Sacrocolpopexy
Ali Azadi
Polina Sawyer
Patrick Culligan
Introduction
Symptomatic pelvic organ prolapse is a common condition affecting women. Currently, it is estimated that 13% to 19% of women in the United States will undergo at least one surgical procedure to repair pelvic organ prolapse in their lifetimes.1,2 Some studies have shown that up to 30% of these patients will require at least one additional surgical repair due to surgical failure and prolapse recurrence.3
The International Continence Society (ICS) defines “apical prolapse” as any descent of the vaginal cuff or cervix, below a point which is 2 cm less than the total vaginal length above the plane of the hymen.4 Sacrocolpopexy is an abdominal procedure in which the apex of the vagina is affixed to the anterior longitudinal ligament overlying the sacral promontory of the sacral hollow at the level of the S1 vertebra using an intervening piece of mesh or graft material. This procedure functionally restores support of the vaginal apex and was originally described as a method specific to addressing prolapse of the apical compartment. Figure 46.1A shows normal pelvic organ anatomy in the sagittal view with Figures 46.1B and 46.1C demonstrating uterovaginal and posthysterectomy vaginal prolapse, respectively.
Sacral hysteropexy is the predecessor to the sacrocolpopexy and was first described in 1957 by Humphrey and colleagues5 (Fig. 46.2). Posthysterectomy abdominal sacrocolpopexy (ASC) for vaginal vault prolapse was then described by Lane6 in 1962. This version of the procedure has been widely adopted and is the most studied, although several other important modifications have been introduced over the years. For example, later authors described the attachment of the mesh material along the full length of the anterior vaginal wall as well as down to the level of the perineal body.7 One important modification, the laparoscopic sacrocolpopexy, was first described in 1994 by Nezhat.8 Currently, minimally invasive approaches using laparoscopy or robotic assistance are commonly adopted to perform sacrocolpopexy.
Regardless of the approach, the procedure uses a suspensory bridge of graft or mesh to attach the vaginal wall to the anterior longitudinal ligament of sacrum in order to suspend the vagina to the sacral promontory (see Fig. 46.2).
Sacrocolpopexy is considered to be the most durable surgical procedure for anatomic support of vaginal apex and has reported reoperation rates of less than 5%.9,10 Although support of the vaginal apex can be provided by vaginal approach procedures such as the uterosacral ligament suspension or sacrospinous ligament fixation, sacrocolpopexy has several distinct advantages over these procedures. Specifically, sacrocolpopexy preserves vaginal length, provides support to anterior and posterior compartment, and reestablishes the anatomic vaginal axis. This is supported by several randomized control trials which suggest better objective anatomic outcomes with ASC as opposed to vaginal native tissue repair.11,12
ANATOMY
Knowledge of pelvic anatomy is critical to the surgeon performing sacrocolpopexy.
First, the surgeon should be familiar with the presacral space, which is a potential retroperitoneal space beginning below the bifurcation of the aorta. This space is bounded laterally by the common and internal iliac vessels and extends inferiorly to the superior fascia of the levator muscles.13 Figure 46.3 shows the typical view encountered laparoscopically of the sacral promontory with an artistic rendering showing the structures typically located within close proximity to this space.
The sacral promontory represents the most superior aspect of the anterior surface of the first sacral vertebra and is a commonly used bony landmark in gynecologic surgery. The fifth lumbar intervertebral disc is found just superior to the sacral promontory. The anterior longitudinal ligament, which overlies the vertebra, is a common anchoring site for the sacral end of mesh during sacrocolpopexy. Several important structures run within close proximity to this space. The sacral promontory and presacral space are partially covered by the sigmoid colon and the ureters and common iliac and internal iliac vessels lie within close proximity to the midpoint of the sacral promontory.
 FIGURE 46.1 A: Normal uterovaginal support. B: Uterovaginal pelvic organ prolapse. C: Posthysterectomy vaginal prolapse. PS, pubic symphysis. |
 FIGURE 46.2 A: Sacrocolpopexy. B: Sacrohysteropexy. PB, perineal body. |
 FIGURE 46.3 Laparoscopic view of sacral promontory with superimposed artistic rendering showing the relative proximity of important anatomic structures. a, artery; v, vein; R, right; L, left. |
Identification of the major vessels within the lateral boundaries of the presacral space is essential during dissection as inadvertent injury to these vascular structures can lead to catastrophic bleeding. The aortic bifurcation generally occurs at the level of L4 with an average distance of 5.3 cm above the sacral promontory (Fig. 46.4). The left common iliac vein is the closest large vascular structure to the midpoint of the sacral promontory with a mean reported distance of 27 mm (9 to 52 mm).14
 FIGURE 46.4 Anatomy of the presacral space. a, artery; n, nerve; v, vein. |
Other important vascular structures within this area include the middle sacral artery, which branches from the posterior surface of the aorta and travels inferiorly within the areolar tissue of the presacral space. Likewise, its partner, the middle sacral vein,
arises from the vessels emerging beneath the common iliac veins and drains into the inferior vena cava. Both the middle sacral artery and vein can be easily identified lying directly on the midpoint of the sacral promontory.
arises from the vessels emerging beneath the common iliac veins and drains into the inferior vena cava. Both the middle sacral artery and vein can be easily identified lying directly on the midpoint of the sacral promontory.
The presacral venous plexus is another important anatomical structure that should be identified and avoided as damage to these structures could result in disastrous blood loss. This vascular plexus is composed of anastomoses between the lateral and median sacral veins from which blood courses into the pelvic fascia covering the body of sacrum. Surgeons should be careful to avoid injuring these vascular vessels during dissection and suturing around the sacral promontory.
The hypogastric plexus carries autonomic innervation to the pelvic viscera and descends into the pelvis anterior to the bifurcation of the aorta. In the presacral space, it is located anterior to the middle sacral artery and vein. Because the two trunks of the hypogastric nerves run within the uterosacral ligaments, the right uterosacral ligament remnant can be used as a landmark by surgeons to help to identify the hypogastric nerve as it enters the presacral space. Damage to the hypogastric plexus can result in bladder, bowel, and sexual dysfunction and should be avoided during the procedure.
The course of the ureters should be carefully considered as they descend from kidneys to enter the pelvis. This anatomy is particularly relevant during dissection of the peritoneum over the sacrum as well as extension of this peritoneal dissection inferiorly toward the posterior vaginal cuff.
 FIGURE 46.5 Surgical potential spaces. a, artery; m, muscle; v, vein. |
The ureters exit the medial aspect of the renal pelvis and course inferiorly and medially over the psoas muscles in the retroperitoneal space of the upper pelvis. Surgically, they are most easily identified at the pelvic brim, where they course over the bifurcation of the internal and external iliac arteries. Here, they are within relatively close proximity to the midpoint of the sacral promontory. From here, the ureters follow the branches of the internal iliac arteries as they course along the medial leaflet of the posterior broad ligament within the pararectal space (Fig. 46.5).
The blood supply of the ureter changes as it courses from proximal to distal (see Fig. 46.4). In addition to being retroperitoneal, they are enveloped by an endopelvic fascial covering that is closely adherent to the peritoneum. Small arterioles travel through in this adventitial endopelvic fascial layer and provide the ureter with its blood supply. The upper ureters closest to the kidneys receive blood supply directly from the renal arteries. The middle ureter receives blood supply from the ovarian vessels and from direct branches of the internal iliac arteries. However, once the ureter crosses the bifurcation of the common iliac vessels as it enters the pelvis, it receives blood supply on its lateral side, from branches of the internal iliac vessels (superior vesical, uterine, middle rectal, vaginal, and inferior vesical arteries).
CHOICE OF MESH/GRAFT
Different types of materials have been used as grafts in sacrocolpopexy. These include autologous and cadaveric fascia, xenograft, as well as synthetic materials. Graft materials should have several important general properties.
First, the ideal graft material should be chemically and physically inert while remaining biocompatible and noncarcinogenic. Secondly, an ideal graft material should be sterilizable and resistant to infection. Also, because the material is used to elevate the vaginal apex and is subject to fluctuations in intra-abdominal pressures, the material should be durable and strong while still maintaining some degree of flexibility. Finally, the material should be affordable and easily manufactured. With these properties in mind, the ideal mesh used in ASC surgery should restore normal anatomy and allow for normal function of the vagina and pelvic organs.
Permanent synthetic mesh has the highest success rates and is the best studied of all of the graft materials used in sacrocolpopexy. Although there are several different types of synthetic meshes that have been used, type 1 mesh is currently the most commonly used and associated with the lowest rates of adverse clinical outcomes. Type 1 mesh consists of light weight monofilament polypropylene with large-pore sizes (>75 µm). Type 1 mesh is commercially available in both Y-shaped and single-stranded configurations, with selection being dependent on surgeon preference (Fig. 46.6).15
Knitted mesh is preferred over woven mesh as it allows macrophages to traverse the mesh (except at the interstices where the spaces are too small for a macrophage to enter) and allows for the deposition of the most ideal collagen type.
 FIGURE 46.6 Typical appearance of a Y-shaped mesh used for sacrocolpopexy. |
Ultralightweight (i.e., ≤25 grams/meter2) loosely knitted polypropylene mesh is currently the best available choice for sacrocolpopexy. The long-term safety and efficacy of this mesh have been well studied.16,17
Besides synthetic meshes, autologous as well as xenograft materials have been used in sacrocolpopexy. A 2005 double-blinded randomized clinical trial comparing the surgical outcomes of solvent dehydrated cadaveric fascia lata with synthetic polypropylene mesh in sacrocolpopexy found improved outcomes with synthetic mesh.18 In this study, 91% of the patients who received synthetic mesh (n = 54) were classified as clinically cured at 1 year as compared to 68% of the fascia lata (n = 46) group. However, a 2013 study comparing the 12-month surgical outcomes of porcine dermis to polypropylene mesh for laparoscopic sacrocolpopexy found no statistically significant difference in “clinical cure” between the two groups.19
EFFICACY AND COMPARATIVE OUTCOMES
ASC is an effective surgical procedure for the treatment of apical prolapse.11
A comprehensive review of outcome of ASC studies has been published by Nygaard.9 The study looked at outcomes of sacrocolpopexy in the time period ranging from 1966 to 2004. Key findings of the study were that success rate, when defined as lack of apical prolapse postoperatively, ranged from 78% to 100%. The median reoperation rates for pelvic organ prolapse and for stress urinary incontinence were 4.4% (range 0% to 18.2%) and 4.9% (range 1.2% to 30.9%), respectively. The study also found relatively low rates of mesh exposure with an overall rate of 3.4%. However, the study found that functional outcomes such as the effect of ASC on bowel or bladder function were not well studied (Table 46.1).
In addition to the aforementioned study, the Colpopexy and Urinary Reduction Efforts (CARE) trial is a landmark study which has provided significant insights into the long-term surgical outcomes of sacrocolpopexy procedures. The study was designed to assess the utility of retropubic urethropexy, or Burch, performed at the time of sacrocolpopexy. Initial 2-year outcome data showed that ASC was associated with very low rates of surgical failure.24 However, a secondary analysis evaluating surgical outcomes at 7 years (the extended-CARE or “e-CARE” trial) reported much higher failure rates ranging from 34% to 48%. Notably, the study used composite outcomes including both subjective and anatomic findings to define success. Consequently, one of the criticisms of this paper is that this strategy of defining failure may not have fully captured the scope of patient bother, which is reflected in the finding that ultimately only 5% of patients underwent reoperation for recurrent prolapse. Another criticism of the e-CARE study was the high rate of attrition because
less than 40% of the original study group completed longterm subjective and objective follow-up.
less than 40% of the original study group completed longterm subjective and objective follow-up.
TABLE 46.1 Landmark Studies of Abdominal Sacrocolpopexy | |||||||||||||||||||||||||||||||||||||||||||||
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In the CARE trial, mesh exposures occurred in 5% of patients at 7 years. Here, it is important to note that the majority of mesh-related complications were associated with the use of a nonpolypropylene (Teflon) mesh material, which is no longer used in practice. The use of contemporary type 1 surgical mesh products seems to be associated with significantly lower rates of mesh exposures.
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