Urogynaecology Department, Mercy Hospital for Women, University of Melbourne, Australia

In a recent article I reviewed for a gynaecological journal on vaginal prolapse and laparoscopy the author proudly stated that he rarely performed vaginal surgery for POP and all was done by laparoscopy and from above. With the development of gynaecological endoscopy there has been a trend away from the vaginal approach and vaginal surgery; not only with gynaecologists performing surgery for pelvic floor conditions such as POP but also in training our young gynaecologists to do vaginal surgery. The abdominal colposacropexy is an effective operation for apical uterovaginal prolapse and is increasing in popularity but does have a higher morbidity including mesh complications.

Loss of skills in vaginal surgery is clearly seen in the decreased use of the vaginal route for hysterectomy. In the USA abdominal hysterectomy accounted for 65% of procedures in 1998, increased to a peak of 68.9% of cases in 2002, and then declined to 54.2% by 2010. The use of vaginal hysterectomy declined throughout, from 24.8% in 1998 to 16.7% in 2010. Use of laparoscopic hysterectomy increased to a peak of 15.5% of cases in 2006 and then declined to 8.6% of procedures, whereas use of robotic hysterectomy increased from 2008 to 2010 (0.9–8.2%). (Wright et al Obstetrics & Gynecology: 2013). Over the last 8 years the American College has tried to change this trend and has repeatedly stated that vaginal hysterectomy is the preferred method because of the well documented advantages of lower morbidity and lower costs. A narrow vagina, a well-supported immobile uterus, nulliparity, previous caesarean section and an enlarged uterus have all been suggested as contraindications to surgery but VH is feasible in these women if the vaginal calibre is adequate to allow access to the uterosacral/cardinal ligament complex even in nulliparous women. Surgical techniques will be presented demonstrating this. The vaginal approach has clearly been shown to be superior in the treatment of many urinary (urethral diverticulum, urethra and vesicovaginal fistula) and rectal conditions (rectovaginal fistula, rectocele, overlapping anal sphincter repair for faecal incontinence). A high degree of skill is required to surgically treat these conditions which are not possible for the occasional vaginal surgeon. This should be an area that gynaecologists excel but this will not happen if these skills are lost because of poor training and lack of experience.