Sacrocolpopexy
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Sacrocolpopexy (sacral colpopexy) is a surgical technique for repairing pelvic organ prolapse. Reconstruction is achieved with an open abdominal technique or with the use of minimally invasive techniques. The specific treatment approach is chosen in accordance with the type and degree of pelvic organ prolapse, as well as the severity of symptoms.
The image below illustrates the Pelvic Organ Prolapse Quantification staging system.
A basic exploratory laparotomy instrument set provides most of the needed surgical instruments. The following may be required:
Balfour, Turner-Warwick, or Bookwalter retractor
Vaginal instruments (eg, weighted speculum, Breisky retractors, a tenaculum, ring forceps, dilators, or an end-to-end anastomotic sizer)
Cystoscope
A graft is used to support the vaginal wall and suspend the apical vault to the sacral promontory. Material types include the following:
Autologous (patient’s own tissue)
Allograft (tissue obtained from members of the same species)
Xenograft (biologic material procured from other species)
Synthetic: The FDA notes that serious complications are not rare with the use of surgical mesh in transvaginal repair of pelvic organ prolapse (see FDA Safety Communication: Update on Serious Complications Associated with Transvaginal Placement of Surgical Mesh for Pelvic Organ Prolapse)
The key aspect of abdominal sacrocolpopexy is the suspension of the vaginal apex to the sacral promontory in a manner that recreates the natural anatomic support provided by the uterosacral and cardinal ligaments.
Steps in an abdominal sacrocolpopexy include the following:
Modified low lithotomy position
Intravenous prophylactic antibiotic (typically cefazolin)
Foley catheter
Pfannenstiel incision a few centimeters cranial to the pubic symphysis
Incision through the rectus fascia and separation of recti abdominis
Entry into peritoneum and exposure of surgical field, with bowel packed away from the field
Dissection of the bladder away from the anterior vagina along the vesicovaginal septum; continued posteriorly to separate the vagina from the rectum along the rectovaginal septum
Placement of an instrument in the vagina
Exposure of retroperitoneal space
Identification of the point for fixation of the graft: the sacral promontory
Selection of graft material and construction of graft
Positioning and fixation of graft in a tension-free manner
Closure of peritoneal reflection over the graft
Surgical concepts of the laparoscopic approach are similar. Additional points include the following:
Use of 4 or 5 trocar sites
Dissection with laparoscopic monopolar scissors and bipolar cautery
Fixation of mesh with nonabsorbable monofilament sutures and laparoscopic needle drivers; alternatively, bone anchoring devices are available
Robotic technology has also been employed. [1]
Alternative operations for apical (vaginal vault) prolapse repair include the following:
Sacrospinous ligament fixation
Uterosacral ligament suspension
Iliococcygeus suspension [2]
Sacrocolpopexy (sacral colpopexy) is a surgical technique to repair pelvic organ prolapse. Specifically, it is intended to address apical or vaginal vault prolapse in women. Reconstruction is achieved using an open abdominal technique or with the use of minimally invasive surgery, such as laparoscopy or robotic-assisted surgery. The salient component of reconstruction is suspension of the apical portion of vagina (or the vaginal cuff in patients after hysterectomy) in a manner that recreates the natural anatomic support that the uterosacral and cardinal ligaments provide, usually by tacking it to the sacral promontory. In postmenopausal women with concomitant uterine prolapse, hysterectomy can be performed at the time of surgical repair. Uterine sparing reconstruction techniques have been described.
The treatment elected is based on the assessment of the type and degree of pelvic organ prolapse, as well as the severity of symptoms. Herniation of other components of the vaginal wall may co-exist with uterine or apical prolapse and may require simultaneous repair. Alternate surgical techniques, such as a transvaginal approach, may provide better access to repair such defects. Combined vaginal and abdominal surgery can be performed if necessary. Proper preoperative assessment is crucial for surgical planning and will be addressed in this article, along with surgical techniques, postoperative care, and alternative therapies.
Pelvic organ prolapse is the symptomatic descent of one or more of components of the vaginal wall, including the anterior wall, posterior wall, and the vaginal apex, which could lead to descent of the cervix and uterus or the vaginal cuff following a hysterectomy. [3, 4] The degree of prolapse is assessed using a quantification system, such as the Pelvic Organ Prolapse Quantification (POPQ) or the Baden-Walker system.
Nomenclature exists to describe the prolapse based on the pelvic organ that has herniated into the vaginal wall. Anterior defects with herniation of the urinary bladder create a cystocele. A rectocele occurs from posterior vaginal wall defects. Apical defects include uterine prolapse or uterovaginal prolapse, vaginal cuff prolapse after hysterectomy, and enteroceles. An enterocele is protrusion of the intestines into the apical vaginal wall and can be in either the anterior or posterior compartment.
DeLancey previously characterized all of these types of prolapse according to defects in three different anatomic levels of support. [5] Objective and ordinal classification systems, such as the POPQ, have demonstrated good intraobserver and interobserver reliability. [6] Sacral colpopexy is one technique for surgical correction of apical or vaginal cuff prolapse.
Epidemiology
The prevalence of pelvic organ prolapse varies between studies, but has been reported in larger observational studies of menopausal women in the range of 31-41.1%. [7, 8] In a multicenter observational study of women presenting to an outpatient gynecology clinic, the distribution of prolapse according to a POPQ assessment was 24% with stage 0 prolapse, 38% with stage I, 35% with stage II, 2% with stage III, and 0% with stage IV. [9]
Nygaard et al studied a smaller population that was a subset of those enrolled in the Women’s Health Initiative Hormone Replacement Therapy trial. They found 2.3% with stage 0 prolapse, 33% with stage I, 62.9% with stage II, 1.9% with stage III, and 0% with stage IV. [10] The lifetime risk of undergoing an operation for pelvic organ prolapse is reported to be 11-19%. [11, 12]
Noting the difference between the lifetime risk of operation and the reported distribution of pelvic organ support suggests that some degree of prolapse may represent a normal finding or at least exist as an asymptomatic state. Swift and colleagues analyzed the symptoms and degree of bother, but did not find a statistically significant linear trend with POPQ stage. Correlation to the leading edge of descent produced a significant linear increase in positive response to symptoms as the leading edge increased from -3 cm to +7 cm. [13]
Etiology
Pelvic organ prolapse shares similarities to abdominal hernias. In fact, it can be considered herniation of pelvic or abdominal contents into structural weaknesses in the support of the pelvic floor. The etiology of the fascial or ligament defects that leads to prolapse is multifactorial and involves genetics, environmental factors, comorbidities, and lifetime events such as the number of vaginal births.
Risk factors for pelvic organ prolapse include the following:
Increasing age
Increasing body mass index (obesity)
Increasing gravidity
Increasing parity
Number of vaginal deliveries
Macrosomic delivery
Chronic obstructive pulmonary disease
Constipation
Strenuous activity, weight bearing, or strenuous labor
In a cohort of 497 women over the age of 18 seen for routine outpatient gynecology evaluation, Swift and colleagues identified a significant prolapse trend with increasing parity, the number of vaginal deliveries, and delivery of macrosomic infants. [14] The study also identified a higher incidence in postmenopausal women. In a subsequent multicenter study of 1,004 women, this group found increasing age, body mass index, gravidity, parity, number of vaginal deliveries, and weight of the vaginally delivered infant to be significant risk factors for prolapse on univariate analysis. [9] On multivariate analysis, only advancing age, Hispanic race, increasing body mass index, and increasing weight of the vaginal delivery were risk factors for prolapse. [9]
Nygaard and colleagues studied patients enrolled in the WHI Hormone Replacement Therapy trial and found varying risk factors for prolapse depending on the definition of prolapse itself. Education level, the number of vaginal deliveries, and the weight of the infant were significant factors in distinguishing patients with Stage II prolapse or greater. [10]
Other factors associated with pelvic organ prolapse are chronic obstructive pulmonary disease, constipation, and a history of strenuous exercise or manual labor. [11, 15, 8] The effect of race appears to change depending on the selection bias of the particular study, and its true implication remains largely undefined.
Consideration for surgical repair of apical (vaginal vault) or uterine prolapse is based on adequate assessment of the patient’s symptoms and degree of bother, as well as a standard method to quantify prolapse. It is important to note that symptom severity may not correlate with the degree of prolapse. Some degrees of prolapse may be found without symptoms and could represent a normal physical finding. [4, 13]
Symptoms of pelvic organ prolapse have been defined in a joint report from the International Urogynecological Association and International Continence Society as “a departure from normal sensation, structure, or function, experienced by the women in reference to the position of her pelvic organs.” [3]
Symptoms may include the following: [3, 16]
Vaginal bulge
Pelvic pressure
Bleeding
Infection
Splinting or digitation (the need to manually assist in reducing prolapse, often to void or defecate)
Back pain
Concomitant symptoms may include the following: [3, 16]
Urinary incontinence symptoms, such as stress, urgency, or postural incontinence
Bladder storage symptoms, such as frequency, urgency, or overactive bladder syndrome
Voiding symptoms, such as hesitancy, slow stream, straining, incomplete emptying, or position-dependent voiding
Sexual dysfunction symptoms, such as dyspareunia or obstructed intercourse
Anorectal dysfunction, such as fecal incontinence, flatal incontinence, fecal urgency, straining to defecate, constipation, and incomplete evacuation
Many of the general contraindications to sacral colpopexy are the same for any surgical procedure. These may include the following:
Bleeding diathesis or the need for anticoagulation
Significant cardiac or pulmonary comorbidities
Active infection such as cystitis, bacterial or fungal vaginal infection, pelvic inflammatory disease, or active sexually transmitted disease
Active venous thromboembolism
Uncontrolled hyperglycemia
Other contraindications specific to sacral colpopexy include the following:
Vaginal cancer, cervical cancer, or uterine cancer that is untreated or cannot be adequately treated due to advanced stage
Fistulas such as vesicovaginal, rectovaginal, vesico-utero, or urethral fistulas
Previous pelvic prolapse repairs with infected or exposed foreign material and erosions
Relative contraindications include the following:
Pelvic irradiation
Previous pelvic surgery or prolapse repair, depending on the nature of the operation and the subsequent pathology, side effects, or complications (the existence of such may warrant additional diagnostic evaluation and may require additional surgical intervention or change of approach to prolapse repair)
Concomitant cystocele, rectocele, or urinary incontinence (the existence of such pathology may require additional surgery, a vaginal approach, or a combined approach)
Complication Prevention
Immediate perioperative complications include bowel obstruction, peritonitis, urine leak from failed intraoperative recognition of a cystotomy, dehiscence, and infection. Although most of these complications occur rarely, they must be included in the differential when symptoms occur. Delayed bleeding is a rare complication but should be entertained in a patient who is hemodynamically unstable.
Postsurgical complications can be reduced by understanding the risks of the surgical procedure, including the risks of anesthesia, positioning, surgical technique, implants, and infection. Neurapraxia can be avoided by proper positioning and padding of pressure points. In the modified lithotomy position for sacral colpopexy, femoral nerve injury can occur by hyperextension at the hip and thus should be avoided. Perineal nerve injury may result from compression against the stirrup if not properly positioned and padded. Reducing surgical time will reduce the length of time the patient is in a position that increases risk for injury. Retractor placement for exposure of the operative field can lead to nerve injury, most commonly the femoral nerve as it traverses within the psoas muscle.
Venous thromboembolism is another complication that results from the hemodynamic state established by general anesthesia, positioning, and surgical manipulation or retractor compression of great vessels. Postoperative thromboembolic complications were found to be threefold more likely on multivariate analysis in Medicare beneficiaries undergoing concomitant prolapse repair with urethral sling surgery compared to urethral sling surgery alone. [17] Prophylactic measures including placement of sequential compression devices or antiembolic compression stockings prior to anesthesia induction, early postoperative ambulation, and prophylactic doses of heparin or low-molecular weight heparin in those with increased risks factors may help reduce thromboembolic events.
Mesh erosion is a late complication of abdominal sacral colpopexy with a reported rate of 3-7.6%. [18, 19, 20, 21] Lower rates of erosion have been identified with monofilament polypropylene mesh. [19] Concurrent hysterectomy was associated with increased erosion rates in one study. [19] Another study did not find associated risk factors or demonstrate increased erosions with concurrent hysterectomy. [22] Symptoms include persistent dyspareunia, vaginal discharge, or bleeding. [19, 22] The time from surgery to erosion varies but has been reported on average to be between 5 and 14 months. [19, 22]
Management of mesh erosion includes transvaginal excision, either partial or complete graft removal, or laparotomy for complete graft removal. [19] Conservative attempts with mesh trimming, vaginal estrogen cream, and antibiotics often fail. [22] Suture erosions into the vaginal mucosa, however, have been successfully remediated through vaginal excision of the suture and cauterization of mucosa, followed by intravaginal estrogen and oral antibiotic administration. [22]
The FDA issued a statement that serious complications are not rare with the use of surgical mesh in transvaginal repair of pelvic organ prolapse, as discussed further in Equipment. The review found that the most common complication was erosion of the mesh through the vagina, which can take multiple surgeries to repair and can be debilitating in some women. Mesh contraction was also reported, which causes vaginal shortening, tightening, and pain.
Implantable materials are increasingly being used in surgery, and with mesh used frequently in the repair of pelvic organ prolapse, it is important to have a standard method of categorizing and reporting erosions. In a joint effort between the International Urogynecological Association and the International Continence Society, the committee on standardization has developed a set of definitions describing different complications and a standardized classification system to be used for records, reporting, and academic research. The system is based on three evaluated variables: category, time, and site. [23] Each variable is assigned an alphanumerical code according to the defined set of complications. [23] An interactive complication classification tool based on the International Continence Society and the International Urogynecological Association Joint Terminology and Classification report is also available.
Outcomes following abdominal sacrocolpopexy typically have been reported in both objective and subjective cure rates. Objective results are based on an anatomic measurement system such as the POPQ or Baden-Walker ordinal classification. Subjective results arise from patient self-reporting on questionnaires. When defined as lack of apical prolapse postoperatively, the cure rates ranged from 78-100%. When defined as no postoperative prolapse, the range of success widened to 58-100%. [20, 24]
If you consider prolapse in any compartment following surgery, not just recurrent apical prolapse, the success is lower in most studies. Reports on patient satisfaction after surgery range from 85 -100%. [20]
In a study of 376 women who underwent prolapse or incontinence surgery, the rate of reoperation was 13% by 71 months. [25] The risk increased to 17% for those women who previously underwent surgery for prolapse or incontinence. [25] Another study demonstrated a reoperation rate as high as 29.2%. [11]
Following surgery, the patient should be discharged with a comprehensive set of postoperative care instructions. Any strenuous activity or heavy lifting should be avoided in the immediate postoperative period, usually 6-8 weeks, to allow adequate time for scar tissue formation. Activities that generate perineal strain or trauma, such as bicycle riding, should be prohibited. The patient must refrain from any sexual intercourse during healing. Additionally, the patient should be instructed to not insert tampons or applicators into the vagina.
History and Physical Examination
Proper evaluation of patients with pelvic organ prolapse begins with a thorough history and physical examination followed by any indicated ancillary studies. The physician should query the patient regarding all of the different aforementioned symptom domains, including prolapse symptoms, urinary, bowel, and sexual symptoms.
Assessment of the types of symptoms and their degree of bother can be completed using validated instruments, such as surveys or questionnaires that have proven to be accurate and reproducible. These quality-of-life tools include the Pelvic Floor Distress Inventory, the Pelvic Floor Impact Questionnaire, and the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire. Short forms of these surveys have been developed and tested to be reliable and accurate. [26]
Additional resources include the Incontinence Impact Questionnaire-7, a quality-of-life tool for urinary incontinence. Patients with voiding and incontinence symptoms should complete a 24-hour volume-frequency diary. Additional information elicited includes details on first menarche, gravidity, parity, number of vaginal deliveries, menstruation cycles, age at menopause if applicable, any history of infections including sexually transmitted diseases, a sexual history, and any comorbidities. Ensure that the patient has had routine cervical cytology screening with any abnormalities thoroughly assessed. A detailed surgical history should be documented.
Physical examination focuses on the pelvis but should not preclude a thorough abdominal examination to identify any prior surgical sites, hernias, or palpable masses. In the dorsal lithotomy position, the external genitalia should be inspected for lesions. The introitus and urethral meatus are evaluated for evidence of bulging or masses.
The posterior blade of a Graves speculum is then used to retract each individual component of the vaginal wall. It is important to have the patient replicate a Valsalva maneuver by bearing down during the examination. The blade is placed on the anterior wall to isolate any posterior defects, such as a rectocele or enterocele. To distinguish an enterocele from a high rectocele, a finger can be placed in the rectum to elevate the rectal wall. The blade is then placed posterior to assess for any anterior prolapse followed by inspection of both lateral walls. [27]
Note is made of the vaginal mucosa and degree of atrophy, visualized as loss of rugae. Stress incontinence and urethral hypermobility (ie, Q-tip test) should be evaluated. A bimanual examination completes the assessment of the uterus, if present, and adnexa, making note of any tenderness or masses. A rectal examination will assess for rectal tone and allow examination of the rectovaginal septum. Any neurological findings should be noted.
The patient can additionally be examined in a standing, upright, or semi-upright position to assess for any changes caused by gravity, although some authors have found no difference in the results between positions. [28]
Additional evaluation with ancillary laboratory tests, imaging modalities, or diagnostic procedures may be recommended by the physician depending on the individual patient’s symptoms and physical examination findings. A urinalysis should be part of a routine workup and results suggesting infection or microhematuria should be investigated.
Cystoscopy is a routine diagnostic study using an endoscope to visualize the inside of the urinary bladder. It is important to exclude tumors if hematuria is present. Vasavada et al have proposed the use of preoperative or intraoperative cystoscopy to differentiate between different components of prolapse. [29]
Concomitant urinary incontinence can be present with pelvic organ prolapse and an attempt should be made to elicit this diagnosis at the time of the initial examination. Stress incontinence may be occult and masked by obstruction secondary to prolapse, such as a kinking of the urethra. [30] During examination, the prolapse can be reduced with either a pessary, a roll gauze, a speculum, or manually to unmask underlying urinary incontinence. [31]
In the Colpopexy and Urinary Reduction (CARE) trial, which was a prospective study of patients with pelvic organ prolapse randomized to sacral colpopexy with or without simultaneous Burch colposuspension, patients in the colposuspension arm demonstrated a statistically significant reduction in postoperative stress incontinence. [32] After 2 years of follow-up, this advantage remained significant. [18] These data provide evidence for the existence of underlying incontinence in the patient with prolapse and suggest the need to identify such pathology prior to surgery.
The role of preoperative urodynamics to diagnose women with outlet obstruction, detrusor overactivity, and stress urinary incontinence prior to prolapse repair has been debated. Occult stress urinary incontinence and detrusor overactivity has been identified in a significant number of women with severe prolapse on preoperative urodynamic evaluation. [33]
In a study of 68 women with genital prolapse who underwent urodynamics, 58% of those with a grade 3 or 4 cystocele were found to have bladder outlet obstruction compared to 4% with grade 1 or 2 cystocele. [31] After vaginal pessary placement, normal free flow was found in 94% of those with grade 3 or 4 cystocele. [31] Detrusor overactivity was identified in 20% of those with grade 1 or 2 cystocele, and in 52% in those with grade 3 or higher. [31] When analyzing patients in the CARE trial, significant differences were noted in the detection of urodynamic stress incontinence dependent upon the method of prolapse reduction. [34]
Overall, 27% of women enrolled in this study leaked with some form of prolapse reduction, while only 3.7% demonstrated stress incontinence without reduction. [34] Patients with preoperative stress incontinence demonstrable on urodynamics were more likely to have postoperative stress incontinence. [34] This was true even in the arm randomized to undergo simultaneous Burch colposuspension. [34]
Conversely, Roovers et al retrospectively reviewed 76 consecutive patients after vaginal prolapse surgery without concomitant anti-incontinence surgery who underwent preoperative urodynamics. They found no predictive parameters for the development of postoperative stress or urge urinary incontinence. [35]
Imaging
The role of medical imaging in evaluating women with pelvic organ prolapse is not standardized. Abnormalities identified on history and physical examination or on other ancillary tests (eg, hematuria on urinalysis) may require further evaluation with abdominal imaging. Empiric upper tract imaging is not mandated. However, an overall 7.7% prevalence of hydronephrosis has been identified in women undergoing prolapse surgery. [36] The prevalence was higher in those with worsening prolapse. [36] In patients with severe pelvic organ prolapse, a preoperative renal ultrasound may identify patients who may require additional assessment or changes in management.
Imaging modalities have been studied for the diagnosis and quantification of pelvic organ prolapse. Pelvic ultrasound can be used to diagnosis prolapse and determine which compartment or organ is responsible for the symptomatic prolapse. [37] Three-dimensional ultrasound has been used to correlate the degree of descent with symptoms. [37] Dynamic magnetic resonance imaging has shown correlation with clinical staging and allows for the measurement of the descent of pelvic organs. [38, 39] Further studies are warranted to assess whether such imaging changes clinical outcomes.
Staging
The International Urogynecological Association and International Continence Society have adopted a standardization of terminology for the evaluation and description of prolapse in the POPQ. [3, 40] The hymen remnant is the fixed reference point in this system. Although the method of measurement and defined stages of prolapse remain under debate, the original description by Bump et al defines six points to compare in relation to the hymen, as shown in the image below. [40]
The degree of prolapse is then stratified into an ordinal staging system: [3]
Stage 0: No prolapse
Stage I: Most distal point is greater than 1 cm proximal to the hymen
Stage II: Most distal point is between 1 cm proximal to the hymen and 1 cm distal to the hymen
Stage II: Most distal point is greater than 1 cm distal to the hymen
Stage IV: Complete eversion of the length of the lower genital tract
The image below shows the POPQ staging system.
Such a classification system allows a standard method of exchanging information between physicians and allows better comparison of research data. Review of this system has shown good interobserver and intraobserver reproducibility. [6]
A basic exploratory laparotomy instrument set provides most of the needed surgical instruments. A Balfour, Turner-Warwick, or Bookwalter type retractor is used for exposure. Vaginal instruments such as a weighted speculum, Breisky retractors, a tenaculum, ring forceps, dilators, or an end-to-end anastomotic sizer should be available. Intraoperative cystoscopy may be required.
The key aspect of sacral colpopexy is the use of a graft to support the vaginal wall and suspend the apical vault to the sacral promontory. The types of materials can be categorized into autologous, allograft, xenograft, and synthetic. The mesh should be biologically compatible and not generate an allergic response. However, inflammatory response cascades allow fibroblast infiltration for the deposition of collagen and elastin. Autologous graft use in such repairs draws questions about the structural integrity of the patient’s own tissue. Because there are likely defects within the structural components of the patient’s own fascia (hence the development of a hernia in the first place) its use may not be best suited for repair of a prolapse.
Allografts are made from tissue obtained from members of the same species, such as harvested cadaveric fascia lata. In a randomized study comparing cadaveric fascia lata to polypropylene mesh grafts for abdominal sacral colpopexy, there was a higher cure rate in those with polypropylene mesh, 91% compared to 68%. [41] Xenografts are biologic material procured from other species, such as porcine dermis or small intestine submucosa, or bovine pericardium. These grafts are acellular and have often been modified by cross-linking to prevent degrading. Paraiso et al studied the use of porcine small intestine submucosa grafts to augment rectocele repair and found that those in the group randomized to receive the graft had a greater failure rate at 1 year. [42]
Synthetic mesh is commonly used and should have sufficient tensile strength to provide support but still be flexible enough for proper placement and to limit erosions or extrusion. The mesh should have large interstitial spaces, greater than 75 µm, to allow leukocytes and macrophages to penetrate. [43] If the pore size is too small, bacteria will pass or be trapped in the interstitial spaces of the mesh, but the leukocytes and macrophages will not traverse. [43] This predisposes the graft to infection. Thus monofilament grafts with larger pore sizes are preferred. Polypropylene monofilament mesh is often used and has a low erosion rate reported in the literature. [19]
On July 13, 2011, the FDA issued a statement that serious complications are not rare with the use of surgical mesh in transvaginal repair of pelvic organ prolapse. Their statement separates out mesh placed via an abdominal approach such as via laparotomy or laparoscopy from transvaginal repairs. The FDA reviewed the literature from 1996-2011 to evaluate safety and effectiveness and found surgical mesh in the transvaginal repair of pelvic organ prolapse does not improve symptoms or quality of life more than nonmesh repair. The review found that the most common complication was erosion of the mesh through the vagina, which can take multiple surgeries to repair and can be debilitating in some women. Mesh contraction was also reported, which causes vaginal shortening, tightening, and pain.
The FDA’s update states, “Both mesh erosion and mesh contraction may lead to severe pelvic pain, painful sexual intercourse or an inability to engage in sexual intercourse. Also, men may experience irritation and pain to the penis during sexual intercourse when the mesh is exposed in mesh erosion.” The FDA is continuing to review the literature regarding surgical mesh in the treatment of stress urinary incontinence and will issue a report at a later date. The full update on FDA Safety Communication: Update on Serious Complications Associated with Transvaginal Placement of Surgical Mesh for Pelvic Organ Prolapse can be viewed online.
Prior to surgical intervention, comorbid conditions should be medically optimized. Evaluation by an internist or medical specialist may be warranted. Voided urine should not show evidence of bacteriuria or infection. Antiplatelet or anticoagulant medications should be discontinued, if medically safe, within adequate time to allow reversal of the medication effects.
Bowel preparation is advised, with the specific regimen at the discretion of the surgeon. The use of intravaginal estrogen cream before surgery has been recommended to improve the integrity of the vaginal mucosa, which is often atrophied in postmenopausal women. A meta-analysis has shown benefit from intravaginal estrogen for both symptom reduction and measurable urogenital atrophy. [44] The safety and tolerability has also been well documented. [45] A 6-week preoperative course of intravaginal estrogen has been proposed to ameliorate vaginal atrophy. [27] An outcomes benefit from preoperative intravaginal estrogen has not been clearly established. [46]
Anesthesia
Either general or regional (spinal) anesthesia can be used for abdominal sacral colpopexy. Adequate abdominal wall relaxation facilitates retractor placement and allows the bowel to be packed out of the operative field. Decompression of the stomach with an orogastric or nasogastric tube reduces bowel distention during surgery. Laparoscopic or robotic-assisted sacral colpopexy requires general endotracheal anesthesia due to the technical requirements of pneumoperitoneum and steep Trendelenburg position.
Positioning
The patient is placed in modified lithotomy position with both legs secured in stirrups, allowing for both abdominal and vaginal exposure. All pressure points should be properly padded to prevent neurapraxia. The patient’s abdomen as well as perineum and vaginal mucosa are prepped for sterile draping.
Following surgery, the patient should be discharged with a comprehensive set of postoperative care instructions. Any strenuous activity or heavy lifting should be avoided in the immediate postoperative period, usually 6-8 weeks, to allow adequate time for scar tissue formation. Activities that generate perineal strain or trauma, such as bicycle riding, should be prohibited. The patient must refrain from any sexual intercourse during healing. Additionally, the patient should be instructed to not insert tampons or applicators into the vagina. A course of antibiotics is often prescribed at discharge, but level I evidence supporting its use is limited.
The key aspect of abdominal sacrocolpopexy is the suspension of the vaginal apex to the sacral promontory in a manner that recreates the natural anatomic support provided by the uterosacral and cardinal ligaments. This is accomplished by dissecting the vagina from the bladder and rectum followed by interposition of a graft attaching the vagina to the sacral promontory.
After positioning in a modified low lithotomy position, the patient is draped using sterile technique. An intravenous prophylactic antibiotic is administered, typically cefazolin, unless the patient is allergic. A Foley catheter is inserted on the field under sterile condition.
A Pfannenstiel incision is made a few centimeters cranial to the pubic symphysis. A horizontal laparotomy incision is made through the rectus fascia and the rectus abdominus muscles are separated midline. The fascia of the transversus abdominis is incised, the peritoneum is entered, and the bowel is inspected. An abdominal wall retractor, such as a Balfour, is placed to expose the surgical field. At this time, the bowel is packed away from the surgical field to expose the peritoneal surface of the bladder, the uterus and ovaries (if present), the vaginal apex, and the rectosigmoid segment of the colon.
The peritoneal reflection over the bladder is incised at the vesicouterine angle, or at the junction of the vaginal vault in patients who have had a hysterectomy. Sharp dissection is used to dissect the bladder away from the anterior vagina along the vesicovaginal septum. As the space is opened, care must be used to avoid cystotomy and injury to the ureters, which insert posteriorly at the trigone. Dissection is continued posteriorly to separate the vagina from the rectum along the rectovaginal septum. An instrument can be placed in the vagina, such as an anastomotic sizer, dilator, or ring forceps, to identify the proximal extent of the apical vault and facilitate dissection.
The retroperitoneal space is then exposed by incising the posterior peritoneum from the level of the rectovaginal septum cranially to the sacral promontory. Avoidance of the middle sacral vessels prevents hemorrhage that can be difficult to control. The sacral venous plexus and middle sacral veins, if injured, can be controlled with applied pressure, suture ligatures, or application of sterilized tacks into the bone. The selected point for fixation of the graft is the sacral promontory, a location chosen as a result of increased hemorrhagic complications that occurred when using other sacral segments. [47] The initial concern regarding changing the normal vaginal axis through fixation to the promontory has not been shown to be a problem. [48]
A graft material is selected (eg, polypropylene mesh) and trimmed to size. A Y-shaped graft is fashioned from two pieces; a long arm placed anteriorly and a shorter posterior arm. The arms are fixed to each other using 2-0 nonabsorbable monofilament suture. The anterior arm is fixed using four nonabsorbable 2-0 monofilament sutures through the pores of the mesh and into the vaginal muscularis. Two are placed at the most distal aspect of the graft and two at the most distal aspect of the anterior vaginal cuff. The sutures are placed deep through the muscularis but should not penetrate through the vaginal mucosa itself. Four sutures are placed posteriorly in a similar fashion.
The graft is positioned along the retroperitoneal space cranial to the sacral promontory. It should be sized to create a tension-free approximation (see image below).
The graft is fixed to the anterior longitudinal ligament close to the sacral promontory using two 2-0 nonabsorbable monofilament sutures, with care to avoid any presacral vessels. The peritoneal reflection is closed over the graft using absorbable sutur es, thus maintaining the graft in a retroperitoneal location. Such a maneuver is proposed to reduce any risk of erosion into the bowel.
Please see the FDA Safety Update (discussed further in Equipment) regarding surgical mesh in pelvic organ prolapse.
Laparoscopic techniques emerged in the 1990s and large series with comparison to the standard abdominal approach have since been published. [49, 50, 51] In a retrospective review comparing consecutive open abdominal sacral colpopexy and laparoscopic techniques at a single center, Paraiso et al found no difference in the reoperation rates for pelvic floor dysfunction. [51]
Surgical concepts of the laparoscopic approach are similar in that a Y-shaped graft is used to suspend the anterior and posterior vaginal wall to the sacral promontory. The patient is placed in low lithotomy position either in stirrups or with spreader bars. As with open surgery, all pressure points are properly padded. The patient is carefully secured to the table for positioning in steep Trendelenburg. Four to five trocar sites are used.
A 10-mm trocar is placed at the level of the umbilicus for the telescope. Equipment is available to assist in holding the telescope, such as the Aesop or Laparostat. [52] An additional 10-mm trocar is placed on the right side, slightly caudal, and approximately 6 to 8 cm lateral to the umbilical port. [52] This will be used for the introduction of needles and the mesh.
A 5-mm trocar is placed on the left side, mirroring the 10-mm port. An additional 5-mm port is placed on the right side approximately 5 cm superior and medial to the anterior superior iliac spine, allowing enough space for movement of the trocar. A fifth port can be placed on the left side in the same fashion if needed for retraction. Typically, the surgeon stands on the patient’s left.
Dissection is completed with laparoscopic monopolar scissors and bipolar cautery. The mesh can be fixed using the same 2-0 nonabsorbable monofilament sutures and laparoscopic needle drivers. Alternatively, bone anchoring devices are available to fix the mesh to the sacral promontory. [20]
A study by Chaudhry et al indicated that in patients undergoing minimally invasive sacrocolpopexy, older age does not increase the risk of urinary tract infection, hospital readmission, or return to the operating room, nor does it increase patients’ chances for an abnormally long hospital stay (3 days or more, as defined in the study). [53]
In recent years, there has been an expanding use of robot technology. Since its introduction in 1999, the da Vinci® surgical system has gained popularity. The basic principles of laparoscopic surgery apply and the setup is similar. Trocar placement must meet the technical requirements of the da Vinci® itself. Newer models have three working surgical arms and a fourth arm for the telescope.
The 12-mm telescope port is placed midline just superior to the umbilicus at a distance 15 cm from the pubic symphysis. Two 8-mm working arms are placed bilaterally along an imaginary line from the camera port to the anterior superior iliac spine. These ports are placed caudally and should be approximately 8 cm away from the camera trocar to prevent the da Vinci® working arms from colliding.
The third working arm can be set up on the left side and placed approximately 8-9 cm away from the other working port. It should be 5 cm cranial and medial to the anterior superior iliac spine. The assistant port is a 10-mm trocar mirroring the third robot arm and is used for insertion of the mesh, needles, and retraction. An additional 5-mm port used for irrigation and aspiration is placed on the right side, cranial to and bisecting the distance between the camera trocar and the left-side working arm. Variations in technique have been described. [54, 55]
Port placement sites for the da Vinci® robot are shown in the image below.
Outcomes for robot-assisted sacrocolpopexy have been limited to small series without direct comparison to other techniques. In a retrospective study, Geller et al reported short-term outcomes confirming improvement in measurable POPQ following robot-assisted sacrocolpopexy in 73 patients, comparable to abdominal sacrocolpopexy at 6 weeks. [56] A smaller series demonstrated successful repair in 95% of patients at a minimum of 12 months follow-up. [54] Two of the 30 patients in their series developed a recurrence that required reoperation. [54] Looking at secondary outcomes measurements, operating time is generally longer in most reported series, but blood loss and length of hospital stay are reported to be less. [54, 55, 56] Surgical complication rates differ between series. Prospective randomized studies are needed to delineate differences in outcomes and complications.
Numerous vaginal operations for apical (vaginal vault) prolapse repair have been described. They most commonly include sacrospinous ligament fixation, uterosacral ligament suspension, and iliococcygeus suspension.
Vaginal sacrospinous ligament fixation has been compared to abdominal sacral colpopexy in two randomized trials. [57, 58] Benson and colleagues randomized 88 women to receive either vaginal sacrospinous ligament fixation or abdominal sacrocolpopexy and terminated the study at the interim analysis due to a disparity in outcome favoring the abdominal approach. [57] Reoperation for cystocele was necessary in 29% of those in the vaginal group versus 10.5% of those in the abdominal group. Vaginal vault prolapse recurred in 12% of the vaginal group versus 2.6% of the abdominal group. [57]
In a study of 95 women randomized to either approach, Maher et al found a subjective success rate of 94% in the abdominal group versus 91% in the vaginal group after a median of 2 years. [58] The objective success rate was 76% in the abdominal group and 69% in the vaginal group. [58] These differences, however, did not reach statistical significance. [58]
In a Cochrane review of 22 randomized controlled trials, abdominal sacral colpopexy was found to have a lower rate of recurrent vault prolapse and less dyspareunia. [59] The trend for a lower reoperation rate after abdominal sacral colpopexy was not statistically significant. [59] There was a longer operating time, longer recovery period, and higher cost associated with the abdominal approach. [59]
For women who are not sexually active, additional surgical options exist. Colpocleisis is a method of approximating and closing the vaginal wall after excising the mucosa to prevent apical or vaginal vault eversion. Total colpocleisis is performed in sexually inactive women for complete vaginal eversion after hysterectomy. A circumferential incision is made in the vaginal mucosa near the hymenal ring and the mucosa is undermined and sharply dissected from the underlying fascia. [60] The anterior and posterior walls of fascia are approximated using absorbable suture in a purse string or interrupted fashion, thus obliterating the vaginal lumen. [60]
If stress incontinence exists, simultaneous procedures for stress incontinence, such as a transvaginal or transobturator sling, can be performed. The dense tissue over the levator ani muscles and perineal membrane near the location of the hymen is approximated to firmly close the pelvic floor. Lastly, the anterior and posterior leafs of the remaining vaginal mucosa are closed. [60] In women with procidentia, the LeFort colpocleisis approximates the anterior and posterior vaginal wall, allowing for uterine or vaginal secretions to drain through open side channels.
Pessaries are ring-shaped devices placed vaginally to reduce pelvic organ prolapse. They are fitted to the largest size that is comfortable and reduces the prolapse. Their use requires instructional training for cleaning and replacement. In a study of 73 women fitted for vaginal pessaries for prolapse, significant improvement in prolapse symptoms, specifically bulge and pelvic pressure, was seen at 2 months. Stress incontinence improved in 45% of this cohort, urge incontinence improved in 46%, and voiding difficulty improved in 53%. [61] Discontinuation of use occurred in 8% of this cohort due to side effects. These side effects can include de novo voiding difficulty, unmasking of occult stress incontinence, defecatory symptoms, and difficulties with sexual intercourse. Vaginal erosion can occur from pessary use and must be monitored.
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Wellman W Cheung, MD, FACS Clinical Professor, Department of Urology and Department of Obstetrics and Gynecology, State University of New York Downstate Medical School
Wellman W Cheung, MD, FACS is a member of the following medical societies: American College of Surgeons, American Medical Association, American Urological Association, Chinese American Medical Society, Endourological Society, American Urogynecologic Society, International Urogynaecology Association, Society of Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction
Disclosure: Received grant/research funds from Astallas for pi.
Brian K Marks, MD Staff Physician, Center for Urologic Care, Concord Hospital
Brian K Marks, MD is a member of the following medical societies: American Medical Association, American Urological Association
Disclosure: Nothing to disclose.
Nicole W Karjane, MD Associate Professor, Department of Obstetrics and Gynecology, Virginia Commonwealth University Medical Center
Nicole W Karjane, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, Association of Professors of Gynecology and Obstetrics, North American Society for Pediatric and Adolescent Gynecology
Disclosure: Received income in an amount equal to or greater than $250 from: Merck<br/>Served as Nexplanon trainer for: Merck.
Kris Strohbehn, MD Professor of Obstetrics and Gynecology, Geisel School of Medicine at Dartmouth; Director, Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, Dartmouth-Hitchcock Medical Center
Kris Strohbehn, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American College of Surgeons, American Urogynecologic Society, Society of Gynecologic Surgeons
Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: I am on the Board for the Society of Gynecologic Surgeons (SGS). SGS is a non-profit organization whose mission is: “is to promote excellence in gynecologic surgery through acquisition of knowledge and improvement of skills…”.
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