Still the Standard

The overall rate of mesh erosion in Dr. Nygaard's review of abdominal sacral colpopexy (using various types of mesh) was 3.4%, with good evidence to support the use of polypropylene mesh.

Dr. A.G. Visco and associates published a series in 2001 evaluating the prevalence of synthetic mesh erosion (predominantly Mersilene mesh) between abdominal sacral colpopexy and various colpoperineopexy procedures. The erosion rate overall was 4.5%. Vaginally introduced mesh, however, was associated with an erosion rate of 40%, compared with an erosion rate of 16% when sutures were placed by the vaginal route and attached to abdominally placed mesh.

In a more recently published study, Dr. P. J. Culligan and associates randomized patients undergoing sacral colpopexy to receive polyprophylene mesh or solvent-dehydrated cadaveric fascia lata. Of the patients who returned for 1-year follow-up, 91% of the synthetic mesh group, and 68% of the fascia group, were classified as cured. Several case series have had similar results.

With the available data, I see little reason to use biologic tissue. One indication, though, may be sacral colpopexy with concomitant sigmoid resection rectopexy. I prefer a macroporous polypropylene mesh for sacral colpopexy.

The Surgery

Whether we perform abdominal sacral colpoplexy through an open, laparoscopic, or even robotic technique, we must always remember that when working within the presacral space there is a risk of life-threatening bleeding.

For this reason, I always dissect the presacral space first. I have learned to be prepared for many variables: Older women sometimes have undetected aneurysms of the blood vessels bordering this area, and the anatomy of the sacrum can vary.

Surgeons handle bleeding in various ways. Some surgeons prophylactically cauterize the middle sacral vessel. For venous bleeding, I have success when I am working laparoscopically with inserting a sponge through a port and holding pressure for 5 minutes. Sterile thumbtacks, bone wax, and hemostatic agents can also be of value.

Once I've made my presacral dissection, I proceed all the way down into the cul-de-sac, having already visualized or palpated both ureters. I make sure I am at least 4 cm medial to the right ureter when I make my incision in the peritoneum overlying the sacral promontory.

I dissect all the way down to the rectovaginal space in the cul-de-sac. Lately, in laparoscopic surgery, I have been making a tunnel between the sacrum and cul-de-sac, because the peritoneum easily lifts off the retroperitoneal structures.

I usually use end-to-end anastomosis sizers for vaginal manipulation, but others will use vaginal palpation or Lucite probes. I dissect into the rectovaginal space first, which consists of areolar tissue.

I believe that when we're treating vaginal apex prolapse, we must attach the graft over a significant portion of the posterior vaginal length and, in cases of perineal descent, all the way down to the perineum.

There's now a caveat to this procedural modification, however, in that there is a new colorectal procedure used for treatment of outlet dysfunction constipation called the STARR procedure (Stapling Transanal Rectocele Resection). Unfortunately, a patient with mesh running all the way down to her perineum may not be able to undergo this colorectal procedure because of the risk of rectovaginal fistula. I inform my colpopexy patients that this is a contraindication to the STARR procedure.

In laparoscopic and some open cases, I will retrograde fill the bladder in order to delineate the bladder and facilitate the anterior dissection. This may be difficult if a patient has undergone an anterior colporrhaphy in the past.

I like to attach the anterior graft all the way down to the bladder base. Often times, what are thought to be stage III or stage IV cystoceles are in fact high anterior apical prolapses. Aggressive anterior vaginal wall dissection results in a more extensive attachment of the anterior vaginal mesh and decreased need for a paravaginal defect repair. Obviously, keeping the bladder from harm is very important.

The beauty of this procedure is that once you've suspended the anterior and posterior vaginal apex to the anterior longitudinal ligament, you're home free.

Surgeons often use a Y-shaped graft for sacral colpopexy. I currently use two pieces of 4-by-15-cm type 1 polypropylene mesh–a macroporous, monofilament mesh. I tension the posterior and anterior straps separately so as to avoid excess tension on the mesh and hence the vagina, and subsequently attach them to the anterior longitudinal ligament of the sacrum at the level of S1 or S2.

Many believe that if you don't stitch (or tack) at the S3 level, you're not allowing the vagina to be in its normal axis–that by going up to S1, you risk exposing the vagina posteriorly to increases in pressure that change the axis and increase posterior vaginal wall recurrence.