C-Gyn 14 Abdominal Sacrocolpoexy

Question 1

What is a sacrocolpoxexy

Answer 1

Suspension of vaginal apex to the anterior longitudinal ligament at the level of the sacral promontory, using a graft, with the possible incorporation of the graft into the fibromuscular layer of the ant/post vaginal walls.

Question 2

What can the graft of be made of ?

Answer 2

Synthetic mesh
Autologous fascia (fascia lata, rectus fascia)
Xenograft or allograft

Question 3

What routes can sacrocolpopexy be performed

Answer 3

Laparotomy
Laparoscopy
Robotic assisted laparoscopy

Question 4

Benefits compared to other vaginal reapirs

Answer 4

Lower risk of awareness of prolapse
Less recurrent prolapse on examination
Less repeat surgery for prolapse
Less post op SUI and dyspareunia

Question 5

Difference between abdominal vs laparoscopic approach

Answer 5

Laparoscopic less blood loss, longer operating time, shorter hospital stay.
Nil clinically different objective or subjective cure rates

Question 6

Risk factors for prolapse recurrence

Answer 6

Parity
Vaginal delivery
Age
BMI
Preoperative symptom severity as measured using PFDI 20
Family history
Connective tissue disorders
Levator avulsion

Question 7

What factors influence choice of procedure ?

Answer 7

Patient related
Surgeon related
Procedure related
Institution related

PATIENT: parity, vaginal, age, bmi, preop symptoms, fam hx, connective tissue, own surgical hx, goals/expectations, symptoms individual risks

Surgeon - prior training, experience current caseload.

Institution - national guidelines, surgical credentialing, local surgical expertise, health fund reimbursement, institutional surgical assets

Question 8

Why is the vaginal apex sutured to the anterior longitudinal ligament at S1/S2 ?

Answer 8

Minimize bleeding and avoid lumbosacral intervertebral disc, reduce risk of discitis

Question 9

Sacrospinous ligament fixation vs open sacrocolpopexy

Answer 9

Sacrocolpoexy = higher anatomical success rate, less SUI, less post op dyspareunia
Longer operating time, longer inpatient stay, slower return to activities, higher cost

Question 10

Uterosacral suspension vs open open sacrocolpopexy

Answer 10

SACROCOLPO: Greater anatomical access, fewer re-operations

BUT greater peri-op complications, no difference in symptoms or QOL at 12 months

Question 11

Can you do sacrocolpopexy with concurrent hysterectomy ?

Answer 11

Paucity of data related to concurrent hysterectomy or subtotal hysterectomy ,confidence is largely derived from post hysterectomy prolapse data

MORE MESH EXPOSURE WITH HYSTERECTOMY (8.5% vs 1.5%)

Question 12

Whats the evidence for lap sacrohysteropexy instead?

Answer 12

Improves C point, TVL on POPQ, EBL, post op pain, function, hospital stay

Downsides: urinary symptoms, operative time, QoL.

Therefore, reserve sacrocolpopexy for post-hysterectomy

Question 13

6 points related to INFORMED CONSENT

Answer 13

Must be wide ranging

1. Asymptomatic people dont necessarily need surgery
2. Alternatives to surgery: pelvic floor, vaginal support pessaries
3. Alternate surgeries: obliterative (colpocleisis, native tissue - SSF, abdo including uterosacral vault suspension)
4. Sufficient info including Ranzcog, ACSQH, IUGA pamhlets
5. Discuss risks
6. Discuss de novo or occult SUI

Question 14

Risks of sacrocolpopexy

Answer 14

General risks: anaestheic, infection, urinary tract, bleeding (requiring transfusion or surgical/radiological intervention), VTE, chest infection, heart problems.

SPECIFIC:
Mesh exposure 3%
Injury to abdo viscus (Bowel 1.4%, bladder 1.8%, ureter <1%)
Osteomyelitis/discitis <1%
Conversion to open if started minimally invasive
General pain, long term dyspareunia 9%
Long term bowel dysfunction

Question 15

Which patients are at increased risk of occult or de novo SUI post op?

Answer 15

Older >65, with positive pessary (urine leakage) test, low MUCP (maximal urtethral closing pressure).

Question 16

How to get accredited

Answer 16

Minimum of 20

AUGS minimium 30 prolapse cases, which 5+ sacrocolpopexy