FIGURE 1Abdominal sacral colpopexy technique
Reconstructive materials
Although many different materials have been described, none have undergone rigorous comparisons. In our institution, we use soft polypropylene (Surgipro; US Surgical, Norwalk, Conn).
Fold a piece of 5-inch mesh over onto itself and suture the layers together to create a double-thickness configuration. Then “fishmouth” the caudal end of this mesh prosthesis, producing both an anterior and posterior leaf. With the obturator still within the vaginal cylinder stretching the vaginal apex, secure the posterior leaf of the mesh to the posterior vaginal wall with 3 to 5 nonabsorbable #0 sutures.
Suture placement. Thread each suture initially through the posterior leaf of the mesh, placed deeply through the fibromuscular thickness of the posterior vaginal wall, then bring it back out through the mesh at the same point. Place the sutures in a transverse line 1 to 2 cm apart and 3 to 4 cm distal to the vaginal apex.
Once all sutures have been placed, tie each of them, thereby securing the posterior leaf of the mesh to the posterior vaginal wall. Now perform a “mirror” procedure to secure the anterior leaf of the mesh prosthesis to the anterior vaginal wall. Then firmly attach the mesh prosthesis to the vaginal apex using several interrupted, permanent sutures.
At this point, the sutures previously placed through the periosteum of the sacral promontory are threaded through the apex of the mesh prosthesis at a point that will allow the vagina to rest comfortably within the pelvis, without undue tension or traction once the sutures are tied into place (FIGURE 1, MIDDLE).
Trim any excess mesh, and close the 6-cm longitudinal peritoneal incision previously created in the cul-de-sac. Close the incision over the top of the mesh, retroperitonealizing the mesh prosthesis (FIGURE 1, BOTTOM).
Paravaginal defect repair
The bladder base is intimately associated with the anterior vaginal wall via a triangular sheet of pubocervical fascia attached to and extending from the arcus tendineus fascia pelvis bilaterally. When the apex of the vagina prolapses through the introitus, as in total vault prolapse, the base of the bladder is torn free from these fascial attachments in the pelvis and herniates through the introitus along with the vaginal apex. By definition, a bilateral paravaginal defect will result. Thus, surgical repair of total vaginal vault prolapse almost invariably requires paravaginal defect repair as well.
The goal of paravaginal defect repair is to reattach, bilaterally, the anterolateral vaginal sulcus and its overlying endopelvic fascia to the pubococcygeus and obturator internus muscles and fascia at the level of the arcus tendineus fascia pelvis.
Technique
Enter and gently develop the retropubic space of Retzius, taking care not to disrupt the myriad venous anastomotic networks of the plexus of Santorini, located on and around the bladder. Bluntly mobilize the bladder bilaterally, exposing the lateral retropubic spaces, the pubococcygeus and obturator internus muscles, and the obturator neurovascular bundles. Within each retropubic space, palpate the ischial spine. Then visualize the arcus, seen as a white ligamentous band, as it courses from the ischial spine caudally toward the ipsilateral posterior pubic symphysis. A lateral paravaginal defect representing avulsion of the vagina off the arcus tendineus fascia pelvis, or of the arcus tendineus fascia pelvis off the obturator internus muscle, can now be visualized.
While gently reflecting the bladder medially with a wide ribbon, insert a few fingers of the nondominant hand into the vagina and elevate the ipsilateral anterolateral vaginal sulcus. Then place a suture through the fibromuscular thickness of the lateral vaginal apex, just above the uplifting fingers in the vagina, and then slightly cephalad into the arcus tendineus fascia pelvis or obturator internus fascia on the pelvic sidewall, at a point 1 to 2 cm distal to the ischial spine. Place 3 to 5 additional sutures in a similar fashion at 1-cm intervals. The most distal suture should be placed as close as possible to the pubic ramus into the pubourethral ligament. If necessary, repeat the procedure on the contralateral side. Then tie all sutures into place, thereby completing the repair.
Why correct all defects at once?
When a patient has complete vault prolapse, she typically has defects in all 3 levels of pelvic support, and thus may need to undergo several different procedures to correct all anatomic defects and restore function.
In other words, vaginal vault prolapse rarely presents as an isolated defect. It more commonly occurs in conjunction with a cystocele, rectocele, enterocele, or some combination of these.1 Richter reported that 72% of patients with vaginal vault prolapse had a combination of other pelvic floor defects as well.2
If all vaginal support defects are repaired at the time of sacral colpopexy, recurrent vault prolapse is rare. Failures can be minimized by suturing the suspensory mesh to the posterior vagina and anterior vaginal apex over as extended an area as possible. Also test the sutures once they are placed within the periosteum of the sacral promontory to ensure they will not pull free.