pelvic support are shown
after wedge of upper urethra and anterior vaginal wall has been
removed (shaded area of inset), exposing anterior surface of rectum. In level III, the vagina is fused to the medial surface of levator ani muscles, urethra, and perineal body. The anterior surface
of the vagina and its attachment to the arcus tendineus fasciae of
pelvis form the pubocervical fascia. The posterior surface,
through its attachment to the superior fascia of levator ani muscles, forms the rectovaginal fascia. (Adapted from DeLancey JO.
Anatomic aspects of vaginal eversion after hysterectomy. Am J
Obstet Gynecol 1992;166:1719. Reprinted with permission from
Elsevier Science.)
lacerations). Menstrual status also should be determined,
and menopausal patients should be asked whether they
are on hormone replacement therapy. Estrogen receptors are found in the connective tissue and vascular structures surrounding the vagina,7,8 and estrogen is felt to play
a role in maintaining pelvic support.
Iatrogenic factors also can contribute to defects of
pelvic support. Inadequate support of the vaginal apex
after hysterectomy can lead to subsequent vaginal vault
prolapse. In addition, failure to address or recognize all
sites of weakness during surgical repair may lead to persistent or recurrent defects.
• How should the pelvic examination be conducted
for proper diagnosis of a pelvic support defect?
• Are imaging studies or other diagnostic tests indicated?
APPROACH TO THE PELVIC EXAMINATION
Pelvic examination should be carried out in a sitespecific manner in order to evaluate each defect and
attempt to locate the area or areas of weakness. Pelvic
examination technique varies greatly from one clinician
to the next. Regardless of the technique used, it is essential that the maximal protrusion be elicited to determine the severity of the problem.
D i a g n o s i s a n d Tr e a t m e n t o f Va g i n a l A p i c a l P r o l a p s e
D
Anterior
wall
Anterior
wall
Aa
Ba
3 cm
Cervix or
cuff
Ba
C
C
Total vaginal
length
Perineal
body
Genital
hiatus
gh
pb
tvl
Aa
Posterior
wall
Bp
Posterior
wall
Ap
Bp
D
tvl
Ap
Posterior
fornix
gh
pb
Figure 4. The 9 aspects of pelvic anatomy evaluated in the
Pelvic Organ Prolapse Quantitation system. These include
6 points along the vaginal apex and anterior and posterior walls
(Aa, Ba, C, D, Bp, and Ap) as well as the genital hiatus (gh), perineal body (pb), and total vaginal length (tvl). (Adapted from
Bump RC, Mattiasson A, Bo K, et al. The standardization of terminology of female pelvic organ prolapse and pelvic floor dysfunction. Am J Obstet Gynecol 1996;176:10. Reprinted with
permission from Elsevier Science.)
The examination begins with the patient in the lithotomy position for visual evaluation of the external genitalia and any prolapsed segment. Next, the prolapse is
reduced with insertion of a standard Graves’ speculum,
and the upper vagina and/or cervix (if present) is inspected; a Papanicolaou smear is obtained if indicated.
The speculum is then removed and split in 2, and each
half of the speculum is used to retract first the posterior
and then the anterior vaginal wall. The anterior and posterior vaginal walls are evaluated at rest and then following Valsalva maneuver until the prolapse is maximally
distended. The posterior wall evaluation should be
accompanied by a concurrent rectal examination in
attempt to locate the bulge of an enterocele above the
examining finger as well as to determine the integrity of
the rectovaginal connective tissue. The vaginal apex
and/or cervix is inspected first with gentle traction anteriorly and posteriorly and then at rest and with strain.
After removing the split speculum, the genital hiatus and
perineal bodies are evaluated at rest and with strain. An
examination is then performed in the standing position,
with Valsalva, to confirm that the full extent of the prolapse has been observed.
Figure 5. Grid for recording quantitative descriptions of pelvic
organ support. The grid can be used to assess the degree of prolapse. (Adapted from Bump RC, Mattiasson A, Bo K, et al. The
standardization of terminology of female pelvic organ prolapse
and pelvic floor dysfunction. Am J Obstet Gynecol 1996;176:10.
Reprinted with permission from Elsevier Science.)
Each identified defect is analyzed and graded separately based on the maximal degree of descent. Although no single system for grading the extent of prolapse is used by all examiners, Pelvic Organ Prolapse
Quantitation (POPQ)—a classification system developed by the International Continence Society Committee on Standardization of Terminology9—is being
used with increasing frequency. The POPQ staging system provides a quantitative description of pelvic architecture using the hymen as a fixed point of reference
and evaluating 9 different aspects of pelvic anatomy
(Figure 4). The POPQ system has been shown to have
good intraobserver as well as interobserver reliability;10
normative data have been collected and assessed.11 A
grid for recording pelvic support characteristics based
on the POPQ system is shown in Figure 5.
ANCILLARY DIAGNOSTIC STUDIES
Even a thorough pelvic examination is limited because only the vaginal portion of the prolapse can be
appreciated. Although it may be clear which parts of
the vagina protrude, the organs on the other side of the
protrusion are not always easily discernible. For this reason, many practitioners have used other modalities to
enhance the pelvic examination. As with the staging
systems, none of the ancillary diagnostic modalities is
considered standard.
Imaging techniques may be most useful for accurately determining which organs are involved in
the prolapse. Ultrasonography allows the observer to
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continuously evaluate the segment of interest under
static and dynamic conditions. Radiography using
contrast material also may be static or dynamic and
includes voiding colpocystourethrography, defecography, peritoneography, and pelvic fluoroscopy.
Recently, new technology has allowed for dynamic
evaluation of patients using magnetic resonance
imaging (MRI).12 The advantages of MRI over other
imaging modalities include the lack of radiation and
need for contrast media, excellent soft tissue visualization, and multiplanar imaging capability. Although
these advances will probably enhance our understanding of pelvic support defects, the role of a relatively expensive MRI in current clinical practice
remains under investigation.
Patients also may be further assessed intraoperatively in a manner similar to that described for the pelvic
examination. However, the effects of anesthesia and any
resultant differences in treatment as well as outcomes
have not been evaluated.
OVERVIEW OF TREATMENT OPTIONS FOR
VAGINAL APICAL PROLAPSE
CASE 1: DIAGNOSIS
The patient is sexually active and wishes to remain
active. She has no other complaints or any additional
pertinent medical history. On examination, she is found
to have descent of the vaginal apex to the hymenal ring
with strain (POPQ point C = 0). The anterior and posterior vaginal walls are well supported (POPQ points
Aa and Ap = –2 and points Ba and Bp = –3).
• What are the treatment options for a patient with
vaginal apical prolapse?
NONSURGICAL OPTIONS
Pessaries
Numerous vaginal pessary devices are available for
the management of various pelvic support defects. In
general, these devices support the anterior and posterior vaginal walls and serve to fill the widened genital hiatus. As a result of pressure on the vaginal walls, pessaries
may cause ulceration and associated bleeding. Rarely,
more serious sequelae, such as fistula formation, can
occur with prolonged, unobserved use. Because of
these potential consequences, pessaries should be removed, cleaned, and reinserted periodically. In addition, the vaginal walls should be inspected for signs of
erosion. Because pessaries do not correct the connec-
6 Hospital Physician Board Review Manual
tive tissue problem, they are a nondefinitive form of
treatment. As a result, pessary use often is reserved for
the older woman for whom vaginal intercourse is not a
concern. However, sexual activity is certainly not precluded in those women who can manage removal and
reinsertion of the pessary at home.
Hormone Replacement Therapy
Although blood supply and tissue quality of the vagina can be improved with estrogen supplementation, it
is unlikely that such therapy will have a significant effect
on a patient with severe pelvic relaxation. It has been
postulated that menopausal patients with no or minimal support defects may accrue prophylactic benefit
from supplemental estrogen, because the supporting
structures of the vagina (uterosacral ligaments,7 levator
ani muscles8) contain estrogen receptors. However, this
hypothesis has not been adequately evaluated. Localized estrogen therapy certainly should be used in preoperative patients with signs of atrophy.
Pelvic Floor Exercises
Kegel exercises involve contracting the pelvic muscles (predominantly the pubococcygeus muscle) in
order to strengthen them. These exercises help to restore strength to pelvic muscles weakened by pregnancy and/or childbirth13 and may be beneficial for patients with mild pelvic support defects. Kegel exercises,
however, have not been shown to correct significant degrees of pelvic prolapse. Patients who have difficulty
contracting the proper muscles involved in Kegel exercises can use a variety of biofeedback techniques to
enhance their ability to perform the exercises.
SURGICAL OPTIONS
Vaginal Obliteration
The Le Fort colpocleisis14 is the classic vaginal obliterative procedure. In this operation, rectangular strips
of anterior and posterior vaginal mucosa are removed,
and the submucosal layers are approximated to close the
vagina, leaving lateral tunnels on either side of the vagina for drainage of secretions or blood. However, urinary
incontinence may occur if the urethra and bladder
neck, which are attached posteriorly to the distal anterior vagina, are pulled excessively. Therefore, a procedure
to buttress the bladder neck, such as a Kelly plication,
often is performed concomitantly with vaginal obliterative procedures. Because the vagina is closed by this
operation, it is intended for a small group of older
patients who are no longer sexually active. One advantage of colpocleisis is that it can be performed without
the need for general anesthesia or significant operating
D i a g n o s i s a n d Tr e a t m e n t o f Va g i n a l A p i c a l P r o l a p s e
time. Thus, it can be of benefit to an elderly, medically
compromised patient with prolapse. One study found
good anatomic results in about 90% of patients.15
Vaginal Vault Suspension
Attachment to cardinal-uterosacral ligament complex.
This ligament complex provides an anatomically correct
reapproximation for the upper vagina. When anatomically normal ligaments are detached from the upper vagina during a hysterectomy, they should be reattached
before concluding the procedure to prevent subsequent
vaginal prolapse. When significant apical prolapse is present, these ligaments will demonstrate some pathology—
either significant stretching and attenuation or a clean
break in otherwise normal ligaments. The latter occurrence, which has been demonstrated by Richardson,16
would support the concept of high or proximal
uterosacral ligament attachment to the upper vagina and
anterior (pubocervical) and posterior (rectovaginal)
components of endopelvic fascia. This approach creates
continuity of the level II (endopelvic fascia) supporting
fibers at the vaginal apex, with level III supports (uterosacral ligaments). This procedure may be performed
vaginally, abdominally, or laparoscopically. At present,
there is little information regarding long-term cure rates
with this procedure. One study reported a very high rate
of ureteral injury (11%) when using a vaginal approach
to the proximal uterosacral ligaments.17 It is unknown
whether the abdominal or laparoscopic approach is safer
as neither has been evaluated sufficiently.
Sacrospinous ligament fixation. When vaginal apical
prolapse is present and the cardinal-uterosacral ligament complex will not provide sufficient strength for
attachment, the sacrospinous ligament and/or the overlying coccygeus muscle can be used as a site of attachment for the vaginal apex.18,19 The main advantages of
this approach include relatively short operating time,
vaginal approach (ie, lack of an abdominal incision),
and a low risk of complications (eg, penetration of a viscus [most likely the rectum], pudendal or sciatic nerve
injury, hemorrhage from pudendal vessels, risk of subsequent anterior wall defects, or urinary incontinence).
Precise success rates are difficult to evaluate due to a lack
of objective long-term prospective data; however, the
largest published series reported success rates ranging
from 65% to 97%.18–22 Use of sacrospinous ligament fixation for patients with uterine prolapse to or beyond the
vaginal introitus has been advocated.23 One study reported a 50% reduction in subsequent apical prolapse when
sacrospinous ligament fixation was used in this setting.24
Sacral colpopexy. The apex of the vagina can be
attached to the periosteum of the sacrum using a syn-
thetic, natural (cadaveric), or autologous fascial graft.
Various modifications have been made to the initially
described approach.25 Sacral colpopexy would clearly
be more feasible than sacrospinous ligament fixation
when the vagina is too short to reach the sacrospinous
ligament via a vaginal approach or when the abdomen
must be opened for another reason (eg, adnexal mass).
As with any abdominal procedure, risks and patient
recuperation will be greater than with vaginal surgery.
These risks include intestinal complications (eg, ileus),
incisional pain, and infection. To minimize these risks,
a laparoscopic approach to sacral colpopexy has been
devised.26 Other concerns associated with sacral
colpopexy via any route include the potential for massive hemorrhage from the presacral plexus of veins,
mesh erosions, chronic sinus formation, and urinary
incontinence with posterior displacement of the vagina.
As with sacrospinous ligament fixation, accurate success
rates are difficult to evaluate because of a lack of longterm prospective data. Among published series, success
rates appear to vary from 85% to 100%.27–29
Vaginal versus abdominal approach. Although information on success rates with sacral colpopexy and sacrospinous ligament fixation is sparse, the available data
appear to indicate slightly better success with the abdominal approach than with the vaginal approach. A yet unanswered question, however, is: how much better would success rates need to be with an abdominal operation than
with a vaginal operation to justify its use as the primary
operation of choice in all patients?
One recent randomized prospective study attempted
to answer this question.30 The authors concluded that
the abdominal approach was more successful in treating
uterovaginal prolapse than the vaginal approach but
that the vaginal approach was successful enough to substantiate its use. This study had several drawbacks, most
notably use of bilateral sacrospinous fixation as the vaginal procedure (instead of the traditional unilateral fixation) and use of needle suspension urethropexies in the
vaginal arm versus Burch procedures in the abdominal
arm. The superiority of the Burch procedure over the
needle suspension procedure for correction of incontinence has previously been demonstrated.31 In trying to
evaluate the results specific to the apical corrective procedures, the authors found a failure rate of 2.5% in the
abdominal group versus 12% in the vaginal group.30
However, when evaluating serious morbidity (ie, excluding urinary tract infection), 30% of patients in the abdominal group had problems (including transfusions,
enterotomy, cystotomy, ileus, sciatica, wound infection,
obturator nerve injury) versus less than 5% in the vaginal group (cystotomy).
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Superior gluteal artery
Sciatic nerve
Nerve to quadratus
femoris muscle
Internal pudendal
artery
Nerve to obturator
internus muscle
Inferior gluteal artery
Ischial spine
Tendinous arch of
levator ani muscle
S1
S2
S3
Figure 6. During sacrospinous ligament fixation, certain structures must be avoided,
including the sciatic nerve and the pudendal
vessels and nerve. (Adapted from Size EMH,
Karram MM. Transvaginal repair of vault
prolapse: a review. Obstet Gynecol 1997;89:
466. Reprinted with permission from the
American College of Obstetricians and Gynecologists.)
Posterior femoral
cutaneous nerve
Pudendal nerve
Levator ani muscle
Coccygeus muscle
VAGINAL SACROSPINOUS LIGAMENT FIXATION
CASE 1: SURGICAL MANAGEMENT
After a discussion of treatment alternatives and their
relative risks and benefits, the patient elects to undergo
vaginal sacrospinous ligament fixation.
• What are surgical anatomic considerations with sacrospinous ligament fixation, and how is the procedure performed?
ANATOMIC CONSIDERATIONS
The sacrospinous ligament spans the ischial spine
and distal portion of the sacrum. It is located in the lateral portion of the pararectal space and is essentially
contiguous with or just beneath the coccygeus muscle.
Important surgical anatomic considerations involve the
sciatic nerve, which is located superiorly and lateral to
the ischial spine, and the pudendal vessels and nerve,
which run posterior to the ischial spine at the medial
site of attachment of the sacrospinous ligament
(Figure 6). In addition, the ureter (in its pelvic course)
runs parallel to the vagina until just cephalad to the
ischial spine, at which point it bends anteriorly along
the lateral aspect of the vagina. The hypogastric venous
plexus and the inferior gluteal vessels are found superi-
8 Hospital Physician Board Review Manual
or to the sacrospinous ligament; the gluteus maximus
muscle is located posteriorly.
SURGICAL TECHNIQUE
With the patient in dorsal lithotomy position, a
V-shaped incision is created in the perineum and an
inverted V-shaped incision is made in the distal vaginal
mucosa. The skin and vaginal mucosa are trimmed; the
posterior vaginal incision is extended longitudinally up
toward the vaginal apex. The rectovaginal space is
entered with the initial dissection and developed progressively in a cephalad direction. Alternatively, the initial incision may be made at the apex and may proceed
distally along the posterior wall to gain access to the rectovaginal space. At the apex of the vagina, an enterocele
sac may be identified. If present, this sac is entered
sharply, intestinal contents reduced, and the sac freed
from surrounding endopelvic connective tissue. The
most cranial portion of the sac is then ligated with a
purse-string suture, and the sac is excised.
For a right-handed operator, the right sacrospinous
ligament is chosen as the site of attachment for the
vaginal apex. The right side of the pararectal space is
separated from the rectovaginal space by the right rectal pillar. After palpation of the right ischial spine, this
pillar is penetrated by sharp or blunt dissection, entering the pararectal space. Retractors are placed to move
the rectum toward the patient’s left side and to move
D i a g n o s i s a n d Tr e a t m e n t o f Va g i n a l A p i c a l P r o l a p s e
the bladder and right ureter anteriorly. Once in the
pararectal space, the ischial spine can be palpated along
with the coccygeus muscle/sacrospinous ligament complex that is medial to the spine. Further blunt dissection
of areolar tissue allows exposure of the ligament. A
lighted suction-irrigation system can be very helpful to
aid visualization in this space.
The standard surgical technique is performed by
placing the operator’s left middle finger on the right
ischial spine and penetrating the muscle/ligament complex (Figure 7) medial to the left index finger (about
2–3 cm medial to the ischial spine) with a Deschamps
ligature carrier. This maneuver ensures that the pass of
the needle is in a safe location, well medial to the pudendal vessels, sciatic nerve, and ureter. A number 1 nonabsorbable Prolene suture is used, and after passage its
loop is cut in the center to provide 2 sutures through the
ligament with a single ligature pass. The substance of the
ligament-muscle complex must be penetrated (rather
than encircled); once through, traction on the suture
ends will often move the patient on the operating table.
More recently, sacrospinous ligament fixation has
been performed using a Capio ligature carrier to pass
the Prolene suture. This instrument is a straight, cylindrical tube with a small, curved needle at the end with a
self-catching apparatus. It, therefore, allows for greater
visualization of the ligament during the suture pass and
ease of retrieval of the suture once placed. In addition,
the suture pass proceeds from superior to inferior, potentially decreasing the risk of bleeding from the superiorly located blood vessels.
A free needle is used to attach the suture ends to the
undersurface of the vagina at the apex. This maneuver
is done using a pulley stitch, in which one end of the
suture is passed through the subvaginal tissue and tied
by a second half-hitch. A suture that is passed through
the full thickness of the vagina, penetrating the mucosa,
is not considered to be problematic. When the knot is
eventually tied, the pulley mechanism allows the operator to place traction on the free end, which will move
the apex into apposition with the sacrospinous ligament. The sacrospinous ligament sutures are not tied
until the upper posterior vaginal wall has been reapproximated. If tied too soon, the posterior wall will be
moved cephalad, substantially reducing exposure and
making subsequent closure difficult.
CASE 1: INTRAOPERATIVE COMPLICATIONS
During the vaginal sacrospinous ligament fixation
procedure, unexpectedly heavy bleeding is encountered in the pararectal space.
Figure 7. Determining the safe location (which is well medial to
the pudendal vessels, sciatic nerve, and ureter) for passage of the
needle during sacrospinous ligament fixation. The middle finger
palpates the ischial spine, and the index finger touches the
sacrospinous ligament as shown. The handle of the Deschamps
ligature carrier is rotated in a clockwise direction, as shown by
the curved arrow. (Adapted with permission from Thompson JD,
Rock JA, editors. Te Linde’s operative gynecology. 7th ed.
Philadelphia: Lippincott;1992:874.)
• How is blood supplied to the pararectal space?
• How is hemorrhage managed in the setting of vaginal sacrospinous ligament fixation?
RISK OF PUDENDAL ARTERY INJURY
Heavy bleeding in the pararectal space is uncommon but may result from dissection superior to the
muscle-ligament complex or lateral to the ischial spine.
Continuous oozing is indicative of venous bleeding and
can be addressed initially with tamponade. If bleeding
continues, localization of lacerated veins and ligation
with vascular clips should restore hemostasis. Adequate
visualization at all times in the pararectal space is necessary and may be accomplished with a fiberoptic forehead light or with a lighted suction-irrigation system. If
bleeding is pulsatile or if localization reveals an arterial
source, the vessels must be directly ligated.
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Because the main blood supply to this region is from
the pudendal artery, knowledge of the origin of these
vessels is a necessary prerequisite for performing this
type of operation. The pudendal artery originates from
the internal iliac (hypogastric) artery (Figure 6). The
internal iliac artery arises from the common iliac artery
and divides into an anterior and posterior division.
Branches arise variably from these divisions. In general,
the superior gluteal artery arises from the posterior division; the internal pudendal, inferior gluteal, uterine,
vesical, umbilical, and obturator arteries arise from the
anterior division.
Pudendal artery injury during sacrospinous ligament
fixation, although possible, is extremely unlikely when
adhering to the standard surgical technique described.
As noted, the suture should be placed 2-fingerbreadths
medial to the ischial spine to provide a safe distance
from the vessels and nerves. Vascular injury is particularly unlikely when using the Capio ligature carrier
because of its small size. Similarly, the blunt tip of the
Deschamps ligature carrier is less likely to be associated
with vascular laceration than the sharp tip of a needle. If
a pudendal arterial injury does occur and the vessel cannot be adequately visualized and ligated, laparotomy
and hypogastric artery ligation may be necessary.
However, a recent anatomic study showed multiple vascular anastomoses around the sacrospinous ligament
and indicated that the inferior gluteal artery is likely the
most often injured vessel during the performance of
this procedure.32 Thus, ligation of the hypogastric
artery may only be effective with an isolated pudendal
artery injury. If this is not the case and the patient is
hemodynamically stable with appropriately trained
and available personnel, radiologic localization and
embolization of the bleeding vessel may be a reasonable alternative.
aspect of the ipsilateral leg (ie, the same side as the
sacrospinous ligament suture), which would be indicative of pudendal or sciatic nerve trauma. Again, adherence to the described surgical technique makes this an
uncommon complication of this operation. The patient,
however, should be evaluated for this symptom. If nerve
entrapment is suspected, it should be treated by reoperation, to de-ligate the nerve and reposition the suture in
a more medial position.
ABDOMINAL SACRAL COLPOPEXY
CASE 1: POSTOPERATIVE FOLLOW-UP
On postoperative day number 1, the patient complains of pain in her right buttock. She is otherwise feeling well and is afebrile with a normal leukocyte count.
CASE 2: PRESENTATION
Patient 2 is a 57-year-old woman, para 2, with complaints of low back pain and a pulling sensation in her
vagina for several years. She denies symptoms of urinary
incontinence now or in the past. Her obstetrical history
is significant for a vaginal delivery of her first child (9 lb,
11 oz) and a cesarean delivery of her second child
(10 lb, 7 oz). At age 51 years, the patient underwent a
vaginal hysterectomy as well as anterior and posterior
colporrhaphies for pelvic organ prolapse. She has a
surgical history of femoral hernia repair at age 26 years
and umbilical hernia repair at age 41 years. She denies
a history of diabetes or known collagen disorders. She
has smoked approximately a half pack of cigarettes per
day for about 35 years. She reached menopause at age
49 years and has not received hormone replacement
therapy.
Physical examination reveals an obese female with
several abdominal scars. Pelvic examination reveals a
total vaginal prolapse, although the urethra is well supported. After replacing the vagina, the anterior and posterior vaginal walls appear well supported (POPQ
points Aa, Ba, Ap, and Bp all = –3) with the defect
appearing exclusively apical (POPQ point C = +3). The
vagina appears shortened and atrophic. Bimanual
examination reveals fullness in the midline extending
toward the right adnexa.
• How should this patient be further evaluated?
• Does she require any additional intervention?
• Does this patient require further evaluation before
treatment options should be considered?
RISK OF NERVE TRAUMA
Buttock pain on the side of the sacrospinous ligament suture is a common postoperative complaint seen
in 10% to 15% of patients. It is generally self-remitting
and should resolve within several days to weeks after
surgery. Of greater concern would be the concomitant
symptom of severe pain running down the posterior
Although this patient’s presenting complaint is related to the benign and treatable condition of pelvic organ
prolapse, the physical examination finding of right
adnexal fullness raises the question of a possible malignancy. Before initiating a discussion of the nonsurgical
and surgical treatment options for pelvic organ prolapse,
this patient’s adnexal finding should be further investigated. The differential diagnosis for an adnexal mass in a
10 Hospital Physician Board Review Manual
D i a g n o s i s a n d Tr e a t m e n t o f Va g i n a l A p i c a l P r o l a p s e
postmenopausal patient would include benign processes
(eg, simple ovarian cysts, peritoneal cysts, inflammatory
lesions, endometriosis, dermoid cysts) and malignancies
(eg, epithelial ovarian cancers [serous and mucinous cystadenocarcinomas], germ cell tumors).
Radiologic evaluation of the pelvis and abdomen via
ultrasonography and/or computed tomography (CT)
would be an appropriate next step in this case. Assessing
levels of a serum tumor marker (eg, cancer antigen
[CA]-125), although not useful for screening purposes,
would be a reasonable adjunct—particularly if later
investigation proves the mass to be malignant—because
response to treatment can be gauged with this marker.
CASE 2: FURTHER EVALUATION
Pelvic ultrasonography reveals a 7 × 5 cm mass, appearing to be mostly fluid-filled but with several septations within. The left ovary is seen and appears normal,
but the right ovary cannot be identified. There is no evidence of free fluid in the pelvis. A CT scan of the
abdomen and pelvis is obtained and reveals the same
mass, with no evidence of lymphadenopathy or other disease outside the pelvis. Serum CA-125 level is 20 U/mL.
• How should this patient be managed?
A large, complex-appearing adnexal mass in a postmenopausal patient is an indication for surgical exploration and removal. Although the patient’s normal
CA-125 level is somewhat reassuring, malignancy must
be ruled out by histologic evaluation. In general, fewer
than 20% of patients with nonmucinous epithelial ovarian malignancies have normal CA-125 values.33
Regarding management of this patient’s vaginal
vault prolapse, the same considerations and options
discussed for patient 1 apply. Since an abdominal operation is required to assess the adnexal mass, correction
of the prolapse by attachment to the sacrum would be
the primary choice for surgical treatment. Given the
patient’s propensity for connective tissue defects (she
has a history of 2 operations for other types of hernias), the use of synthetic material for grafting the vagina to sacrum may be more appropriate than use of
autologous fascia.
CASE 2: SURGICAL MANAGEMENT
The patient is counseled about the differential diagnosis for the adnexal mass and the treatment options
for the vault prolapse. After the informed consent process, she is prepared for exploratory laparotomy for
removal of the mass and for abdominal sacral
colpopexy. She receives an overnight bowel preparation
before surgery. Intraoperatively, a thin-walled, fluidfilled mass is found midpelvis, between the bladder and
rectum. The mass is ruptured intraoperatively on dissection, and the cyst wall is entirely removed. Both
ovaries are identified and appear to be within normal
limits. Frozen section of the cyst wall reveals a benign
simple epithelial layer, consistent with the clinical
impression of a peritoneal cyst. After removal of the
ovaries, the sacral colpopexy is undertaken.
• How is sacral colpopexy performed?
SURGICAL TECHNIQUE
Before performing the colpopexy, the deepest portion of the cul-de-sac is often obliterated; any one of
various techniques may be used.34 The peritoneum at
the vaginal apex is incised transversely and then is dissected free of the anterior and posterior vaginal walls.
To facilitate identification and mobilization of the vagina, the patient is maintained in a frog-leg position, and
an instrument, such as a sponge forceps or EES sizer, is
placed in the vagina preoperatively. Dissection proceeds
approximately 2 to 3 cm in either direction to provide
mobility of the vagina for graft attachment. A graft (synthetic, natural, or autologous material) is then sewn
securely to the full thickness of submucosal fibromuscular tissue of the mobilized vaginal apex using nonabsorptive suture material in an interrupted fashion. Care
is taken, with the support of the sizer, to avoid placing
these permanent sutures through the vaginal mucosa.
A midline incision is then created in the parietal peritoneum over the sacral promontory proceeding caudally to the obliterated cul-de-sac, with the sigmoid colon
retracted to the left. The position of the aortic bifurcation into the common iliac arteries is noted as are the
locations of the middle sacral artery and vein arising
from this area and the ureters located along the lateral
aspects of the peritoneal dissection. Careful dissection of
areolar tissue exposes the anterior longitudinal ligaments and the periosteum for subsequent attachment of
the graft, which is then sutured in place with 2 to
3 sutures of permanent material. The dissection proceeds directly over the sacral promontory (not in the
hollow of the sacrum) to avoid dangerous hemorrhage
from the presacral venous plexus. The peritoneum is reapproximated in order to place the graft entirely in a
retroperitoneal location (Figure 8). The intent of the
procedure is to place the vaginal apex in a normal
anatomic position and not to pull the vagina toward the
apex. Thus, the graft is measured so it reaches the
sacrum without placing undue tension on the vagina.
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D i a g n o s i s a n d Tr e a t m e n t o f Va g i n a l A p i c a l P r o l a p s e
ated with synthetic materials is the risk of infection and
tissue reaction, leading to erosion. No studies have
demonstrated clear superiority of one synthetic material over another.
To avoid the dissection and possible tissue weakness
associated with the use of autologous materials as well as
the potential for erosion with the synthetic materials,
heterologous materials (including cadaveric fascia lata
and dura mater) have been used. However, graft autolysis and procedure failure have been reported with
these materials39; therefore, their long-term benefit is
unclear.
CASE 2: INTRAOPERATIVE COMPLICATIONS
During dissection of the sacral promontory, heavy
bleeding is encountered.
Figure 8. Abdominal sacral colpopexy. The graft (inset) connects the vagina to sacrum and lies without tension in the deep
pelvis. The Halban technique is used to obliterate the cul-de-sac
below the graft. (Adapted from Walters MD, Karram MM. Urogynecology and reconstructive pelvic surgery. 2nd ed. St. Louis:
Mosby; 1999:250. Reprinted with permission from Elsevier
Science.)
• What are the relative pros and cons of the different
graft materials that may be used in the performance
of sacral colpopexy?
GRAFT MATERIALS
Many different materials have been used in various
types of reconstructive pelvic operations. Autologous
tissue, such as fascia lata or anterior rectus sheath, was
the first material used for this purpose. The advantages
include cost savings and a lack of rejection or foreign
body response. However, additional dissection needs to
be undertaken to harvest this material from the patient,
which requires greater operating time and may be associated with an increase in postoperative pain. In addition, autologous tissue may not have the same strength
as synthetic materials.
Synthetic materials (eg, Prolene,35 Mersilene,36 Marlex,37 Goretex38) are the most commonly used materials
for this procedure, do not require a separate dissection
to harvest, and have greater tissue strength and durability than natural materials. However, long-term cure
rates are good with all materials used and not necessarily better with the synthetics. The main difficulty associ-
12 Hospital Physician Board Review Manual
• Describe the anatomy of the presacral space, including neurovascular supply and the course of the
ureter.
• How is hemorrhage managed in the setting of sacral
colpopexy?
ANATOMIC CONSIDERATIONS
The aorta bifurcates at approximately the level of the
fourth lumbar vertebra into the left and right common
iliac arteries. It lies just to the left and over the vena
cava. The presacral space (Figure 9) begins below this
level. The iliac vessels mark the lateral boundaries of
this space. The middle sacral artery and vein emanate
from the dorsal aspects of the aorta and vena cava,
respectively, near the bifurcation points. The entire pelvic collateral circulation, beginning at the aorta, is
shown in Figure 10.
The superior hypogastric plexus, or presacral nerve,
is found on the ventral surface of the aorta (Figure 9),
extending over the sacrum before splitting into the
hypogastric nerves, which end in the inferior hypogastric plexus around the medial aspect of the internal iliac
vessels. Transection of the presacral nerve has been
used to treat dysmenorrheal and pelvic pain syndromes
because this plexus receives afferent pain fibers from
the pelvic organs.
The ureter is about 25 to 30 cm long, with approximately equal portions in the abdomen and pelvis. The
abdominal portion extends from the renal pelvis and is
attached to the posterior parietal peritoneum. The
ureter may be found during presacral dissection just lateral to the common iliac arteries (Figure 10). The
ureter then crosses over the bifurcation of the common
iliacs into the external and internal iliacs, just medial to
the ovarian vessels. The ureter then descends into the
D i a g n o s i s a n d Tr e a t m e n t o f Va g i n a l A p i c a l P r o l a p s e
Peritoneum
Tela subserosa
Common iliac
a. and v.
Superior hemorrhoidal
a. and v.
Superior hypogastric p.
Medial
hypogastric p.
L5
Median sacral v.
Promontory
Ureter
Inferior
hypogastric p.
Hypogastric a.
Sympathetic
trunk
Figure 9. Presacral nerve plexus, showing
passage of sympathetic trunk over bifurcation of aorta. Note division of trunk into left
and right presacral nerves. a = artery;
p = plexus; v = vein. (Adapted with permission from Curtis AH, Anson BJ, Ashley FL,
et al. The anatomy of the pelvic autonomic
nerves in relation to gynecology. Surg
Gynecol Obstet 1942;75:743.)
Sigmoid
colon
Ovary
Uterus
Bladder
pelvis, attached to the medial leaf of the broad ligament, and crosses under the uterine artery, running
along the anterolateral cervix and vaginal wall before it
turns anteriorly into the bladder.
BLEEDING IN THE PRESACRAL SPACE
Bleeding in the presacral space can be very difficult
to manage because of the complexity of the venous network and the propensity for the veins to retract into the
underlying bone. Packing may provide some control
for bleeding, but more than likely, visualization and
direct suturing or clipping will be necessary. If unsuccessful, bone wax and possibly placement of sterilized
thumbtacks into the anterior sacrum may be needed to
control life-threatening hemorrhage. Ultimately, the
best treatment is prevention. Avoiding the presacral
venous network by meticulous dissection and remaining high up on the sacrum, near the promontory,
improves the safety of this procedure.
CASE 2: POSTOPERATIVE FOLLOW-UP
Six months after surgery, the patient presents with
persistent vaginal discharge and staining.
• At this time, how should the patient be evaluated and
managed?
COMPLICATIONS FOLLOWING SACRAL COLPOPEXY
Although abdominal sacral colpopexy has an excellent track record for curing vaginal apical prolapse, the
procedure is not without complications. Among the
most troublesome complications is mesh erosion of synthetic material into the vagina, which can lead to symptoms of staining, bleeding, dyspareunia, and/or chronic
vaginal discharge. The precise incidence of mesh erosion is difficult to determine because of generally small
series reported in the literature. One meta-analysis of
synthetic mesh use in gynecologic surgery found erosion
rates of up to 10% for various synthetic materials, with
nearly 3% of patients requiring some form of revision or
removal of material.40
Given this patient’s presenting symptoms, mesh erosion should clearly be suspected. Erosion may present
as early as 6 weeks or as late as 6 years postoperatively.27
Examination will typically reveal a defect of variable size
at the vaginal cuff, with granulation tissue and visible
mesh material. Alternatively, some patients with these
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D i a g n o s i s a n d Tr e a t m e n t o f Va g i n a l A p i c a l P r o l a p s e
Aorta
Lumbar
Common iliac
Ovarian
Iliac branch
Inferior
mesenteric
Iliolumbar
Hypogastric
Midsacral
Anterior division
of hypogastric
Lateral sacral
Superior gluteal
Superior
hemorrhoidal
Umbilical
Tubal
Inferior gluteal
Ovarian
Inferior
hemorrhoidal
Middle
hemorrhoidal
Inferior
pudendal
Inferior epigastric
Vaginal
Ascending
branch
Lateral
circumflex
Figure 10. Collateral circulation of the
pelvis. (Adapted with permission from
Thompson JD, Rock JA, editors. Te
Linde’s operative gynecology. 7th ed.
Philadelphia: Lippincott; 1992:874.)
Uterine
Obturator
Medial circumflex
Vaginal
Femoral
Profunda
femoral
symptoms may have suture, rather than mesh, erosion.
Although the optimal management in these patients
has not been well assessed, initial conservative therapy
will often be successful for patients with suture erosion.
Conservative therapy includes use of local estrogen
cream and observation for reepithelialization. If suture
erosion persists, removal of vaginal erosions will often
eradicate the problem. Mesh erosion, however, does
not typically respond to conservative measures and will
usually require surgical intervention.36
Although abdominal and laparoscopic approaches
to mesh removal have been reported, a transvaginal
approach usually provides the safest course. Abdominal
excision has been associated with life-threatening hemorrhage from dissection in the scarred presacral space.
Using the vaginal approach, the visible portion of mesh
should be dissected free of the vaginal apex and the
mesh should be cut as high as possible. The vaginal
mucosa and underlying connective tissue are then
mobilized and repaired in several layers, using delayed
absorbable suture material. In this manner, hemorrhagic morbidity is reduced, the proximal mesh is well
14 Hospital Physician Board Review Manual
removed from the vaginal apex, and multiple layers
exist between the remaining mesh and the vagina,
reducing the risk for future erosion. Apical support,
presumably as a result of fibrosis, appears to remain
adequate in most patients treated in this manner.
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