Sacrospinous mesh colpopexy: a new technique for vaginal suspension
© Springer-Verlag Berlin / Heidelberg 2004
Published: 31 August 2004
A novel new approach to correct vaginal vault prolapse using a Prolene mesh sling suspended between both sacrospinous ligaments is described. The technique utilises reusable equipment and the mesh repair is easily extended to repair posterior vaginal wall defects concurrently.
A novel new approach to correct vaginal vault prolapse using a Prolene mesh sling suspended between both sacrospinous ligaments is described. The technique utilises reusable equipment and the mesh repair is easily extended to repair posterior vaginal wall defects concurrently. Sacrospinous colpopexy has, since its description in 1968 , become a commonly used procedure for the treatment of vaginal vault prolapse after hysterectomy. There is some controversy as to whether the abdominal route or the vaginal route results in optimum success [2, 3]. Many studies, however, show high success rates with sacrospinous fixation [4, 5, 6, 7], and there are many benefits of the vaginal route, particularly in terms of operating time and postoperative recovery . There have been a number of modifications to the original procedure, with variable degrees of apparent improvement [4, 6] or perceived ease of operating .
Sacrospinous fixation is most commonly performed unilaterally, with good results , but also has been described bilaterally . Good apposition of the vaginal vault to the ligament is essential, as is the eradication of co-existing enterocoele, preventing vaginal evisceration following sacrospinous fixation . An inherent problem with traditional sacrospinous suspension is that while the sacrospinous ligament is an undoubtedly strong anchor point, the vaginal submucousa to which the other end of the permanent suture is attached is not. The result is that in a proportion of patients the sutures tear through the vaginal attachments and vault prolapse recurs. This is especially likely to occur in the more active patients, where greater forces are exerted through the vaginal fixation points. In an effort to eliminate this problem we have adapted the technique of sacrospinous colpopexy by incorporating a polypropylene mesh, which acts as a sling between the sacrospinous ligaments to which the vaginal vault can be secured at various points. An extension of mesh down the post wall can easily be included for treatment of co-existing rectocoele. A description of the procedure developed by the second author follows.
Materials and methods
To date over 30 SMS procedures have been performed for vaginal vault prolapse following hysterectomy, over 60% with concomitant posterior wall extension. Operating times have varied between 26 to 58 min. Perioperative antibiotic prophylaxis is used in all cases. No complications have occurred during the procedure, although care is required to ensure that the Miya hook does not penetrate the rectum or damage the pudendal neurovascular bundle. Two patients have required small areas of mesh to be removed. The first was for a small area of mesh erosion through the lower left posterior vaginal wall identified at the 3-month follow-up. The second presented 6 months post-procedure with an uncomfortable horizontal ridge found under the lower third of the posterior vaginal wall as a result of the mesh detaching from the perineal body and retracting. Another patient had persistent, intractable buttock ache that abated once the sacrospinous sutures were released 5 months postoperatively. Unfortunately, the mesh became infected as a consequence of the second procedure, and a third operation was required to remove it completely.
Buttock pain is an immediate postoperative problem for all patients undergoing sacrospinous suspension, but resolves over a 2-week period with anti-inflammatory analgesia. Persistent pain particularly with radiation down the leg can represent entrapment of the lower fibres of the sciatic nerve, which can happen if the Miya hook is placed close to the upper border of the ligament. No other postoperative complications were reported or identified at follow-up 3 months post-procedure, and all women had a well-supported vault with good functional vaginal length and capacity. One-year follow-up for all patients is planned with formal POP-Q grading and patient-completed questionnaires, which once completed will be reported.
The use of this mesh sling enables anatomical reconstruction of the vaginal vault, maximising functional vaginal length, as vaginal skin is not excised. The upper vagina is restored towards the hollow of the sacrum over the levator plate, hence increases in intra-abdominal pressure force the upper vagina back against the sacrum, rather than back down through the vagina itself. This surgical approach has the added advantage of allowing concurrent repair of posterior wall defects by extending the mesh. The technique utilises existing reusable equipment and widely available Prolene mesh; hence costs are kept to a minimum.
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