Abdominal Sacral Colpopexy Case File

Abdominal Sacral Colpopexy Case File

Eugene C. Toy, MD, Konrad P. Harms, MD, Keith O. Reeves, MD, Cristo Papasakelariou, MD, FACOG

Case 24

A 59-year-old G4 P4004 woman presents with a complaint of a bulge that is exiting her vagina, which is bothersome and she desires surgery. The patient had a vaginal hysterectomy 15 years earlier for uterine prolapsed. Two years ago, she had a vaginal sacrospinous ligament fixation (SSLF) for vaginal vault prolapsed. She does not complain of any urinary incontinence, and states that her health is otherwise excellent. She is frustrated with the failure of the prior vaginal SSLF procedure and is skeptical of another vaginal procedure for this condition.

➤ What is the most likely diagnosis?

➤ What is your next step?

ANSWERS TO CASE 24:

Abdominal Sacral Colpopexy

Summary: A 59-year-old G4P4004 woman, who has had a prior vaginal hysterectomy and later vaginal sacrospinous ligament fixation, presents with a recurrent vaginal defect.

➤ Most likely diagnosis: Vaginal vault prolapse following previous vaginal sacrospinous ligament fixation.

➤ Next step: Evaluate the patient for surgical repair, most likely to consist of abdominal sacral colpopexy (ASC).

ANALYSIS

Objectives

1. Learn the advantages and disadvantages of ASC.
2. Learn the types of materials to be used in the performance of this operation.
3. Learn the complications associated with this operation.

Considerations

This 59 year old woman presents with recurrent vaginal vault prolapse following a prior operation, which unfortunately is not an uncommon experience. Likewise, as in the case of this patient, many patients will not consent to another operation essentially identical to the one that failed in the first place. Unfortunately, operations for vaginal vault prolapse fail about 25% of the time. It is the wise surgeon who can offer his patient either the vaginal or abdominal approach for correction of a previous failed surgical procedure. The patient who presents with vaginal vault prolapse is not always a surgical candidate, however, and the surgeon must discuss nonsurgical options with his patient before deciding on the surgical approach (see Case 23). As the population in the United States ages, the number of patients presenting for potential surgical repair of vaginal vault prolapsed will inevitably increase significantly. ASC has been referred to as the “gold standard” operation for vaginal vault prolapse, because it has the lowest incidence of recurrence, ranging from 78% to 100%.1 Proponents of the operation suggest that it is the procedure of choice for the younger, physically active woman who wants to have one operation last her for a lifetime, since it is statistically less likely to fail than a vaginal or laparoscopic approach. Those who prefer other operative procedures point to the laparotomy incision, the increased complication rate, and the higher costs. Comparing operative approaches is necessary for the surgeon discussing these with his/her patient, but the data is mixed, the advantages of one over another are not clearly delineated, and there is no clear answer to which operation is the “best.” In the absence of contraindication, an abdominal sacral colpopexy is likely the best option for this patient.

APPROACH TO

Abdominal Sacral Colpopexy

The basics of the ASC operation consist of a laparotomy approach to gain access to the pelvis, affixing a graft to the vaginal apex and possibly laying it under the posterior peritoneum, and then attaching it superiorly to the anterior surface of the first sacral vertebra. Multiple variants of this operation have been described, and some are discussed here.

CLINICAL APPROACH

ASC has been performed using a strip of fascia derived from the patient’s own fascia lata, a portion of her own abdominal wall fascia, xenograft material, and synthetic materials (Figure 24–1). When sewing the graft to the vaginal apex, care should be taken to place the permanent suture into the vaginal muscularis, but not all the way through the vagina and into the vaginal mucosa. Some surgeons make a “Y” of the synthetic tissue they attach to the vaginal apex and secure it to both the dorsal and ventral vaginal surfaces. The graft should be placed under the posterior peritoneum, and attention paid to avoiding the course of the right ureter coursing along the right side of the graft. The graft should be sewn into the ventral surface of the S1 vertebrae with at least two permanent monofilament sutures, and there should not be any tension on the graft as it courses from the top of the vagina to the sacral promontory. Use of this location on the S1 level has been the standard location for some time, and has been shown to be optimal for being able to visualize and avoid the middle sacral artery and to maintain the vaginal angle least likely to result in stress urinary incontinence postoperatively. Placing several sutures into the portion of the mesh covering the vaginal segment of graft to distribute tension equally is a key surgical concept.

The issue of which graft material to use is still not clearly defined, but there has been enough experience to indicate that cadaveric fascia should no longer be used. Not enough literature exists to state whether synthetic or biological material is preferable, or which is more prone to cause erosion, or which will yield the overall best result. Other variables, such as patient age, vaginal health, estrogen use, concurrent antibiotic usage, and operative technique differences, will make this a difficult question to answer. The ideal graft does not yet exist. Autologous fascia is not going to be rejected and is not likely to erode through the vagina, but it is more prone to failure than synthetic materialsm.4

Figure 24–1. Abdominal sacrocolpopexy suing a polypropylene bridge from the

sacral promontory to the vaginal apex. (Reproduced, with permission,from Schorge JO,

Schaffer JI, Halvorson LM, et al. Williams Gynecology. New York: McGraw-Hill, 2008.)

Synthetic material pore size has been shown to be a factor in the development of infection and mesh erosion at all sites in the pelvis (Case 25).

Peritoneal closure over the mesh used for suspension to avoid the potential for mesh erosion and bowel obstruction is not clearly demonstrated to be effacacious in the literature. Bowel erosion is a relatively rare complication (~1.1%), and therefore this question is not going to be answered quickly with randomized studies. There is little harm in reperitonealization, however, and the benefit seemingly outweighs any risk involved, but studies have shown that this is no guarantee to avoid bowel erosion.

Whether concurrent hysterectomy increases the risk for infection and graft erosion is still controversial, with some studies suggesting that hysterectomy increases this risk, and others show no difference.4 The theoretical risk is that hysterectomy accompanying ASC would allow bacteria to enter into the site.

Complications

Overall bowel function seems to improve for women who have ASC, but the data are limited. Causality is hard to discern in this regard, though, because for some patients bowel dysfunction may antedate prolapse, and the opposite may be true for others. This may be because straining to effect satisfactory bowel activity is reduced following successful ASC, and the procedure may create enough beneficial fibrosis to eliminate some defecatory dysfunction. In other patients, the surgery may result in scarring and pain with defecation that did not predate the surgery. Whitehead and colleagues found that1 woman in 20 will have significant gastrointestinal morbidity, including problems such as ileus and small bowel obstruction, and that the older patient is at increased risk for these complications.2

Bladder function following the procedure is related to the degree of voiding dysfunction the patient had prior to the procedure, and whether any concomitant procedures were done at the time of the ASC. As with other procedures involving vaginal suspension, ASC can change the urethrovesical angle and create urinary incontinence for the woman who did not have this problem preoperatively. The gynecologist then has to decide whether to do a routine prophylactic operation for urinary incontinence if none is present when performing ASC, or wait until after the procedure to see if there is incontinence and then operate for urine loss.

Complications of ASC and their mean occurrence rate include urinary tract infection (10.9%), wound problems, including hematoma and infection (4.6%), hemorrhage and/or transfusion (4.4%), cystotomy (3.1%), enterotomy (1.6%), ureteral injury (1%), and deep vein thrombosis (3.3%). Mesh erosion occurred in 3% of patients reported in the largest review article. The Cochrane review of ASC concluded that the abdominal approach had less apical failure, but a greater propensity for complications, while encountering less stress incontinence and postoperative dyspareunia.

Successful surgeons list some key concepts for best surgical outcomes: (1) use graft tissue rather than trying to approximate either the vagina or the uterus to the sacrum; (2) place the graft at the S1-S2 level; (3) do not strip the abdominal vaginal apex down to the mucosal level before affixing the synthetic graft material to it; (4) place the graft between the anterior vagina and the sacrum without too much tension to reduce the risk of postoperative stress incontinence; (5) use many sutures in the vaginal end of the graft to equilibrate tension on the graft and the vagina.4

Whether the abdominal or vaginal approach is preferable for a given patient with vaginal vault prolapse is not clear from the extant literature. Prospective, randomized trials do not exist to answer this question, and therefore factors which will determine the answer to this question will, of necessity, involve the patient’s age, the strength of her tissue, her lifestyle, the durability of the proposed operative procedure, and the opinion and experience of the surgeon taking care of the patient. All of the above are pertinent when discussing the best approach for a given patient with vaginal prolapse.

Comprehension Questions

24.1 A 55-year-old woman presents to the gynecologist’s clinic with the complaint of “there’s something falling out of my vagina.” She had undergone an abdominal hysterectomy for uterine fibroids 15 years previously. She denies leakage of urine. On examination, she is noted to have a third-degree vaginal vault prolapse. The gynecologist counsels her about the options of abdominal sacrocolpopexy versus sacral ligament fixation to address the problem. As compared to ASC, which of the following complications is seen more often with SSLF?

A. Urinary tract infection

B. Wound infection

C. Hemorrhage and/or transfusion

D. Nerve injury

24.2 The gynecologist explains to the patient in question 24.1 that ASC has been referred to as the “gold standard” for repair of vaginal vault prolapse. Which of the following is the reason for this label?

A. ASC is more cost-effective than vaginal procedures.

B. ASC is less likely to fail and result in recurrent prolapse.

C. ASC is associated with less pain than vaginal procedures.

D. ASC is less likely to result in hemorrhage than vaginal SSLF and USLF.

24.3 A 69-year-old woman is noted to have a vaginal vault prolapse after a vaginal hysterectomy performed 25 years previously for pelvic pain. The patient is in fairly good health and is very active physically and sexually. She is 5 ft 4 in tall and weighs 180 lb (82 kg). After being counseled about the various options, she agrees to sacral spinous ligament fixation. Which of the following is the most important preoperative management in her case?

A. Lose 10 lb (4.5 kg) of weight prior to surgery.

B. Identify and treat any urinary tract infection.

C. Identify and treat bacterial vaginosis.

D. Apply topical estrogen to the vagina.

ANSWERS

24.1 D. Nerve injury is rare, occurring only in 1% to 2% of patients. With sacrospinous ligament procedures, the pudendal nerve can be entrapped.

24.2 B. ASC is considered the “gold standard” because there is less apical failure with this operation than with vaginal procedures for vault prolapse.

24.3 D. In a woman who is remote from menopause, the vaginal epithelium is typically thin and atrophic. Vaginal surgery is difficult in this circumstance and can lead to a greater incidence of wound breakdown and infection. The technical aspects of vaginal surgery are likewise difficult. Topical estrogen cream to the vaginal region can assist to allow the vaginal epithelium to be more pliable, thicker, and easier to manipulate in the OR.

Clinical Pearls

See Table 1-2 for definition of level of evidence and strength of recommendation

➤ ASC is occasionally complicated by bleeding from the site of attachment of the graft tissue to the anterior surface of the sacral vertebrae (Level B).

➤ Visualize and avoid small arterioles coursing over the bone surface. If bleeding occurs, have some sterile orthopedic thumbtacks available to push into the vertebra or bone wax to stop the bleeding (Level C).

➤ The “vaginal hand” instrument, consisting of a rigid vaginal dilator attached to a right-angle retractor, is placed into the vagina to delineate the apex of the vault from within the laparotomy incision.This instrument provides an easy method to manipulate the vagina while maintaining a sterile laparotomy field (Level C).

➤ A thorough bowel preparation prior to this operation facilitates packing the empty bowel out of the way to gain access to the pelvic floor for correct placement of the graft (Level B).

REFERENCES

1. Nygaard IE, McCreery R, Brubaker L, et al. Abdominal sacrocolpopexy: a comprehensive review. Obstet Gynecol. 2004:805-823. A definitive review of a challenging topic. 

2. Whitehead WE, Bradley CS, Brown MB, et al. Pelvic floor network. Gastrointestinal complications following abdominal sacrocolpopexy for advanced pelvic organ prolapse. Am J Obstet Gynecol. 2007;197:78.e1-7. 

3. The American College of Obstetricians and Gynecologists. Pelvic organ prolapse. ACOG Practice Bulletin No. 85. Obstet Gynecol. 2007;110:717-730. 

4. Bensinger G, Lind L, Lesser M, Guess M, Winkler HA. Abdominal sacral suspensions: analysis of complications using permanent mesh. Am J Obstet Gynecol. 2005;193:2094-2098. 

5. Wu JM, Wells EC, Hundley AF, Connolly A, Williams KS, Visco AG. Mesh erosion in abdominal sacral colpopexy with and without concomitant hysterectomy. Am J Obstet Gynecol. 2006;194:1418-1422. 

6. Maher C, Baessler K. Surgical management of posterior vaginal wall prolapse: an evidence based literature review. Int Urogynecol J. 2005;17:84-88.

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