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Abdominal Sacrocolpopexy: How Low Should the Mesh Go?

Friday 06 May 2016 {{NI.ViewCount}} Views {{NI.ViewCount}} Views

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Abdominal sacrocolpopexy is considered the gold standard surgical repair for vaginal vault prolapse. In the 1970s and 1980s, several transvaginal apical procedures were developed to offer patients less invasive procedures. However, the sacrocolpopexy remains as the most successful and durable surgery for apical prolapse. This is supported by level 1A evidence. In terns of rectal prolapse, the “rectal sister” of sacrocolpopexy: ventral rectopexy or promontofixation is the gold standard procedure of choice.

In the early 1990s, the development of surgical laparoscopy allowed for a minimally invasive approach to sacrocolpopexy. The main obstacles of laparoscopic sacrocolpopexy are it’s technical difficulty and long learning curve. Despite the technical difficulty, Arnaud Wattiez’ group in France, based on the concepts disseminated on the preceding years by Jon DeLancey and Peter Petros, advocated the importance of an extended dissection and a global approach to all vaginal compartments.[1]

From 2008 on, the FDA warning statements on the risks of vaginal mesh led to a resurgence in the application of sacrocolpopexy. Adding to this was the introduction and dissemination of robotically-assisted laparoscopic surgery. However, there is no uniformity in techniques. One area of variability is the extension of dissection distally along the anterior and posterior vaginal walls. A tendency toward less dissection in order to promote an easier, safer, faster and more reproducible procedure has been advocated by many groups. Yet ventral rectopexy, which is nothing more than an extension of the posterior vaginal wall dissection on a sacrocolpopexy (as advocated by Wattiez since the early 2000s), is being promoted by many colorectal surgeons as the gold-standard for rectal prolapse and Obstructed Defecation Syndrome[3]. However, this is not based in high level evidence.[4]

A new study by Wong et all, Laparoscopic sacrocolpopexy: how low does the mesh go? demonstrates via 4-D ultrasound that the closer down to the bladder neck the mesh is attached, the better the anatomical and functional results.[2] The data presented in this novel study raise the following questions. Would faster and easier procedures really be safer? If yes, would the functional and anatomical results of extended dissection be important enough to compensate for increased morbidity?

Article by the Publications and Communications Committee

Additional Information:

Gabriel B, Nassif J, Barata S, Wattiez A. Twenty years of laparoscopic sacrocolpopexy: where are we now? Int Urogynecol J. 2011 Sep;22(9):1165-9. doi:10.1007/s00192-011-1361-z.

Wong V, Guzman-Rojas R, Shek KL, Chou D, Moore KH, Dietz HP. Laparoscopic sacrocolpopexy: how low does the mesh go? Ultrasound Obstet Gynecol. 2016 Feb 15. doi: 10.1002/uog.15882.

Reche F, Faucheron JL. Laparoscopic ventral rectopexy is the gold standard treatment for rectal prolapse. Tech Coloproctol. 2015 Oct;19(10):565-6. doi:10.1007/s10151-015-1358-6.

Lundby L, Laurberg S. Laparoscopic ventral mesh rectopexy for obstructed defaecation syndrome: time for a critical appraisal. Colorectal Dis. 2015 Feb;17(2):102-3. doi: 10.1111/codi.12830.

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