Master Class

Still the Standard


 

Vaginal prolapse repair kits have gained popularity, as has laparoscopic sacral colpopexy. The learning curve associated with laparoscopic suturing has also fostered an interest in robotic-assisted laparoscopic approaches. Behind this changing landscape, however, is a long history of experience with open abdominal sacral colpopexy.

It is an approach with a record of success that we should know, appreciate, and retain in our armamentarium of surgical options while at the same time continuing to investigate which procedures for vaginal apex prolapse provide optimal effectiveness and safety.

Key Studies on Cure Rates

The sacral colpopexy, introduced in 1957, is a procedure that bridges the support tissue of the anterior and posterior vaginal apex to the anterior longitudinal ligament of the sacrum. A modification of the procedure, called sacral colpoperineopexy, was developed later to treat patients with vaginal apex prolapse and perineal descent; it results in contiguous posterior vaginal wall support from the anterior longitudinal ligament to the perineum.

Indications for sacral colpopexy include a previously failed vaginal route apex suspension procedure, a foreshortened vagina, a weak or denervated pelvic floor, chronic increases in abdominal pressure related to medical comorbidities and/or heavy manual labor, collagen disorders, and the need for concomitant abdominal surgery. Some physicians argue that sacral colpopexy is undoubtedly indicated in young women with severe uterine or vaginal apex prolapse.

A literature review of over 90 articles with outcomes data on sacral colpopexy published in 2004 by Dr. Ingrid E. Nygaard and members of the Pelvic Floor Disorders Network showed anatomic cure rates of 78%-100% when cure was defined as lack of apical prolapse postoperatively, and cure rates of 58%-100% when cure was defined more broadly as lack of any postoperative prolapse (anterior, posterior, apical).

Of interest, the review showed that concomitant paravaginal defect repair or culdoplasty neither improved anatomic cure nor decreased the recurrence of prolapse.

The follow-up for most of the studies in Dr. Nygaard's review ranged from 6 months to 3 years. The longest follow-up duration was almost 14 years in a study conducted by Dr. W.S. Hilger and associates. This long-term outcomes analysis of abdominal sacral colopopexy showed a cure rate of 74%.

A few randomized clinical trials have compared abdominal sacral colpopexy to other vaginal apex suspension procedures for the treatment of vaginal prolapse, with variable outcomes but with an overriding message that abdominal sacral colpopexy is an effective procedure.

In 1996 Dr. J.T. Benson and associates reported an optimal anatomic cure rate of 58% in patients who underwent abdominal sacral colpopexy with concomitant vaginal reconstructive procedures, and 29% in patients who underwent bilateral sacrospinous ligament suspension with pelvic reconstruction. Because of the significant failure rate associated with vaginal surgery, however, this trial was aborted prior to reaching adequate power.

In 2004, Dr. C.F. Maher and associates compared abdominal sacral colpopexy and concomitant Burch procedure with vaginal sacrospinous colpopexy and concomitant Burch procedure. Anatomic cure was similar in both groups after a 2-year follow-up, but abdominal sacral colpopexy was associated with more posterior vaginal wall recurrences, and vaginal sacrospinous colpopexy was associated with more anterior vaginal wall recurrences.

Of recent importance for the future practice of abdominal sacral colpopexy are the results of a randomized, multicenter clinical trial conducted by the Pelvic Floor Disorders Network that compared open sacral colpopexy with or without concomitant Burch colposuspension in women without preoperative stress incontinence.

Investigators of the CARE trial (Colpopexy and Urinary Reduction Efforts) found that stress incontinence was prevalent 3 months postoperatively in almost twice as many women who did not undergo the Burch procedure as in those who did (approximately 44% vs. 24%).

The results, which were reported by Dr. L. Brubaker and associates in the New England Journal of Medicine, clearly support the value of performing a prophylactic retropubic suspension for potential urinary incontinence along with abdominal sacral colpopexy. (These data do not extrapolate to midurethral slings as prophylactic procedures concomitant with sacral colpopexies.)

Regarding the issue of laparoscopic versus open abdominal sacral colpopexies, my colleagues and I found through a chart review of 117 consecutive patients that the two approaches have comparable clinical outcomes. Laparoscopic sacral colpopexy was associated with both a significantly decreased hospital stay and a significantly longer operating room time.

Key Studies on Mesh

The use of various types of mesh material is an issue that has been addressed to some extent in the literature. Certainly there is no ideal biologic or synthetic mesh. But in general, outcomes data addressing any type of biologic graft in abdominal repair of apical prolapse are sparse and inconsistent, while there is good literature to support the use of nonabsorbable synthetic implants.

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