Vaginal sacrocolpopexy: a facile new method of augmented recto-enterocele repair

This abstract evaluates a transvaginal alternative to ASCP, which allows a completely anatomic re-suspension of a prolapse in the sacral hollow (at about S3 level). Endopelvic fascia in the postero-apical compartments forms a roughly diamond-shaped suspensory hammock, running from extraperitoneal portion of uterosacral ligaments (USLs), across inferior edge of sacrospinous ligaments (SSLs), down the fascial white lines (arcus tendineus fascia pelvis & arcus tendineus fascia rectovaginalis), to perineal body. This suspensory hammock supports the uterus and upper vagina (preventing vault prolapse) and partitions the uro-genital tract from the recto-sigmoid (guiding the stool smoothly through the pelvis). Recto-enteroceles usually arise through a transverse obstetric tear in this hammock, avulsing the proximal margin of rectovaginal septum from the posterior margin of pericervical ring. The descending fetal head pushes the torn septum into the distal vagina, creating a fascial defect that is difficult to close by re-suture of native tissues from below. Abdominal sacropexy (ASCP) can easily compensate this defect in the sagittal plane (ie, from sacral hollow to perineal body), but not in the coronal plane (ie, from sidewall to sidewall). Comprehensive repair in the coronal plane cannot be done from above, because the laparoscopist cannot simultaneously establish lateral communication between the rectovaginal and pararectal spaces. In contrast, the skilled vaginal surgeon has no difficulty in developing an operative field stretching from sidewall to sidewall and from sacral hollow to perineum. At vaginal sacrocolpopexy (VSCP), all three posterior pelvic spaces are opened, and stay sutures are placed in the extraperitoneal USLs (~5 cm from ureter) and the coccygeus fascia (ie, the SSLs). The postero-apical compartment fascia can then be reconstituted in all four directions by attaching a shaped bridging graft (preferably of tissue inductive biomesh) to the USL/SSL stay sutures, both pelvic sidewalls and the perineal body. Methods: A retrospective study comparing a cohort of 136 consecutive VSCPs (112 augmented with tissue-inductive xenografts and 24 with polypropylene mesh) to 106 historical controls (treated by plication of the native tissues and suture re-anchoring to the SSLs). Main outcome measures were ‘same site’ prolapse recurrence; worsened or persistent defecatory difficulties and significant peri-operative complications. Mean follow-up time was 72 months (range=16–141 months). Statistical analysis was by chi-squared test, Kaplan-Meier survival analysis and logrank test. Results: In this sample of 242 rectocele repairs, native tissue plication and augmented VSCP delivered comparable rates of bulge control [78.3% versus 89%]. However, traditional rectocele repair was very disappointing for treatment of constipation symptoms. Obstructive defecation (prolonged straining and incomplete evacuation) was resolved in 68 of 88 (79%) VSCPs versus 18 of 43 plication repairs [χ²=19.07; p<.001]. Of 65 women who practiced perineal splinting or vaginal digitation, the need for manual assistance was abolished in 39 of 52 (75%) VSCPs versus just 6 of 13 plication repairs [χ²=4.06; p<.05]. Perioperative complication rate attending VSCP was 4.4% (one status asthmaticus; two haemorrhages; one pelvic cellulitis; two aggravated back pain). Conclusion: Unlike plication repair, VSCP was equally efficacious for both bulge control and resolution of disordered defecation symptoms. Operative technique is facile, easily learned, minimally invasive, and carries no risk of ureteral obstruction. VSCP automatically resuspends the uterus or vault, and also maintains the pelvic organs in the correct vaginal axis. Perhaps most importantly, VSCP provides the mechanotransduction signals necessary for constructive remodeling of a second generation xenograft, thus permitting a permanent prolapse repair with zero risk of mesh morbidity.