Restoring apical support is increasingly recognized as an essential component of any surgical procedure for pelvic organ prolapse. Although the anterior vaginal wall is the most common clinically recognized site of prolapse,1 recent clinical and radiographic studies have demonstrated that support of the vaginal apex plays a critical role in anterior wall support.2-5
Surgeries for correction of apical prolapse generally involve a vaginal or an abdominal route, or a combination of these methods. The surgical approach is often chosen based on prolapse severity, risks of recurrence, surgeon comfort, patient preference, and surgical goals.6
Abdominal sacrocolpopexy (ASC) is considered by many to be the “gold standard” procedure for apical prolapse repair and can be performed via laparotomy, conventional laparoscopy, and with robotic assistance. Most commonly a synthetic graft is used to augment native tissues and suspend the vaginal vault to the sacrum. Success rates of 78% to 100% have been reported,7,8 and optimal results depend on a number of factors including patient characteristics, graft properties, and surgical technique.8-11
Graft dimensions are not standardized and surgeons often tailor the graft based on patient anatomy and prolapse severity. Many different graft configurations have been described, including folded grafts, Y-shaped grafts, and separate strips of mesh with varying extension down the anterior and posterior vaginal walls.8 Of these, separate strips of mesh are commonly used to reduce the amount of foreign body at the vaginal apex.12 A broad vaginal attachment is also typically employed to reduce failures.13,14 The distal extent of attachment of the anterior and posterior strips of mesh is often guided by the extent of anterior and posterior vaginal wall prolapse noted on preoperative evaluation. A sacrocolpoperineopexy is a variation of the ASC where the posterior strip is attached to the posterior vaginal wall down to the perineal body.
All patients should have a routine history and physical examination, including POP-Q examination. Since significant apical descent is frequently present with both anterior and posterior wall prolapse,5 the relative contribution of each compartment should be evaluated with simulated apical support to determine the need for concomitant procedures.3 A stress test, with and without prolapse reduction, and complex urodynamic testing can help determine suitable patients for additional anti-incontinence procedures. Preoperative estrogen may increase vaginal wall thickness and facilitate the procedure, but no randomized controlled trials exist evaluating the efficacy of this treatment.
Patients must be counseled on the operative risks of transfusion from presacral space hemorrhage, and potential injury to the urinary and gastrointestinal tracts. Upper and lower extremity neuropathies may result from retractor and patient positioning, especially during lengthy procedures. Postoperatively, bowel obstruction related to adhesions may occur, sometimes years after the original procedure.6 The overall mesh erosion risk is 3.4%8 and may be increased with vaginotomy, concomitant hysterectomy, or severe atrophy. Patients may also develop recurrent prolapse, and voiding, defecatory, or sexual dysfunction.8,15 In women with no symptoms of stress incontinence, the Colpopexy and Urinary Reduction Efforts (CARE) trial showed that significantly more women without an anti-incontinence procedure developed new symptoms of stress incontinence up to two years after index surgery.16 However, because many women do not develop symptoms of stress incontinence after ASC, the decision to perform a concomitant anti-incontinence procedure in asymptomatic women is taken only after careful consideration and thorough counseling.
Box 34-1 Master Surgeon Corner
If robotic approach is used, position patient correctly in Allen stirrups, use appropriate padding for upper extremities, and secure shoulders using antislip devices or appropriate foam padding. A “tilt test” to ensure no slippage during steep Trendelenburg is useful prior to abdominal prepping and draping. If slippage is noted, then appropriate adjustments can be made.
Having the buttocks flush with the distal end of the OR table is important so that vaginal/uterine manipulation can easily be performed.
A Deaver retractor can be used for ease of suturing posterior mesh in laparoscopic or robotic cases once dissection in correct plane has been performed.
Due to the need for bowel manipulation and potential risk of bowel injury, patients may be instructed to consume a clear liquid diet and to do a mechanical bowel preparation the day prior to surgery.
Broad-spectrum antibiotics should be administered as recommended by the American Congress of Obstetricians and Gynecologists for urogynecology procedures.17
Sequential compression devices and/or subcutaneous heparin should be used depending on risk stratification as recommended by the American Congress of Obstetricians and Gynecologists.18 The appropriate venous thromboembolism method should ideally be in place prior to induction of general anesthesia.
The patient is placed in modified low lithotomy in Allen stirrups with care to ensure proper positioning to avoid lower extremity nerve injury. For robotic cases, shoulder pads and antislip equipment may be needed to prevent the patient from slipping or falling off the table during steep Trendelenburg position. After the patient is prepped and draped, a Foley catheter is placed in the bladder and a uterine or vaginal manipulator of surgeon’s choice is used.
Careful preoperative consideration should be given to the type of incision to ensure maximal exposure and ease of operation. A Pfannenstiel incision usually affords adequate exposure; however, care should be taken to avoid excessive lateral extension of the fascia, which may result in ilioinguinal nerve entrapment.19 Alternatively, a Maylard or a vertical incision may be chosen based on patient’s body habitus, previous surgical history, intra-abdominal pathology, and/or surgeon’s preference. Following entry into the abdominal cavity, the pelvis and upper abdomen are explored to assess for presence of pathology or adhesions. If adhesions are encountered that prevent safe mobilization of the bowel into the upper abdomen, these are sharply dissected prior to packing. A Balfour or similar self-retaining retractor is placed for optimal exposure. Special care is taken to avoid compression of the psoas muscle by the lateral blades of the retractor in order to avoid femoral nerve compression and potential neuropathy. The bowel is packed away into the upper abdomen using moist laparotomy sponges, giving access and exposure to the pelvis. Attempts should be made to mobilize the sigmoid colon to the left during packing to aid with visualization of the sacral promontory.
Box 34-2 Master Surgeon’s Corner
Laparoscopic port placement for ASC involves camera placement at umbilicus, 10/12 mm port in left paramedian region, and two additional 5 mm ports. Sutures and mesh are passed through left paramedian port and sutures are typically tied in extracorporeal fashion.
Anterior dissection to the pubocervical fascia in the vesicovaginal space can be facilitated by retrograde filling of the bladder through a three-way Foley.
Use of a Breisky–Navratil or medium-sized Deaver retractor can assist in the posterior dissection in the rectovaginal space and suturing onto the rectovaginal fascia.
Limited data suggest that a hysterectomy at the time of sacrocolpopexy leads to increased rates of mesh erosion.20,21 To minimize the risk of mesh erosion at the cuff, some surgeons advocate supracervical hysterectomy, theorizing that the cervical stump may act as a barrier to prevent ascending infection and erosion.15 If a total abdominal hysterectomy is performed, the vaginal apex is closed with absorbable suture such as 0 Vicryl in a running or interrupted fashion and a second imbricating layer using the same suture may be placed to reduce potential mesh erosion at the cuff. Another potentially preventive measure is avoiding suture fixation of the mesh in proximity to the cuff closure. A suture-free margin of approximately 1 cm should prevent early erosion of the mesh during the healing phase of the cuff.
Critical anatomic landmarks should be identified prior to the posterior peritoneal incision (Figure 34-1A). These include the aortic bifurcation and sacral promontory superiorly, the rectosigmoid on the left, and the right ureter and common and internal iliac vessels on the right. The rectosigmoid is gently retracted to the left with a ribbon or similar retractor to expose the sacral promontory, which represents the upper anterior surface of S1. The peritoneum overlying the sacral promontory is elevated with atraumatic tissue forceps and incised sharply (Figure 34-1B). The incision is extended inferiorly toward the posterior cul-de-sac and kept between the right border of the rectum and the right uterosacral ligament. 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 excessive deviation to either side can cause bowel injury on the left and ureteral injury on the right. If the peritoneal incision is extended above the sacral promontory, special attention should be paid to the location of the left common iliac vein, which is usually within 1 cm from the promontory22 and generally difficult to visualize (Figure 34-1).
The loose connective tissue between the peritoneum and the sacrum is sharply and bluntly dissected in order to expose the anterior longitudinal ligament on the midportion of the sacrum. Generally, this dissection is started at the level of the promontory and continued 3 to 4 cm inferiorly to the upper extent of the second sacral vertebra (S2). Fibers of the superior hypogastric plexus, right and left hypogastric nerves, and the inferior mesenteric vessels are embedded within the connective tissue fibers of the presacral space (Figure 34-2). During dissection, attempts should be made to avoid transection of the right hypogastric nerve, which courses inferiorly and laterally from the area of the promontory toward the right pelvic wall. The middle sacral vessels are identified on the anterior surface of the ligament (Figure 34-1). Anastomoses between the middle and lateral sacral veins contribute to the sacral venous plexus and can be very extensive, especially in the lower part of the sacrum22 (Figure 34-3). Careful exposure of the anterior longitudinal ligament and the overlying vessels should help prevent bleeding complications during suture placement. When the middle sacral vessels are found in the area exposed for mesh attachment, they can be avoided, ligated, or cauterized based on surgeon’s preference and intraoperative findings.
Injury to the sacral venous plexus can result in rapid and substantial blood loss. In these cases, sustained pressure against the bleeding area, hemostatic sutures or agents, and appropriate vascular surgery consultation are warranted. Injury to the common iliac vessels or aorta necessitates vascular surgery consultation.
Typically, three to four permanent sutures are placed through the anterior longitudinal ligament of the sacrum to fix the sacral portion of the mesh to this structure (Figure 34-4). Sutures are placed approximately 0.5 to 1 cm apart starting with the lowest suture. Sutures placed in a horizontal orientation and closer to the sacral promontory have been shown to have maximum tensile strength23; however, procedural failures from sacral mesh detachment are rare. Although mesh fixation to the anterior surface of S2 and S3 may yield more anatomic results, many surgeons prefer to place sutures at and above the level of the promontory in order to avoid injury to the sacral venous plexus. However, when sutures are placed above the level of the promontory, identification of the left common iliac vein and aortic bifurcation is critical prior to suture placement. Avoidance of deep suture penetration at the level of the L5–S1 disc is important to prevent pain associated with disc irritation or inflammation (Figure 34-1).
Dissection of the bladder from the upper third of the anterior vaginal wall is facilitated by the use of an end-to-end anastomosis (EEA) sizer, Lucite rod, or similar instrument placed in the vaginal canal. The cervical stump or vaginal apex is displaced upward and slightly posteriorly and the bladder is sharply dissected from the anterior vaginal wall for a distance of approximately 4 to 6 cm depending on preoperative and intraoperative findings. In posthysterectomy vault prolapse, careful identification of the vaginal apex and superior extent of bladder attachment is critical to avoid unintended cystotomies. This is especially important in women with short vaginal lengths or bladder adhesions from previous surgery. In these cases, retrograde filling of the bladder and identification of the Foley bulb may help delineate the upper extent of bladder attachment.
A similar vaginal manipulator is used to displace the vaginal apex anteriorly. Gentle upward traction of the apex can assist with exposure of the lower aspect of the posterior wall. With upward traction of the vaginal apex, the tip of the vaginal manipulator can be gently directed to the part of the posterior vagina being dissected to aid with visualization and dissection. The reflection of the rectum onto the posterior vaginal wall is identified and the peritoneum is incised transversely 2 to 3 cm above the rectal reflection. The right and left uterosacral ligaments can be used as the lateral boundaries of dissection. With gentle traction on the peritoneum and the apex, the rectovaginal space is developed with a combination of sharp and blunt dissection. In the absence of adhesions from previous surgery or infection, the rectovaginal space can easily be developed all the way down to the superior extent of the perineal body, which is generally 3 to 4 cm above the hymen. Identification of loose connective tissue fibers with a “fluffy” appearance usually indicates dissection in the correct plane. Visualization of the white glistening tissue of the posterior vaginal wall is important and dissection should be kept close to this tissue to avoid inadvertent rectal entry.
Whether two separate strips or a fashioned Y-mesh is used, the same surgical principles are generally followed. Depending on the extent of the anterior and posterior dissections, six to eight permanent sutures are typically placed approximately 1 to 1.5 cm apart through the mesh and the vaginal wall muscularis. Alternatively, delayed absorbable suture may be used based on surgeon’s preference. Care should be taken to avoid suture placement through the vaginal lumen as reepithelialization over the sutures may not be complete, especially when braided sutures are used. Sutures should be tied down loosely to avoid tissue strangulation and vaginal wall necrosis that may lead to mesh or suture erosion. The lower extent of the mesh should not abut the bladder or rectal reflection onto the vaginal walls in order to minimize risk of potential organ erosion or dysfunction. For similar reasons, mesh that extends beyond the lateral boundaries of the anterior and posterior dissections should be trimmed. Excessive folding of the mesh on the anterior and posterior vaginal walls should be avoided.
Symmetry of mesh placement should be checked after the first few sutures are placed, as displacement of the manipulator to either side of the midline is common in the setting of excessive vaginal tissue.
Placement of the posterior mesh strip below the posterior cul-de-sac peritoneum effectively repairs or prevents apical enteroceles, obviating the need for obliteration of the cul-de-sac. The mesh is commonly attached to the posterior vaginal wall with three or four rows of 2-0 permanent sutures placed approximately 1 to 1.5 cm apart. Alternatively, delayed absorbable suture may be used based on surgeon’s preference. The inferior and lateral extent of the vaginal dissection should be adequately exposed prior to suture placement in order to avoid incorporation of rectal tissue into the needle purchase.
Attachment of the anterior mesh strip over a broad area for a distance of 4 to 6 cm below the vaginal cuff level usually helps with correction of transverse anterior defects or “high cystoceles.”
The previously performed sacral dissection is exposed and the two mesh strips are then held together with a right angle or similar clamp (Figure 34-5). Using a vaginal manipulator, the apex of the vagina is gently pushed upwards and toward the lower half of the sacrum. The lowest portion of the sacral mesh to be attached is presented against the anticipated placement site on the anterior surface of the sacrum (Figure 34-5). The intervening piece of mesh material between the vagina and sacrum should be tension free and not appear stretched. A vaginal examination may be performed at this point to confirm adequate suspension of the upper third of the vagina and adjustments should be made prior to suture placement. The sacral sutures are passed through the right side of both mesh strips, through the anterior longitudinal ligament, through the left side of the mesh, and then tied down. To prevent air knots during placement of the lowest sacral suture, the vaginal apex can be gently pushed against the sacrum, while an assistant secures the lower part of the mesh against the sacrum below the suture placement point. Slip knots are useful when securing mesh laparoscopically or robotically to the sacrum. Many variations in technique for suture placement exist, depending on surgeon’s preference, surgical approach, and presence of vessels in the exposed area of the ligament. Excessive mesh at the sacral attachment site should be trimmed as the common iliac vein, right ureter, and other vascular structures are all within 1 or 2 cm of the fixation site.8,22 In addition, excess mesh from the lateral aspects of the intervening segment may also be trimmed to reduce mesh load and rectal impingement; however, care should be taken to avoid excessive trimming that may compromise the strength of the repair.24
Reapproximation of the peritoneum over the mesh remains controversial, but can be accomplished in a running or interrupted fashion using 3-0 or 2-0 absorbable suture. During closure, the right ureter should be kept in constant view to avoid kinking or direct injury from suture placement. Use of Lapra-Ty (Ethicon) devices can aid in closure during robotic or laparoscopic suturing. Although retroperitonealization may theoretically lower the risk of bowel obstruction, this complication has been reported despite peritoneal closure.25
Cystourethroscopy should be routinely performed prior to closure of the abdominal cavity to document ureteral integrity and absence of bladder sutures or injuries. Administration of intravenous indigo carmine facilitates visualization of urine efflux from the ureteral orifices. Examination of the urethra is important if an anti-incontinence procedure is performed.
Box 34-3 Caution Points
During sacral dissection, the sigmoid colon should be retracted to the patient’s left, the right ureter should be identified, and peritoneal dissection should begin at the level of the promontory.
If bleeding is encountered from middle sacral vessels or the venous plexus at the hollow of the sacrum, use compression with a sponge and consider use of hemostatic agents. Large venous or arterial bleeding may require conversion to open laparotomy, if a laparoscopic approach has been used compression of vessels, and vascular repair.
Cystoscopy and rectal examination are necessary to insure bladder and bowel integrity and absence of suture or mesh within these organs.
The fascia is closed with 0-PDS or similar suture. Alternative methods of closure are used in patients at high risk for dehiscence. In obese patients, the subcutaneous layer is approximated with 2-0 or 3-0 absorbable suture or a subcutaneous suction drainage may be placed. The skin is closed with either staples or a subcuticular stitch.
Routine postoperative care is indicated. A passive or active voiding trial can be performed on postoperative day one or two, depending on the patient’s condition, extent of dissection, and progress. Some patients have urinary retention after apical suspension, even in the absence of an anti-incontinence procedure. If unable to void spontaneously by the time of discharge, the patient can be discharged with a catheter and followed-up within a week for a voiding trial and possible removal.
Box 34-4 Complications and Morbidity
Synthetic mesh erosion into the vagina can occur in approximately 3% of cases, and is increased when concomitant hysterectomy is performed.
De novo stress incontinence can be decreased by concomitant anti-incontinence surgery.
Most common site of recurrence following sacrocolpopexy involves the posterior vagina.
The sacrospinous ligament fixation (SSLF) procedure involves direct attachment or fixation of the vaginal apex to the coccygeus–sacrospinous ligament (C-SSL) complex. Many modifications of this procedure have been described that advocate attachment of both posterior and anterior vaginal walls to the SSL, and bilateral versus unilateral suspension of the vaginal cuff.26-28 However, fixation of the vaginal apex to the right sacrospinous ligament is most commonly described, likely because it is easier to retract the rectum to the left and for right-handed surgeons to place sutures in a forehand fashion. Recommended location for suture placement remains approximately two fingerbreadths medial to the ischial spine29,30 (Figure 34-6).
While recurrence of apical prolapse following SSLF is reported in less than 10% of women, rates of anterior vaginal wall prolapse of up to 30% have been reported.31 These higher rates of anterior compartment prolapse are commonly attributed to the exaggerated posterior deflection of the vaginal axis.6
Potential complications of the SSLF include injury to the nerves and vessels that are found in close proximity to the C-SSL complex (see Chapter 2). Low-pressure vessel bleeding encountered during dissection and exposure of the pararectal space is generally attributed to retractor or needle injury of the extensive venous plexuses that drain the rectum and vagina. This bleeding can usually be controlled with sustained pressure by packing of the pararectal space. Bleeding of arterial origin in the sacrospinous ligament region or the pararectal space is best controlled by ligation or clipping of the bleeding vessel. Because this procedure is most commonly performed through an extraperitoneal approach, ureteral and rectal injuries are rarely reported.
All patients should have a routine history and physical examination, including POP-Q examination. Since significant apical descent is frequently present with both anterior and posterior wall prolapse,5 the relative contribution of each compartment should be evaluated with simulated apical support to determine the need for concomitant procedures.3 A stress test, with and without prolapse reduction, and complex urodynamic testing can help determine suitable patients for additional anti-incontinence procedures. Preoperative estrogen may increase the vaginal wall thickness and facilitate the procedure, but no randomized controlled trials exist evaluating the efficacy of this treatment.
In addition to the general risks of bleeding, infection, and organ and nerve injury, patients should be counseled about the risk of recurrent prolapse, which appears to occur with greater frequency in the anterior compartment.6 The risks of neuropathy from patient positioning or nerve entrapment should be discussed. As with any apical suspension procedure, voiding or defecatory dysfunction can occur, and de novo dyspareunia has been reported.32
Adequate exposure is necessary for proper visualization and palpation of the sacrospinous ligament prior to suture placement. Patients should self-administer an enema the evening prior to surgery and again on the morning of surgery to empty the rectum in order to facilitate medial displacement with retractors.
Broad-spectrum antibiotics should be administered as recommended by the American Congress of Obstetricians and Gynecologists for urogynecology procedures.17
This procedure is typically performed under general anesthesia. A suitable venous thromboembolism prophylactic method should ideally be in place prior to anesthesia induction. The patient is placed in modified standard lithotomy with careful attention to proper positioning and cushioning to avoid nerve injury. A Foley catheter is placed in the bladder.
After completing the vaginal hysterectomy, the lateral edges of the anterior and posterior vaginal walls are grasped with Allis clamps and brought into direct contact with the SSL to be used for fixation. This is done to assess whether excessive vaginal tissue is present on the anterior and/or posterior vaginal wall that may need to be excised. A vertical incision is then made through the posterior vaginal wall for a distance of 2 to 3 cm from the cuff. The extraperitoneal space between the vaginal wall and the peritoneum is entered and gentle blunt dissection is used to open the pararectal space as described below. If a posterior colporrhaphy is planned, the posterior vaginal incision is extended down to the hymeneal ring.
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