Sacrocolpopexy

Overview  

Sacrocolpopexy is a surgical procedure used to treat pelvic organ prolapse, a condition where one or more pelvic organs, such as the bladder, uterus, or rectum, descend into the vagina. This occurs when the muscles and tissues that usually support these organs become weakened or damaged, often leading to discomfort and complications.  

During a sacrocolpopexy, the surgeon restores the affected organs to their normal position by lifting them back into place and securing them with surgical mesh. This mesh provides additional support, helping to relieve common symptoms of prolapse, such as a feeling of bulging, pelvic pressure, or urinary incontinence, which is the unintentional leakage of urine. 

Most sacrocolpopexy procedures are performed laparoscopically, using small incisions and a camera to guide the surgeon’s movements. Some surgeons also utilize robotic assistance to perform the surgery, which can offer increased precision and control during the procedure. Both methods aim to improve recovery times and reduce the invasiveness of the operation. 

Reasons for undergoing the procedure  

Sacrocolpopexy is a surgical procedure used to treat pelvic organ prolapse, which affects the area between your left and right hip bones, your pubic bone, and your tailbone. The pelvic organs include the vagina, uterus, cervix, bladder, urethra (the tube that carries urine out of your body), intestines, and rectum.  

These organs are supported by a group of muscles known as the pelvic floor, as well as ligaments that connect the vagina to the backbone. The pelvic floor functions like a hammock, holding the organs in place. When these supporting muscles and ligaments become stretched, weakened, or torn, the pelvic organs can slip out of their normal position or sag. This condition is called pelvic organ prolapse, and sacrocolpopexy helps address cases where organs are slipping into the vagina. 

Types of pelvic organ prolapse 

• Uterine prolapse: The uterus and cervix slide down the vaginal canal, sometimes extending beyond the vaginal opening. 
• Vaginal prolapse (vaginal vault prolapse): This occurs when the top of the vagina (vaginal vault) descends into the vaginal canal, often affecting individuals who have had a hysterectomy (removal of the uterus). 
• Cystocele: The bladder bulges into the vaginal wall. 
• Rectocele: The rectum protrudes into the vagina. 
• Enterocele: The small intestine pushes against the vaginal wall. 

Sacrocolpopexy helps restore the pelvic organs to their normal positions and alleviates the symptoms of prolapse. 

Risk 

As with any surgical procedure, sacrocolpopexy carries certain risks. It’s important to discuss these with your healthcare provider to fully understand the potential risks. Risks associated with sacrocolpopexy include:  

• Potential harm to the intestines, bladder, rectum, or other nearby organs.  
• Risk of severe bleeding from damaged veins or arteries.  
• Formation of clots that could lead to further complications.  
• Blood clots.   
• Infection.  
• Difficulty with regular bowel movements or urination.  
• Ongoing discomfort or failure to relieve prolapse symptoms.  
• Issues with the surgical mesh, such as erosion where the mesh wears through vaginal tissue.  
• Pain during intercourse or in the pelvic area.  
• Possibility of requiring further surgical intervention or an unsuccessful outcome.

Additionally, side effects from anesthesia may include nausea, vomiting, tiredness, and confusion, typically resolving within the first 24 hours post-surgery. Gas pain and abdominal swelling from the gas used to inflate the abdomen during the procedure are also common.  

Procedure  

During a sacrocolpopexy, the surgeon uses a specialized surgical mesh to create a supportive structure between the upper vagina and the sacrum (tailbone), functioning as a synthetic ligament. The procedure begins with the surgeon carefully separating the bladder and rectum from the vagina to create space for the mesh. The mesh is then positioned along the front and back walls of the vagina and anchored to a ligament on the sacrum, which sits above the vagina, effectively lifting and supporting the pelvic organs.

In some cases, the surgeon may also perform a hysterectomy, which involves the removal of the uterus and possibly the fallopian tubes and ovaries. This additional step can help reduce the risk of uterine cancer and lower the chances of developing ovarian or fallopian tube cancer. The decision to remove these organs is based on factors such as your medical history, cancer risk, and personal preferences.  

Before the procedure  

Prior to your scheduled surgery, the healthcare providers will ask you to arrive a few hours before. If you haven’t received pre-operative instructions, contact your healthcare provider. These instructions typically detail when to stop eating and drinking the night before, any medications to avoid, and other important guidelines.

Common pre-operative instructions include:  

• Avoid eating or drinking after midnight on the night before your surgery.  
• Refrain from smoking or using tobacco products after midnight.  
• Certain medications may be taken with a small amount of water.  
• Clear liquids, such as water or black coffee or tea (without sugar or milk), are generally allowed up to two to three hours before the surgery.  

During the procedure  

Sacrocolpopexy is often performed laparoscopically, which involves making several small incisions in your abdomen. Here’s how the procedure typically unfolds:  

• You will be under general anesthesia to ensure you do not experience any pain during the surgery.  
• The surgeon makes four to five small incisions in your abdomen.  
• Your abdomen is then inflated with carbon dioxide gas to create a space for the surgery.  
• A laparoscope, a thin tube with a camera, along with other surgical instruments, is inserted through these incisions.  
• The surgeon attaches a piece of surgical mesh to both the top and bottom walls of your vagina and secures it to the sacrum. This procedure helps lift the top of your vagina or cervix back into its proper position.  
• If additional support is needed for the bladder or rectum, the surgeon may perform repairs on these areas as well.  
• For those with urinary incontinence, a small piece of mesh may be placed beneath the urethra to provide extra support when you cough, laugh, or sneeze.  
• At the end of the surgery, the surgeon uses a small camera to inspect the bladder and ensure it hasn’t been damaged.  
• All instruments are then removed, and the incisions are closed.

In robotic-assisted sacrocolpopexy, similar steps are followed, but the surgeon uses robotic controllers to maneuver the instruments through small incisions.

After the surgery, your healthcare team will conduct a voiding trial. Before the procedure, a catheter was placed in your bladder to drain urine. During the voiding trial, your bladder will be filled with saline, and the catheter will be removed. If you can void two-thirds of the saline on your own, you can go home without the catheter and resume normal urination.

If you are unable to empty your bladder independently, you may need to use a catheter at home for a few days. You will be provided with instructions for catheter care and will have a follow-up appointment to perform another voiding trial.

The surgery generally lasts between two to four hours. Once completed, you will be moved to a recovery area to wake up from the anesthesia. You will remain there until the effects of the anesthesia wear off. Depending on the outcome of the surgery, you might need to stay overnight for observation if there are any concerns.  

After the procedure  

After your surgery, your surgeon will close the incisions using glue or tape. It’s important to keep these areas clean and dry. Any internal stitches will dissolve on their own. Frequent handwashing is essential, particularly before touching the incisions or changing bandages. Your healthcare provider will give specific instructions on how to care for your incisions.

Recovery typically takes about six to eight weeks for most people. You will receive post-operative instructions on activity modifications, self-care, and medication. A follow-up appointment will be scheduled within two weeks to ensure the procedure was successful and that you are healing properly.

While sacrocolpopexy is generally safe, all surgeries carry risks. Historically, complications have arisen with the use of mesh for pelvic organ prolapse repairs performed vaginally. Consequently, mesh is now typically used only through abdominal surgery. If you’ve had a vaginal repair using mesh and experience any unusual symptoms, contact your provider for further evaluation.  

Outcome 

Recovery from sacrocolpopexy generally takes about six to eight weeks. During this time, your healthcare provider will advise you to avoid certain activities, such as heavy lifting and sexual intercourse, for a designated period. It’s important to follow these guidelines and consult with your provider regarding any lifestyle adjustments needed during your recovery.

Sacrocolpopexy is typically performed as an outpatient procedure, meaning you can usually return home on the same day. However, in some cases, your healthcare provider may recommend an overnight stay. This decision may depend on factors such as the severity of your prolapse, any complications encountered during the surgery, or your overall health. 

The procedure has a high success rate, approximately 90%. However, the outcome can be influenced by factors such as the severity of your prolapse, the specific organs involved, and the surgical technique used.

It’s important to be aware that pelvic organ prolapses can sometimes recur. To reduce the risk of a recurrence, maintaining a healthy weight, avoiding straining during bowel movements, and steering clear of heavy lifting are crucial steps.  

If you start experiencing symptoms of prolapse after your surgery, contact your healthcare provider. In some cases, the initial surgery may not fully resolve the issue, and alternative treatments may be necessary.  

You should reach out to your healthcare provider if you experience any of the following:  

• Inability to urinate for several hours or only producing small amounts of urine at a time.  
• A fever of 100.4 degrees Fahrenheit (38 degrees Celsius) or experiencing chills.  
• Redness, swelling, or foul-smelling discharge from your incisions.  
• Persistent nausea or vomiting.  
• Heavy vaginal bleeding, such as soaking more than one pad per hour.  
• Unpleasant-smelling vaginal discharge.  
• Severe pain that is not relieved by medication.  
• Pain and swelling in your legs.  
• Foul-smelling or cloudy urine, or pain during urination.