Abdominal sacrocolpopexy (ASC) using graft material is a widely accepted transabdominal prolapse operation, and many consider it the preferred procedure to correct advanced apical prolapse. Grafts of autologous, cadaveric, or synthetic materials may be used, but permanent (synthetic) mesh has the best success rate and is selected unless otherwise contraindicated (Culligan, 2005). The graft augments native tissue and suspends the upper third of the vagina to the anterior longitudinal ligament of the sacrum. In addition to correcting apical prolapse, the graft also covers proximal portions of the anterior and posterior vaginal walls. As such, ASC also corrects apical segment prolapse of the anterior vagina wall (“apical” or “transverse” cystoceles) and of the posterior vaginal wall (enteroceles and “high” rectoceles). A modification of the procedure, sacrocolpoperineopexy, is used if concomitant perineal descent is present and believed to contribute to patient symptoms (Cundiff, 1997).
One advantage to ASC is its durability, and long-term success rates for apical suspension approximate 90 percent. It may be used as a primary procedure or alternatively as a repeat surgery for patients with recurrences after other prolapse repair failures. In addition, ASC is often chosen for women believed to be at high risk for recurrence and for whom mesh would augment their own tissue. Examples include those with connective tissue disease, history of recurrent hernia, obesity, or chronically increased intraabdominal pressure such as chronic obstructive pulmonary disease or chronic constipation. Abdominal synthetic mesh aids durability, but its use is balanced against the potential for complications, as discussed later.
Although the vaginal apex can also be successfully suspended with vaginal approach procedures such as sacrospinous ligament fixation and uterosacral ligament suspension, ASC offers distinct advantages. First, ASC maintains or lengthens the vagina, in contrast to vaginal approaches, which may shorten it. Second, the use of synthetic “permanent” mesh with multiple attachment sites to the vagina has a very low risk of apical failure. Finally, unlike vaginal approaches, in which the vaginal apex is directly affixed to a structure such as the uterosacral or sacrospinous ligament, ASC repositions the vaginal apex to its nearly normal anatomic position using intervening graft material. Thus, the apex typically remains mobile, which possibly lowers dyspareunia rates.
Sacrocolpopexy can be performed by laparotomy, by conventional laparoscopy, and with robotic assistance. If minimally invasive surgery (MIS) is performed in the same manner as the open operation, similar results can be expected. However, only limited data are currently available on long-term success rates with these MIS approaches (Freeman, 2013; Maher, 2013; Paraiso, 2011).
Prolapse of the vaginal apex often coexists with other prolapse sites along the vagina. Accordingly, a careful preoperative search is performed for other prolapse sites. If necessary, ASC can be completed concurrently with paravaginal defect repair, posterior repair, or other prolapse surgeries. Beer and Kuhn (2005) found that approximately 70 percent of ASC procedures were performed with other pelvic reconstructive operations. With the technique we describe, a concurrent enterocele will be repaired by the colpopexy, and other enterocele repairs are thus unnecessary.
Prior to ASC, patients with symptoms of urinary incontinence undergo simple or complex urodynamic testing to clarify the type of incontinence and determine if an antiincontinence procedure will be beneficial. For those with SUI, a concurrent antiincontinence operation is generally performed. Because prolapse correction can unmask occult SUI in some women, clinicians also test those without incontinence while manually reducing the prolapse. Last, apical suspension can predispose to later development of anterior vaginal wall prolapse and SUI. Thus, stress-continent women undergoing ASC may elect a prophylactic SUI procedure. To evaluate this practice, the CARE (Colpopexy After Reduction Efforts) trial found that continent women undergoing ASC plus a prophylactic urethropexy had a 2-year postoperative SUI incidence of 32 percent. Without preventive urethropexy, SUI rates following ASC were 45 percent (Brubaker, 2006, 2008). Importantly, adding an antiincontinence procedure decreases, but does not eliminate, the risk of later de novo SUI. At this time, it is unclear how best to extrapolate these findings to women who elect to have sacrocolpopexy and midurethral sling procedures.
Recurrent prolapse is common following any corrective surgery. Thus, a surgeon should be aware of recurrence rates quoted in the literature and his or her own personal rates. Although apical prolapse recurrence is infrequent, later prolapse of the anterior and posterior vaginal walls is more common. An extension of the CARE trial used a clinically based definition of anatomic failure. It showed that by 5 years, nearly one third of women met the composite definition of failure (Nygaard, 2013). However, 95 percent had no retreatment for their prolapse.
Mesh erosion develops in 2 to 10 percent of cases. It is generally found at the apex and occurs more often if hysterectomy is performed concurrent with ASC. Erosion may arise soon after surgery or years later (Beer, 2005; Nygaard, 2004, 2013). Many technical points described in the following steps aim to prevent this complication.
Bowel preparation will vary depending on surgeon preference. Patients can be instructed to take only clear liquids the day prior to surgery and complete one or two enemas that night or the morning of surgery. Alternatively, a mechanical bowel preparation using agents listed in Chapter 39 may be preferred. Ballard and associates (2014), however, noted no distinct advantage to this for urogynecologic operations. Antibiotics and thromboprophylaxis are given as outlined in Tables 39-6 and 39-8.
For postmenopausal women, vaginal estrogen cream use during the 6 to 8 weeks prior to surgery has been routinely recommended. Estrogen treatment is thought to enhance vascularity and thereby increase tissue strength and promote healing. Although this is logical and commonly practiced, no data suggest that preoperative vaginal estrogen cream decreases mesh erosion or prolapse recurrence rates.
Instruments and Materials
The upper vagina must be elevated and distended by a vaginal manipulator to allow adequate dissection and delineation of the vaginal wall fibromuscular layers for mesh placement. The manipulator may be a cylindrical Lucite rod or a large EEA (end-to-end anastomosis) sizer, which is present in most operating rooms and shown in Figure 46-21.4.
The ideal bridging material for this procedure is permanent, nonantigenic, easily cut or customized, and readily available. The ideal mesh has a large pore size to allow host tissue ingrowth, is monofilament to decrease bacterial adherence, and is flexible. Currently, polypropylene mesh is the most common synthetic graft used (American Urogynecologic Society, 2013, 2014b).
Anesthesia and Patient Positioning
Following administration of general anesthesia, the patient is positioned in a modified supine position with thighs parallel to the ground and legs in booted support stirrups. Correct positioning prevents nerve injury and allows access to the vagina for manipulation and examination, to the bladder for cystoscopy, and to the abdomen for proper self-retaining retractor placement. The buttocks are positioned at the table edge or slightly distal to allow full range of vaginal manipulator motion. The vagina and abdomen are surgically prepared, and a Foley catheter is inserted.
A vertical or transverse abdominal incision may be used, and selection is directed by a woman’s body habitus and by planned concurrent procedures. A Pfannenstiel incision generally provides adequate access to the sacrum and deep pelvis. If a Burch colposuspension, paravaginal defect repair, or other surgery in the space of Retzius is planned, then a low transverse incision that is positioned closer to the symphysis may be preferred.
A self-retaining retractor, preferably a Balfour type, is placed, and the bowel is packed up and out of the pelvis with moist laparotomy sponges. Bowel packing attempts to shift the sigmoid colon farther to the patient’s left, thereby permitting access to the midline and right aspects of the sacrum.
Some data suggest that hysterectomy at the time of ASC leads to higher mesh erosion rates (Culligan, 2002; Griffis, 2006). To reduce erosion risks at the cuff, some surgeons advocate supracervical hysterectomy, theorizing that the cervical stump may act as a barrier to prevent ascending infection and erosion (McDermott, 2009). If a total abdominal hysterectomy is performed, the vaginal apex is closed with absorbable suture such as 0-gauge polyglactin 910 (Vicryl) in a running or interrupted fashion. A second imbricating layer using the same suture may be placed to reduce potential mesh erosion. Another preventive measure is avoiding mesh fixation near the cuff suture line. Specifically, a 1-cm margin from this suture line may avert early mesh erosion during the cuff’s healing phase.
Identification of Pelvic Anatomy
Important boundaries during presacral space dissection are identified beneath the peritoneum prior to the posterior peritoneal incision. These include the aortic bifurcation, iliac vessels, right ureter, right uterosacral ligament, medial border of the rectosigmoid colon, and sacral promontory, which is the upper anterior surface of the S1 vertebra. An understanding that the right ureter, right common iliac artery, and left common iliac vein all lie within 3 cm of the sacral promontory’s midline may lower rates of their injury during surgery in the presacral space (Good, 2013b; Wieslander, 2006). Moreover, both ureters are threatened during dissection of the bladder off the anterior vaginal wall and during suturing of the anterior mesh strip.
The rectosigmoid colon is gently retracted to the left with a malleable ribbon or similar retractor. The peritoneum overlying the sacral promontory, between the rectosigmoid colon’s medial border and the right ureter, is elevated with tissue forceps and incised sharply. The incision is extended caudally into the posterior cul-de-sac of Douglas. As the incision approaches the deeper portion of the cul-de-sac, it is kept between the medial border of the rectum and the right uterosacral ligament. A vaginal manipulator directed ventrally to create tension aids dissection. The incision may then be continued to the posterior vaginal wall and toward the vaginal apex.
Maintaining proper orientation is critical during this step as inadvertent deviation can cause ureteral or iliac vessel injury on the right, or colon injury on the left. Similarly, if the initial peritoneal incision is extended above the sacral promontory, the left common iliac vein should be identified and avoided. This vessel can lie less than 1 cm from the promontory and is generally difficult to visualize or palpate due to its absent pulsatility and decreased tone. Final closure of this peritoneal incision allows the mesh to lie retroperitoneally. This may lower the risk of bowel-to-mesh adhesions and of bowel obstruction from small-bowel loops entrapped below the bridging mesh strip.
Identification of Anterior Longitudinal Ligament
Following peritoneal incision, the loose connective tissue between the peritoneum and the sacrum is sharply and bluntly dissected to expose the anterior longitudinal ligament lying along the sacrum’s vertical midsection. Generally, this presacral space dissection is started at the promontory and continued 3 to 4 cm inferiorly to the upper extent of the S2 vertebra. Within the connective tissue of the presacral space, fibers of the superior hypogastric nerve plexus, right and left hypogastric nerves, and the inferior mesenteric and superior rectal artery and vein are embedded (Fig. 38-23). Of these, the right hypogastric nerve is the most common structure identified during dissection. Below the aortic bifurcation, this midline cordlike nerve courses laterally and at the lower sacral levels, reaches the right pelvic sidewall. Transection of this nerve is ideally avoided.
Also of seminal importance, the middle sacral vessels typically adhere to the anterior surface of the ligament. Once found in the area exposed for mesh attachment, middle sacral vessels can be avoided, ligated, or coagulated depending on surgeon’s preference and operative findings. The middle sacral vein also forms anastomoses with the lateral sacral veins that contribute to the sacral venous plexus. Vessels of this plexus can be extensive, especially in the lower part of the sacrum.
Presacral Space Hemorrhage
Careful exposure of the anterior longitudinal ligament and overlying vessels helps prevent bleeding during suture placement. Despite these efforts, laceration of the sacral venous plexus can lead to rapid and substantial blood loss, and several steps are critical to its control. First, pressure is applied immediately and held for several minutes. This may be particularly effective for venous bleeding. Sutures and clips may be useful, but tearing of small veins frequently worsens with suturing. Additionally, as vessels retract into the bone, isolation and ligation becomes difficult. Sterile thumbtacks directed through lacerated vessels and pushed into the sacrum can effectively compress such vessels. Unfortunately, these tacks are not routinely found in many operating rooms.
Alternatively, various topical hemostatic agents have been used to control bleeding refractory to these initial steps (Table 40-5). Of these, the fibrin sealant family allows conformation to irregular wounds, which is a distinct advantage for presacral space hemorrhage. In refractory cases, vascular surgery consultation may be prudent. Also, injury to the iliac vessels or aorta necessitates immediate consultation.
Sacral Suture Site Selection
To anchor the suspending mesh strips proximally, a surgeon must decide whether to place sutures through the anterior longitudinal ligament at higher or lower sacral levels. Suture placement at the S3 or S4 vertebral bodies increases the risk of sacral venous plexus laceration, and this practice has largely been abandoned. Suture placement above the sacral promontory risks left common iliac vein injury and penetration of the L5-S1 disc, which may lead to painful discitis or osteomyelitis (Good, 2013a; Wieslander, 2006). However, this disc is the most protuberant structure in the presacral space, and mesh is commonly affixed here, especially during the learning phase of ASC (Abernathy, 2012).
For correct sacral promontory identification, the steep angle of descent between L5 and S1 can be used. That said, even correct suture placement at S1 and the sacral promontory still risks middle sacral vessel laceration. However, at S1, the middle sacral vessels are visible and can be easily isolated and avoided or when necessary, clipped or coagulated. Additionally at S1, the anterior longitudinal ligament is thicker and stronger than at lower sacral levels (White, 2009). Affixing sutures here minimizes suture avulsion risks. Finally, attachment of the mesh at S1 may result in a more anatomic suspension of the vaginal apex (Balgobin, 2013).
For these reasons, we prefer to affix mesh to the anterior surface of S1, with the most cephalad suture placed at or just below the sacral promontory. If safe suture placement over the S1 vertebra is prohibited, then the level of the L5-S1 disc is an alternative. Shallow tissue “bites” are needed here to avoid the disc as the anterior longitudinal ligament is only 1 to 2 mm thick.
Typically, three or four serial permanent sutures are used to affix the sacral portion of mesh to the anterior longitudinal ligament. These stitches can be placed first, as described here, or later after vaginal mesh attachment. Needle passage moves from right to left with each stitch, and sutures are aligned vertically. Starting with the lowest suture, they are spaced approximately 0.5 to 1 cm apart. With suturing, 2-0 gauge permanent material, each double-armed with SH needles, is passed through the full thickness of the anterior longitudinal ligament (Fig. 45-17.1). During this, based on findings, suture “bites” either encompass or avoid vessels. Once completed, sutures are held by a hemostat and not tied. Their needles are covered with a surgical towel to avoid stick injuries.
Placement of sacral sutures.
Anterior Vaginal Wall Dissection
Prior to mesh attachment, the peritoneum and bladder must be dissected off the proximal vagina. Dissection of the bladder from the upper third of the anterior vaginal wall is aided by the vaginal manipulator. The cervical stump or vaginal apex is displaced cephalad and dorsally, and its covering peritoneum is incised transversely and proximal to the bladder’s cephalad margin. With prior hysterectomy, careful identification of the vaginal apex and superior extent of bladder is critical to avoid cystotomy. This is especially important in women with short vaginal lengths or vesicovaginal adhesions. In these cases, retrograde bladder filling and Foley bulb identification may help delineate the upper bladder margin. With cystotomy, several options are possible. If the cystotomy is small and close to the bladder dome, then a two- to three-layered bladder closure, followed by an interposition flap (omental or peritoneal), may be considered. However, if the cystotomy is large or nears the trigone, an alternative approach to vault suspension using native tissue may be considered to minimize mesh erosion into the bladder or fistula formation. Alternatively, the cystotomy can be repaired, and ASC deferred for a later time.
Once the correct vesicovaginal space is entered, the bladder is sharply dissected from the anterior vaginal wall for a distance of approximately 4 to 6 cm caudad to create an extensive surface for mesh fixation. However, the extent of this dissection varies depending on intraoperative anatomy. Sharp rather than blunt dissection is preferred in the vesicovaginal space (Fig. 45-17.2). Electrosurgical energy use is minimized to reduce risks of delayed thermal bladder injury. Dissection progresses at a depth above the fibromuscular layer of the vaginal wall. Entry into this proper plane lowers the rate of incidental entry into the vagina, which may increase future mesh erosion risks. If the vaginal lumen is entered, the opening is irrigated copiously and closed in two imbricated layers using 2-0 or 3-0 gauge delayed-absorbable suture.
Dissection of the anterior vaginal wall.
Posterior Vaginal Wall Dissection
To expose an area of adequate size for mesh fixation, the rectovaginal space is entered, and the rectum is separated from the posterior vagina. For this, the vaginal manipulator now displaces the vaginal apex ventrally. The reflection of the rectum against the posterior vaginal wall is identified, and the peritoneum is incised transversely 2 to 3 cm proximal to this reflection line. The right and left uterosacral ligaments are used as lateral dissection boundaries. With gentle outward traction on the peritoneum, the rectovaginal space is developed with a combination of sharp and blunt dissection. In the absence of adhesions or fibrosis, the rectovaginal space easily opens inferiorly to the superior margin of the perineal body, which lies 3 to 4 cm above the hymen. Identification of loose gauzy connective tissue fibers usually indicates dissection in the correct plane. Also, the white, glistening posterior vaginal wall provides another visual clue, and dissection is kept close to this tissue to avoid inadvertent rectal entry. In contrast, fatty tissue or excessive bleeding generally indicates incorrect plane dissection and potential proximity to the rectum.
Whether two separate strips of self-cut mesh or a commercially preformed Y-shaped mesh is used, several surgical principles are generally followed. First, depending on the extent of dissections, six to 12 sutures on the anterior and a similar number on the posterior vaginal wall are placed through the mesh and the vaginal wall muscularis. Sutures ideally do not enter the vaginal lumen because epithelial healing over the stitches may be incomplete, especially with braided suture. However, if the fibromuscular layer is thin, this may not be possible. In this setting, many select monofilament, delayed-absorbable suture, which has a greater propensity for epithelialization postoperatively.
Second, sutures are tied down loosely to avoid tissue strangulation and vaginal wall necrosis, which may lead to mesh or suture erosion. Third, the lower extent of the mesh does not abut the bladder or rectal reflections to minimize potential risks of pelvic organ dysfunction or mesh erosion of into these organs. Last, mesh is positioned symmetrically across the width of both the anterior and posterior vaginal walls.
At our institution, we fashion the two mesh strips only after vaginal dissection is completed. The broader area of each strip will cover the dissected anterior vaginal surface and posterior vaginal surface, respectively. Each strip also has a narrowed portion that will extend to the sacrum and be affixed to the anterior longitudinal ligament. This narrowed portion reduces mesh bulk, especially near the rectum on the left and the iliac vessels and ureter on the right, to lower mesh erosion rates. However, excessive narrowing may compromise overall repair strength (Balgobin, 2011). Generally, the narrow portion of mesh measures approximately 2 cm. Lengthwise, the proximal end of mesh is initially left long to allow correct positioning to the sacrum and later is trimmed.
To begin, the vaginal manipulator is pushed cephalad and ventrally to fully expose the dissected posterior vaginal wall and stabilize the vagina for suturing. The mesh is commonly attached to the posterior vaginal wall with two to four rows of 2-0 gauge permanent or delayed-absorbable sutures, and rows are placed approximately 1.5 cm apart (Fig. 45-17.3). Depending on the vaginal width and the lateral extent of dissection, each row consists of two to three sutures spaced 1 to 1.5 cm apart. The inferior and lateral extents of the dissected vagina are adequately exposed prior to suture placement to avoid incorporation of rectum into a stitch.
Posterior mesh secured and draped forward. Initially placed sacral sutures are seen in the background.
For the anterior vaginal wall, mesh is sutured in exactly the same fashion as was performed on the posterior wall (Fig. 45-17.4).
Anterior and posterior mesh in place.
Mesh Sizing and Sacral Attachment
For this step, the prior sacral dissection is again exposed, and the two proximal portions of each mesh strip are held together by a right-angle clamp for maneuvering. The vaginal manipulator is removed and replaced by surgeon fingers. Then, by digital pressure directed cephalad, the cuff is gently elevated, and the proximal portions of mesh are extended to the earlier placed sacral sutures. Alternatively, the cuff can be gently elevated by the vaginal manipulator. With correct positioning, apical suspension reduces prolapse of the apex and the apical segments of the anterior and posterior vaginal walls. Moreover, the mesh segment between the vagina and sacrum should be tension free. Once the desired mesh position and length are determined, the excess mesh above the most cephalad sacral suture is trimmed off. This avoids mesh contact with the right ureter, iliac vein, and other vascular structures that all lie within 1 to 2 cm of the fixation site (Kohli, 1998; Nygaard, 2004).
The six needles of the three double-armed sacral sutures are then passed through the proximal portions of both mesh strips (Fig. 45-17.5). Each of the three sutures is then tied to secure the proximal mesh to the anterior longitudinal ligament (Fig. 45-17.6). To prevent air knots while the lowest sacral suture is secured, the surgeon gently pushes the vaginal apex against the lower part of the sacrum with the vaginal manipulator.
Mesh attachment to the sacrum.
Reapproximation of the peritoneum over the mesh can be accomplished in a running or interrupted fashion using 3-0 or 2-0 gauge absorbable suture (Fig. 45-17.7). Placing this mesh retroperitoneally theoretically may lower the risk of bowel obstruction, but this complication has been reported despite peritoneal reapproximation (Pilsgaard, 1999). During closure, the right ureter is kept in constant view to avoid kinking or direct injury.
Cystoscopy is routinely performed prior to laparotomy closure to document ureteral integrity and absence of bladder sutures or injury. Urethral examination is important if an antiincontinence procedure is also performed.
The abdomen is closed in a standard fashion (Section 43-1 or 43-2).
Postoperative in-hospital management is similar to that for other intraabdominal surgeries. Specific to ASC, a passive or active voiding trial can be performed on postoperative day 1 or 2, depending on the patient’s condition and extent of dissection. Some women have urinary retention after apical suspension, even without an antiincontinence procedure. If unable to void spontaneously by the time of discharge, a patient can go home with a catheter and be seen again within a week for removal. A stool softener is prescribed when regular diet is tolerated, and constipation and straining are ideally avoided.
At routine postoperative visits, the patient is evaluated for prolapse recurrence and mesh or suture erosion. Symptoms of pelvic floor dysfunction are also elicited. Anatomic success does not always correlate with functional success, and vice versa. Thus, continual evaluation of surgical results is based on anatomy and on symptoms such as urinary incontinence, defecatory dysfunction, pelvic pain, and sexual dysfunction.
Following ASC, the graft material or its attaching sutures can erode through the vaginal epithelium. On average, symptoms develop 14 months following surgery, and vaginal bleeding and discharge are classic symptoms (Kohli, 1998). The diagnosis is generally straightforward, as mesh or sutures can be seen directly during speculum examination.
Mesh erosion through the vaginal mucosa may initially be treated with a 6-week or longer course of intravaginal estrogen cream. For those with exposed mesh and symptoms, surgical removal in an operating suite may be performed vaginally. Epithelium around the erosion site is sharply dissected from the mesh and undermined. The mesh is grasped, placed on gentle tension, dissected off the overlying tissue, and as much mesh as can be identified is resected. The vaginal epithelial edges are then trimmed to freshen edges and reapproximated in a running or interrupted fashion using 2-0 gauge delayed-absorbable suture. Failure of these wounds to heal is interpreted as a sign of graft or tissue infection, and more extensive or complete removal of the graft is considered. Sutures that are eroding into the vagina may be cut and removed in the office. Fortunately, removal of sutures or portions of eroding mesh does not generally compromise prolapse correction.