17.1: Sacrocolpopexy

Definition

Sacrocolpopexy (SCP) is the suspension of the vaginal vault to the sacrum. A synthetic mesh is usually used which is fixed to the vaginal vault and to the anterior longitudinal ligament of the sacrum opposite S1 – S2. The mesh is usually placed retroperitoneally and the procedure is done abdominally by laparotomy or laparoscopy.

Variations

There are numerous variations:

1. Tension

The tension of the mesh can vary from tension-free to a moderate tension. Due to fibrosis the mesh shrinks and therefore, excessive tension should be avoided.

2. Length

The length of mesh along the vagina can vary: From: Introïtus or mid-vagina or Vault Vagina to Sacrum or Perineal body or mid-vagina or Vault

The longer the mesh extends along the vagina, the lower the recurrence rate for prolapse. However, complications such as overactive bladder symptoms and mesh erosion increase with longer mesh.

3. Material

Type 1 macroporous monofilament synthetic mesh is recommended.

4. Rectum

Rectum mobilization with elevation and fixation of it to the mesh (rectopexy) is recommended but not proven to be beneficial.

Indications

Any type of prolapse, stage 3 or 4 (POPQ). It is particularly useful for vault prolapse and large enterocoeles. It is also performed for anterior compartment prolapse, but the larger the cystocoele, the greater the extent of bladder mobilisation.

Contraindications

Patients too young (<40 yr) Patients too old (> 70 yr) Marked obesity Medical problems that may create post-operative problems such as deep vein thrombosis. Patients on anticoagulants, including Disprin.

Age group

The ideal age group is 45 – 65 years.

Recommended technique

The operation consists of a laparotomy and can be divided in three parts:

(i) Abdominally

Separate the bladder from the vagina to the level of the bladder neck. Open the peritoneum medially to the rectum from the sacral promontory to the vagina. Open the rectovaginal space for a short distance. Open the presacral space and aggressively mobilize the rectum down to the pelvic floor.

(ii) Vaginally*

Open the bladder neck area. Open the space already made from above (between bladder and vagina). Insert a strip of mesh (about 15 x 3 cm) into the abdomen. Fix the bottom of the mesh to the arcuate ligament below the symphysis pubis and surrounding vaginal wall. Close the anterior vagina. Open the posterior vaginal wall. Open the rectovaginal space and join it with the abdominal cavity. Insert a second strip of mesh. If necessary, perform a perineal body repair. Fix the mesh to the perineal body and surrounding vaginal wall. Close the vagina.

*Hydrodissection is recommended before incision. Use 200ml saline with 2 ampules Por-8 (omnipressin). It is injected between the vagina and bladder or rectum.

(iii) Abdominally

The two strips of mesh are fixed to the vaginal vault and then to the sacrum at level S1-2. Moderate tension should be applied. Thereafter the rectum is pulled upwards and along its medial side fixed to the mesh. Finally, the peritoneum is pulled over the mesh (it is often trimmed) and sutured to the rectum. A markedly elevated pouch of Douglas is characteristic of this operation.

A suprapubic catheter is usually inserted for determining the residual volume on day 3-4 postoperatively. It should be less than 70ml. A vaginal plug is inserted after the operation and removed 36-48 hours postoperatively. The skin stitches are kept in for 2 weeks. Anticoagulant therapy is applied from the first day after the operation.

Bowel action is important postoperatively and when she is discharged. Initially, laxatives should be given. Antibiotics are also given for the first few days.

Results:

The main results of SCP as described above are the following: Recurrent prolapse about 10% (depending on the surgeons’ experience and the type of prolapse).

Mesh erosion about 10-15% of which 95 – 98% can be treated in the consulting room by excision of the exposed mesh followed by vaginal estrogen cream 1 – 2x/ week.

Overactive detrusor 40-60%, but the incidence decreases over time. Stress urinary incontinence in about 10% of cases. Physiotherapy or a mid-urethral tape should be considered.

Abdominal pains during the first 6 months.

Vaginal bleeding during the first month.

Dyspareunia 5 – 6% (the same figure as preoperatively). Although the bowel action improves markedly in most patients, a minority of women have persistent constipation. If obstructive defaecation persists after the operation, a defaecogram should be done (very similar to a barium enema). If a rectocoele (particularly with rectal intussusception) is demonstrated, a STARR procedure could be considered (consult a colorectal surgeon).

Outcomes

1. Cronjé HS. Colposacrosuspension for severe genital prolapse. Int J Gynecol Obstet 2004; 85: 30-35.

• Recurrent prolapse: 8%
• Repeat surgery: 4%
• TVT /Ob-tape postoperatively: 12%

2. Cronjé HS, De Beer JAA. Abdominal hysterectomy and Burch colposuspension for uterovaginal prolapse. Int Urogynecol J 2004; 24: 408-413.

• Recurrent prolapse: 10%
• Repeat surgery: 9%
• TVT/Ob-tape: 3%

3. Cronjé HS, De Beer JAA. Vault prolapse treated by sacrocolpopexy. S Afr J Obstet Gynaecol 2007; 13: 80-83.

• Recurrent prolapse: 14%
• Repeat surgery: 8% TVT/Ob-tape: 8%

4. Cronjé HS, De Beer JAA. Combined abdominal sacrocolpopexy and Burch colposuspension for the treatment of stage 3 and 4 anterior compartment prolapse. S Afr J Obstet Gynaecol 2007; 13: 84-90.

• Recurrent prolapse: 16%
• Repeat surgery: 6%
• TVT/Ob-tape: 8%

5. Cronjé HS, De Beer JAA. Culdocele repair in female pelvic organ prolapse. Int J Gynecol Obstet 2008; 100: 262-266.

• Recurrent prolapse: 10%
• Repeat surgery: 5%
• TVT/Ob-tape: 13%