Ultrasound Obstet Gynecol 2017; 49: 404–408

Published online 7 February 2017 in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/uog.15882

Laparoscopic sacrocolpopexy: how low does the mesh go?

V. WONG*, R. GUZMAN ROJAS*†, K. L. SHEK*‡, D. CHOU§, K. H. MOORE§ and H. P. DIETZ*
*Nepean Clinical School, University of Sydney, Penrith, NSW, Australia; †Clinica Alemana de Santiago, Santiago, Chile; ‡Liverpool
Hospital, University of Western Sydney, Penrith, NSW, Australia; §St George’s Hospital, University of New South Wales, Kogarah, NSW,
Australia

K E Y W O R D S: 4D ultrasound; imaging; laparoscopic sacrocolpopexy; mesh; pelvic floor; pelvic organ prolapse

ABSTRACT neck on Valsalva, the likelihood of cystocele recurrence

increased by 6–7%.
Objective Laparoscopic sacrocolpopexy is becoming an
increasingly popular surgical approach for repair of Conclusion At an average follow-up of 3 years, laparo-
apical vaginal prolapse. The aim of this study was scopic sacrocolpopexy was highly effective for apical
to document the postoperative anterior mesh position support; however, cystocele recurrence was common
after laparoscopic sacrocolpopexy and to investigate despite an emphasis on anterior mesh extension. Pro-
the relationship between mesh location and anterior lapse recurrence seemed to be related to mesh position
compartment support. and mobility, suggesting that the lower the mesh is from
the bladder neck, the lower the likelihood of anterior com-
Methods This was an external audit of patients who
partment prolapse recurrence. Copyright © 2016 ISUOG.
underwent laparoscopic sacrocolpopexy for apical pro-
Published by John Wiley & Sons Ltd.
lapse ≥ Stage 2 or advanced prolapse ≥ Stage 3, between
January 2005 and June 2012. All patients were
assessed with a standardized interview, clinical assess- INTRODUCTION
ment using the International Continence Society Pelvic
Organ Prolapse quantification and four-dimensional Laparoscopic sacrocolpopexy has become accepted
transperineal ultrasound to evaluate pelvic organ sup- widely as an alternative to abdominal sacrocolpopexy
port and mesh location. Mesh position was assessed for treatment of prolapse, and surgical outcomes seem
with respect to the symphysis pubis whilst dis- to be comparable1–3 . Recent evidence has shown that
tal mesh mobility was assessed using the formula laparoscopic sacrocolpopexy is associated with a shorter
√ length of hospital stay and a quicker return to normal
[(XValsalva – Xrest )2 + (YValsalva – Yrest )2 ], where X is the
horizontal distance and Y is the vertical distance between activity, with less morbidity4 . Given the recent controver-
the mesh and the inferior symphyseal margin, measured sies over using mesh in vaginal prolapse repair, there is
at rest and on Valsalva. a palpable shift in practice away from inserting mesh in
the vagina to placing it abdominally instead. Mesh placed
Results Ninety-seven women were assessed at a mean abdominally appears to give fewer incidences of mesh
follow-up of 3.01 (range, 0.13–6.87) years after laparo- erosions, dyspareunia and chronic pelvic pain5 .
scopic sacrocolpopexy, 88% (85/97) of whom considered The primary goal with sacrocolpopexy is to provide
themselves to be cured or improved, and none had apical support for women with a predominantly vault
required reoperation. On clinical examination, prolapse or uterine prolapse. During the procedure, a ‘Y-shaped’
recurrence in the apical compartment was not diagnosed polypropylene mesh is attached from the anterior
in any patient; however, 60 (62%) had recurrence in the longitudinal ligament of the sacral promontory to the
anterior compartment and 43 (44%) in the posterior anterior and posterior vaginal vault. This provides robust
compartment. On ultrasound examination, mesh was prolapse repair, with high success rates of 78–100%,
visualized in the anterior compartment in 60 patients. especially for the apical compartment. However, it is less
Both mesh position and mobility on Valsalva were sig- successful for the anterior and posterior compartments6 .
nificantly associated with recurrent cystocele on clinical Prolapse recurrence in the anterior and posterior
and on ultrasound assessment (all P < 0.01). For every compartments may be due to a more challenging
mm that the mesh was located further from the bladder caudad dissection during sacrocolpopexy, which is often

Correspondence to: Dr V. Wong, Sydney Medical School Nepean, University of Sydney, Nepean Hospital, Penrith, NSW 2750, Australia
(e-mail: [email protected])
Accepted: 9 February 2016

Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd. ORIGINAL PAPER
Laparoscopic sacrocolpopexy 405

limited by poor tissue-plane separation and bleeding. satisfaction with their surgical outcome by answering
Consequently, it is not surprising that the majority of ‘yes’, ‘no’ or ‘not sure’ to the question ‘are you satisfied
failures following sacrocolpopexy occur in repair of with the procedure?’
the anterior compartment2 . Fortuitously, mesh appears Significant prolapse recurrence on clinical examination
highly echogenic on ultrasound, which permits convenient was defined as the most distal point of either the anterior,
assessment of its location and the functional impact it has apical or posterior walls ≥ −1 cm from the hymenal
on pelvic organ support following insertion7 . Therefore, remnant (i.e. ICS POP-Q ≥ Stage 2). Prolapse recurrence
the aim of this study was to document the postoperative on ultrasound was diagnosed using previously defined
anterior mesh position after laparoscopic sacrocolpopexy cut-off values: 10 mm below the symphysis pubis for
and to investigate the relationship between mesh location significant cystocele, 15 mm below the symphysis pubis
and anterior compartment support. for significant rectocele and at the level of symphysis pubis
for significant uterine/vault prolapse10 .
Ultrasound volumes were acquired by V.W. and
METHODS
R.G.R., with the patient in the supine position after blad-
This was an external surgical audit of patients who der emptying, using techniques described previously11 .
underwent a laparoscopic sacrocolpopexy procedure by Volumes obtained at rest, on maximal Valsalva and on
an experienced endoscopic surgeon at a tertiary center, maximal pelvic floor muscle contraction (PFMC) were
over a 7-year period between January 2005 and June selected for analysis. Post-processing analysis of these
2012. Laparoscopic sacrocolpopexy was performed in all datasets was undertaken with the proprietary software
patients who had apical prolapse ≥ Stage 2 or advanced 4D View (versions 7.0 and 10.0; GE Medical Systems) by
prolapse ≥ Stage 3 in the anterior compartment. V.W., blinded against all clinical data.
The laparoscopic procedure was performed with dissec- The status of the puborectalis muscle was assessed
tion of the peritoneum overlying the vault and reflection of using tomographic ultrasound imaging, as described
the bladder off the vagina anteriorly and the rectum poste- previously12 . Validated minimal criteria for the diagnosis
riorly. Dissection was then continued pararectally, using a of puborectalis muscle/levator avulsion12 were used.
combination of blunt- and thermo-dissection towards the Briefly, a patient was rated as having a levator avulsion
anterior portion of the levator ani muscle bilaterally. The if the plane of minimal hiatal dimensions and slices 2.5
peritoneum was then incised over the sacral promontory, and 5 mm cranial to that plane all showed an abnormal
exposing the anterior longitudinal ligament of the sacrum, insertion, with a levator–urethra gap of ≥ 2.5 mm13 .
and the incision was extended along the right lateral pelvic Levator hiatal dimensions (cm2 ) were measured using
side-wall towards the vault. Once the dissection was con- rendered images14 .
sidered satisfactory, anterior and posterior polypropylene Mesh was identified on ultrasound as a highly echogenic
meshes (Gynecare Gynemesh™, Ethicon US, LLC, Cincin- structure in all three orthogonal planes (mid-sagittal,
nati, OH, USA) were introduced into the abdomen. The coronal and axial; Figure 1), at rest and on maximum
anterior mesh was secured onto the anterior vaginal wall Valsalva. Lowest mesh position was identified in the
using six 2.0 dissolvable polydioxanone sutures and poste- mid-sagittal plane on maximum Valsalva, with the most
riorly the mesh was placed onto the levator muscle using caudal aspect of the mesh plotted against a reference line
two 5-mm tackers (ProTack™, Tyco Healthcare, Nor- drawn from the inferoposterior margin of the symphysis
walk, CT, USA) bilaterally. The meshes were then sutured pubis (Figure 2). Unfortunately, due to poor visualization
together, away from the vault. At the sacral promontory, of the cranial end of the mesh on Valsalva, recording of
the mesh was triple-folded and anchored without ten- cranial mesh co-ordinate measurements was not possible.
sion onto the sacral promontory using the ProTack and Distal mesh mobility was assessed using the formula
√
reperitonealized. If deemed necessary, upon completion [(XValsalva – Xrest )2 + (Y Valsalva – Y rest )2 ], from rest to
of the sacrocolpopexy, a concomitant paravaginal repair, maximum Valsalva, where X is the horizontal distance
a modified Tanagho technique8 for colposuspension, or between mesh and inferior symphyseal margin and Y
anterior/posterior colporrhaphy was performed. is the vertical distance between the mesh and inferior
All patients were invited to return for an audit symphyseal margin. Where mesh was not visible along
assessment by an independent clinician who had not been the anterior vaginal wall, the location of the vaginal apex
involved in the index surgery or immediate postoperative was used to measure co-ordinates. The distance of the
care. All patients underwent a standardized interview, a mesh from its lowest position to the bladder neck was
clinical assessment by International Continence Society also determined at rest and on maximum Valsalva.
(ICS) Pelvic Organ Prolapse quantification (POP-Q)9 and Statistical analysis was performed with SAS v.9.2
a four-dimensional (4D) transperineal ultrasound, using (SAS Institute, Cary, NC, USA) and SPSS Statistics v.20
either a GE Voluson 730 Expert system or a Voluson S6 (IBM Corp., Armonk, NY, USA). A two-sample t-test
(RAB 8–4 transducer) system (GE Medical Systems, was performed for continuous variables and chi-square
Zipf, Austria). Patients were evaluated subjectively (i.e. analysis for categorical variables. P < 0.05 was considered
symptoms of vaginal bulge or lump) and objectively to be statistically significant. This study was approved
(clinical examination and ultrasound assessment) for by the University of Sydney, Human Research Ethics
prolapse recurrence. Patients were also evaluated for Committee (protocol 15216).

Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd. Ultrasound Obstet Gynecol 2017; 49: 404–408.
406 Wong et al.

Figure 1 Mesh location (arrows) on four-dimensional transperineal ultrasound in mid-sagittal (a), coronal (b) and axial (c) planes on
maximum Valsalva.

Figure 2 Measurement of mesh mobility by four-dimensional transperineal ultrasound at rest (a) and on Valsalva (b), using the formula:
√
[(XValsalva – Xrest )2 + (Y Valsalva – Y rest )2 ], where X is horizontal distance and Y is vertical distance of mesh from symphysis pubis.

RESULTS and perineorraphies. There were no conversions to an

abdominal sacrocolpopexy, nor were there any rectal or
Between January 2005 and June 2012, 231 patients bladder injuries.
underwent laparoscopic prolapse surgery. Of all patients Eighty-three patients were satisfied with their procedure
who were invited to return for an audit assessment, 114 and 85 (88%) considered themselves cured or improved
(49%) were seen at a mean follow-up of 3.01 (range, overall. Recurrent prolapse symptoms were reported in
0.13–6.87) years. Three patients were excluded as they 30 (32%) women. Clinical prolapse recurrence (ICS
had undergone laparoscopic sacrohysteropexy. Fourteen POP-Q ≥ Stage 2) was diagnosed in 80 patients, including
ultrasound volumes were excluded due to a technical error 60 cases affecting the anterior compartment and 43
with volume acquisition, leaving 97 available for analysis. affecting the posterior compartment; however, recurrence
All subsequent results refer to this dataset. Mean age was in the apical compartment was not diagnosed in any
61 (range, 40–77) years, mean body mass index was 26.9 patient. Nine patients had de-novo development of
(range, 18.6–39.5) kg/m2 and mean parity was 3 (range, anterior compartment prolapse and 17 of posterior
0–8). compartment prolapse. No patient had undergone a
Twenty-six patients had previous vaginal hysterec- reoperation for prolapse in the follow-up interval. The
tomy with or without pelvic organ prolapse repair, and tacks in the levator muscle were palpable in 20 patients, 16
five had a previous anti-incontinence procedure, pre- (17%) of whom complained of tenderness upon palpation
dominantly colposuspensions. Preoperatively, all patients and 12 (12%) had symptomatic dyspareunia.
who underwent surgery had prolapse ≥ Stage 2: 64 had Ultrasound volume analysis was performed approx-
anterior compartment prolapse ≥ Stage 3, 84 had api- imately 6 months after data acquisition. Eighty-one
cal compartment prolapse ≥ Stage 2 and 32 had posterior patients had sonographic prolapse recurrence: 52 in the
compartment prolapse ≥ Stage 3. Concurrent procedures anterior compartment, 64 in the posterior compartment
performed were 67 total laparoscopic hysterectomies, one and 11 in the apical compartment. Mean ± SD bladder
subtotal hysterectomy, 49 paravaginal repairs, 23 laparo- neck descent was 24.0 ± 4.2 mm, mean cystocele descent
scopic colposuspensions and 34 posterior colporrhaphies was 10.6 (range, 18.7 to −52.3) mm below the symphysis

Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd. Ultrasound Obstet Gynecol 2017; 49: 404–408.
Laparoscopic sacrocolpopexy 407

Table 1 Association between recurrent prolapse symptoms and recurrent cystocele on clinical and ultrasound assessment 3 years after
laparoscopic sacrocolpopexy in 97 women

Recurrent Recurrent cystocele Recurrent cystocele on

prolapse symptoms on clinical assessment ultrasound assessment
Mesh parameter OR (95% CI) P OR (95% CI) P OR (95% CI) P

Lowest mesh position 0.99 (0.97–1.02) NS 0.94 (0.91–0.97) 0.001 0.93 (0.90–0.96) 0.001
Mesh mobility 1.00 (0.96–1.03) NS 1.05 (1.01–1.09) 0.013 1.05 (1.01–1.09) 0.012

Odds ratios (OR) are per mm of mesh position or mobility. NS, not significant.

pubis, mean apical descent was 24.2 (range, −23.2 to lowermost point of the mesh was located 26 ± 13 mm
56.1) mm above the symphysis pubis and mean rectocele from the bladder neck at rest and 48 ± 25 mm from the
descent was 12.3 (range, −45.9 to 22.0) mm below the bladder neck on Valsalva.
symphysis pubis, with a negative value representing a posi- On univariate analysis, the lowest mesh position on
tion below the level of the symphysis pubis. Six patients Valsalva and mesh mobility on Valsalva were both
had sonographic findings of an enterocele, with mean significantly associated with recurrent cystocele on clinical
measurements of 13.2 (range, −27.1 to 9) mm below the as well as on ultrasound assessment (Table 1). Odds ratios
symphysis pubis. were significant when correlating the risks of clinical
In patients who had concomitant paravaginal repairs, and sonographic prolapse recurrence in the anterior
49 had significant preoperative cystocele on clinical compartment with the most distal position of the mesh
examination with 45 being ≥ Stage 3, and 24 had a as well as with mesh mobility. That is, for every mm
significant rectocele with 15 being ≥ Stage 3. At follow-up, the mesh was located further from the bladder neck on
35 patients had recurrence in the anterior compartment Valsalva, the likelihood of cystocele recurrence increased
with three patients having cystocele recurrence ≥ Stage 3, by 6–7%.
and 24 had recurrence in the posterior compartment
with four cases of de-novo prolapse. Although univariate
DISCUSSION
analysis of the effect of paravaginal repairs was significant
for clinical prolapse recurrence (P = 0.05), this was no At an average of 3 years after laparoscopic sacro-
longer significant on multivariate analysis (P = 0.276). colpopexy, we have demonstrated an unexpectedly high
Levator avulsion was diagnosed in 39 (40%) patients prevalence of recurrent prolapse in the anterior and
on tomographic ultrasound imaging; 18 were unilateral posterior compartments. Sacrocolpopexy mesh can be
and 21 were bilateral. The mean levator hiatal area on visualized with ultrasound and appears highly echogenic
Valsalva was 32.41 cm2 . in all three orthogonal views. In this study, we were able
In 37 patients, the mesh was not visible on ultrasound. to visualize the mesh in 62% of patients and it was evident
This was likely because the mesh was located too cranial that the more distal the mesh was placed in the anterior
for visualization. Analysis of these patients showed that compartment, that is the closer the mesh was placed to the
30% (11/37) were symptomatic of prolapse and 84% bladder neck, the less likely it was for prolapse to recur
(31/37) had significant prolapse on POP-Q assessment: in the anterior compartment. Our data suggested that for
21 in the anterior compartment, 17 in the posterior every mm that the mesh is placed closer to the bladder
compartment and none in the apical compartment. neck, the risk of prolapse recurrence in the anterior com-
On ultrasound, 76% (28/37) of these patients had partment on clinical examination was reduced by 6% and
significant prolapse, 21 in the anterior compartment, on ultrasound by 7%.
16 in the posterior compartment and three in the The use of transperineal ultrasound has made it much
apical compartment. Of those patients in whom mesh easier to assess mesh material in the pelvis as it often
could be visualized on ultrasound, 33% (20/60) were appears highly echogenic. To date, there is only one
symptomatic of prolapse at follow-up and 88% (53/60) other study that has assessed abdominally placed mesh15 ,
had recurrent prolapse on POP-Q assessment: 39 in the and this methodology to assess sacrocolpopexy mesh has
anterior compartment, 30 in the posterior compartment been shown to be feasible. This is particularly relevant
and none in the apical compartment. On ultrasound, 75% given the ease of access to ultrasound machines in
(45/60) of these women had recurrent prolapse, with 29 most institutions and with the increasing re-uptake of
in the anterior, 33 in the posterior and seven in the apical abdominally placed mesh. This appears advantageous
compartment. especially when monitoring outcomes of patients who
In women in whom mesh was identified in the have undergone such a procedure.
anterior compartment, the mesh was located, on average, It is interesting to note that, in this study, despite
24 ± 11 mm dorsoventral and 38 ± 11 mm craniocaudal a well-supported apical compartment, on both clinical
from the symphysis pubis at rest. The respective figures on and sonographic assessment, this excellent apical support
Valsalva were 35 ± 12 mm and 24 ± 17 mm. On average, seemed to have little effect on the support of the
the mesh descended 20 ± 11 mm on Valsalva. The mean anterior and posterior compartments. These findings

Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd. Ultrasound Obstet Gynecol 2017; 49: 404–408.
408 Wong et al.

are not unprecedented, with up to 57% of patients of the mesh in the posterior compartment and the effects
diagnosed with recurrent rectocele following laparoscopic of different mesh anchorage techniques.
sacrocolpopexy in a study by Baesseler et al.16 . Therefore, In conclusion, using 4D ultrasound for evaluation of
although apical suspension is thought to be an important mesh mobility and location following laparoscopic sacro-
factor in success of anterior compartment surgery17 , this colpopexy has given us a perspective on where placement
study suggests that addressing and providing support to of mesh may result in failure. We found a correlation
the mid-vaginal level is just as important in maintaining between mesh location and prolapse recurrence, particu-
a successful anatomical outcome following prolapse larly for the anterior compartment. Despite a higher rate
repair. Hence we feel that one should aim to place of prolapse recurrence in the anterior and posterior com-
the mesh as caudal along the anterior and posterior partments, we found excellent apical suspension outcomes
vagina as possible, in the hope of reducing recurrence with neither clinical apical recurrence nor requirement
at mid-vaginal level. One potential consideration may for reoperation in 97 patients over an average of 3 years.
be to infiltrate with local anesthetic and adrenaline the
vesico/rectovaginal space prior to commencement of the
laparoscopic vault dissection for sacrocolpopexy. This DISCLOSURE
might reduce intraoperative bleeding when dissecting the
bladder off the vaginal vault, thus facilitating more caudal H.P.D. and K.L.S. have received unrestricted educational
dissections. grants from GE.
We acknowledge several limitations of this study.
First, this was a retrospective study and we were able
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Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd. Ultrasound Obstet Gynecol 2017; 49: 404–408.