PERITONEOCOLPOPEXY TECHNIQUE
implantation. In addition, although used in only 2 cases in this series, we performed this procedure after removal of infected mesh to secure the vaginal vault in place and prevent secondary prolapse. In these 2 cases after complete removal of infected mesh the sacral promontory was deemed too hostile for safe anchoring of the proximal mesh without risking inoculation of microorganisms and ensuing discitis or osteomyelitis. Although their series is small and the followup relatively short, Culligan et al reported on the natural history of SCP procedures performed with synthetic mesh in a retrospective series of 245 patients and noted an anatomical failure rate of 15% with 94.6% of objective failures occurring within the first 24 months after surgery.10 They concluded that future prospective studies involving sacrocolpopexy may be designed with only 1 or 2 years of followup without significantly compromising outcome validity. Our current experience is encouraging as we continue to use this procedure selectively to minimize
2093
the known devastating complications related to promontory fixation. We are cognizant of the longer term followup data from the CARE (Colpopexy And urinary Reduction Efforts) trial study by Nygaard et al, which showed increased failure rates of sacrocolpopexy in both treatment groups.11 Longer term data and larger case volumes will be required to demonstrate the durability of this technique. Sexual function was not specifically investigated in this series which focused primarily on anatomical restoration.
CONCLUSIONS Peritoneocolpopexy performed reliably to correct symptomatic apical prolapse. The use of strong unidirectional and delayed absorbable sutures to secure the mesh to the peritoneum and surrounding fat around the vaginal apex resulted in satisfactory anatomical outcomes with good permanent integration of the mesh at short-term followup. Further studies and longer outcomes are required for evaluation of repair durability.
REFERENCES 1. Parikh PM, Davison SP and Higgins JP: Barbed suture tenorrhaphy: an ex vivo biomechanical analysis. Plast Reconstr Surg 2009; 124: 1551.
5. Sutton GP, Addison WA, Livengood CH 3rd et al: Life-threatening hemorrhage complicating sacral colpopexy. Am J Obstet Gynecol 1981; 140: 836.
2. H€ogstr€om H, Haglund U and Zederfeldt B: Tension leads to increased neutrophil accumulation and decreased laparotomy wound strength. Surgery 1990; 107: 215.
6. Grimes CL, Tan-Kim J, Garfin SR et al: Sacral colpopexy followed by refractory Candida albicans osteomyelitis and discitis requiring extensive spinal surgery. Obstet Gynecol 2012; 120: 464.
3. Brown S: Utilization of a porcine model to demonstrate the efficacy of an absorbable barbed suture for dermal closure. UTSW 2010.
7. Muffly TM, Diwadkar GB and Paraiso MF: Lumbosacral osteomyelitis after robot-assisted total laparoscopic hysterectomy and sacral colpopexy. Int Urogynecol J 2010; 21: 1569.
4. Gilleran JP and Zimmern P: Abdominal mesh sacrocolpopexy for recurrent triple-compartment pelvic organ prolapse. BJU Int 2009; 103: 1090.
8. Good MM, Abele TA, Balgobin S et al: Vascular and ureteral anatomy relative to the midsacral
promontory. Am J Obstet Gynecol 2013; 208: 486. 9. Abernethy M, Vasquez E, Kenton K et al: Where do we place the sacrocolpopexy stitch? A magnetic resonance imaging investigation. Female Pelvic Med Reconstr Surg 2013; 19: 31. 10. Culligan PJ, Murphy M, Blackwell L et al: Long-term success of abdominal sacral colpopexy using synthetic mesh. Am J Obstet Gynecol 2002; 187: 1473. 11. Nygaard I, Brubaker L, Zyczynski HM et al: Long-term outcomes following abdominal sacrocolpopexy for pelvic organ prolapse. JAMA 2013; 309: 2016.
EDITORIAL COMMENTS Surgical repair of pelvic organ prolapse is one of the oldest surgical repairs documented in the history of surgery. Accordingly, the literature is loaded with descriptions of procedures in which the authors and reviewers of studies have defended their innovation with various technical, clinical and recently patient defined outcomes advantages. Lee and Zimmern describe the short-term results of a technical innovation in the abdominal repair of POP in which the anchoring mesh is fixed to loose connective tissues around the perirectal space.
Although the series is small and followup is short, there are a number of important factors that deserve attention. The newly Accreditation Council for Graduate Medical Education recognized subspecialty of Female Pelvic Medicine and Reconstructive Surgery has energized a cadre of young urologists and gynecologists to address numerous unanswered scientific and technical challenges of this field. In addition, during the last few years the issue of managing the altered anatomy of the female pelvis that has had previous surgery, including the
2094
PERITONEOCOLPOPEXY TECHNIQUE
use of mesh, has presented itself as a challenge to many female pelvic surgeons, demanding new innovations in how to handle the altered anatomy. It is in this environment that this seemingly simple and relevant procedure carries importance. This technique, in which the prolapsed cuff of the vagina is loosely fixated to loose tissue, challenges the old thinking that the cuff of the vagina has to be anchored to a hard point of fixation such as the sacrum promontory. For many years female pelvic surgeons have used the perirectal fascia and tissue
for plication through a vaginal route or other methods to assist in the repair of POP. It seems that this new technique could be added to our surgical armamentarium to be used in particular cases in which access to well established and time-tested anatomical sites may not be available.
The authors are to be congratulated on the description of a technical alternative to sacrocolpopexy for proximal mesh anchorage at apical prolapse repair. With this technique mesh is not fixated to the sacral promontory, thereby eliminating potential complications such as bleeding and osteomyelitis. The authors note this complication is rare, as is the inability to safely identify these anatomical locations. Therefore, it is not clear how often and why one would choose to perform peritoneocolpopexy. The durability of this procedure is unclear, with an average followup of 19.6 months. With longer followup the gold standard, sacrocolpopexy, shows
greater failure rates (although the majority of patients did not require repeat surgery) (reference 11 in article). Similar findings are seen with autologous fascial sling and urethropexy with greater followup.1 So, are long-term “failures” that are not bothersome and do not require further intervention truly failures, and what is the optimal definition of long-term “success” for a surgical procedure?
Firouz Daneshgari Department of Urology Case Western Reserve University Cleveland, Ohio
David A. Ginsberg USC Institute of Urology Keck School of Medicine of USC Los Angeles, California
REFERENCE 1. Brubaker L, Richter HE, Norton PA et al: 5-Year continence rates, satisfaction and adverse events of Burch urethropexy and fascial sling surgery for urinary incontinence. J Urol 2012; 187: 1324.
REPLY BY AUTHORS Although rare, the complications of mesh sacrocolpopexy can be disastrous. The impetus to consider developing an alternative approach to the standard mesh sacrocolpopexy came from hearing a case report by Dr. C. Nager on osteomyelitis and discitis requiring major corrective spinal surgery (reference 6 in article). Recent anatomical and magnetic resonance imaging studies of the promontory area have since highlighted the risks of operating in its vicinity (reference 11 in article).1
Our approach allows us to stay clear of the promontory yet provide good securement of the vaginal apex. Apical support is still dependent on mesh incorporation into surrounding tissues and strong fibrosis formation. This technical variant would have been unthinkable without the lasting and strong V-Loc 180 sutures which fix the apex in place while this fibrotic process unfolds. However, we agree that time will tell if this repair holds durably. So far it has done so sufficiently well to justify sharing this limited experience with others.
REFERENCE 1. Brubaker L, Richter HE, Norton PA et al: 5-Year continence rates, satisfaction and adverse events of Burch urethropexy and fascial sling surgery for urinary incontinence. J Urol 2012; 187: 1324.
implantation. In addition, although used in only 2 cases in this series, we performed this procedure after removal of infected mesh to secure the vaginal vault in place and prevent secondary prolapse. In these 2 cases after complete removal of infected mesh the sacral promontory was deemed too hostile for safe anchoring of the proximal mesh without risking inoculation of microorganisms and ensuing discitis or osteomyelitis. Although their series is small and the followup relatively short, Culligan et al reported on the natural history of SCP procedures performed with synthetic mesh in a retrospective series of 245 patients and noted an anatomical failure rate of 15% with 94.6% of objective failures occurring within the first 24 months after surgery.10 They concluded that future prospective studies involving sacrocolpopexy may be designed with only 1 or 2 years of followup without significantly compromising outcome validity. Our current experience is encouraging as we continue to use this procedure selectively to minimize
2093
the known devastating complications related to promontory fixation. We are cognizant of the longer term followup data from the CARE (Colpopexy And urinary Reduction Efforts) trial study by Nygaard et al, which showed increased failure rates of sacrocolpopexy in both treatment groups.11 Longer term data and larger case volumes will be required to demonstrate the durability of this technique. Sexual function was not specifically investigated in this series which focused primarily on anatomical restoration.
CONCLUSIONS Peritoneocolpopexy performed reliably to correct symptomatic apical prolapse. The use of strong unidirectional and delayed absorbable sutures to secure the mesh to the peritoneum and surrounding fat around the vaginal apex resulted in satisfactory anatomical outcomes with good permanent integration of the mesh at short-term followup. Further studies and longer outcomes are required for evaluation of repair durability.
REFERENCES 1. Parikh PM, Davison SP and Higgins JP: Barbed suture tenorrhaphy: an ex vivo biomechanical analysis. Plast Reconstr Surg 2009; 124: 1551.
5. Sutton GP, Addison WA, Livengood CH 3rd et al: Life-threatening hemorrhage complicating sacral colpopexy. Am J Obstet Gynecol 1981; 140: 836.
2. H€ogstr€om H, Haglund U and Zederfeldt B: Tension leads to increased neutrophil accumulation and decreased laparotomy wound strength. Surgery 1990; 107: 215.
6. Grimes CL, Tan-Kim J, Garfin SR et al: Sacral colpopexy followed by refractory Candida albicans osteomyelitis and discitis requiring extensive spinal surgery. Obstet Gynecol 2012; 120: 464.
3. Brown S: Utilization of a porcine model to demonstrate the efficacy of an absorbable barbed suture for dermal closure. UTSW 2010.
7. Muffly TM, Diwadkar GB and Paraiso MF: Lumbosacral osteomyelitis after robot-assisted total laparoscopic hysterectomy and sacral colpopexy. Int Urogynecol J 2010; 21: 1569.
4. Gilleran JP and Zimmern P: Abdominal mesh sacrocolpopexy for recurrent triple-compartment pelvic organ prolapse. BJU Int 2009; 103: 1090.
8. Good MM, Abele TA, Balgobin S et al: Vascular and ureteral anatomy relative to the midsacral
promontory. Am J Obstet Gynecol 2013; 208: 486. 9. Abernethy M, Vasquez E, Kenton K et al: Where do we place the sacrocolpopexy stitch? A magnetic resonance imaging investigation. Female Pelvic Med Reconstr Surg 2013; 19: 31. 10. Culligan PJ, Murphy M, Blackwell L et al: Long-term success of abdominal sacral colpopexy using synthetic mesh. Am J Obstet Gynecol 2002; 187: 1473. 11. Nygaard I, Brubaker L, Zyczynski HM et al: Long-term outcomes following abdominal sacrocolpopexy for pelvic organ prolapse. JAMA 2013; 309: 2016.
EDITORIAL COMMENTS Surgical repair of pelvic organ prolapse is one of the oldest surgical repairs documented in the history of surgery. Accordingly, the literature is loaded with descriptions of procedures in which the authors and reviewers of studies have defended their innovation with various technical, clinical and recently patient defined outcomes advantages. Lee and Zimmern describe the short-term results of a technical innovation in the abdominal repair of POP in which the anchoring mesh is fixed to loose connective tissues around the perirectal space.
Although the series is small and followup is short, there are a number of important factors that deserve attention. The newly Accreditation Council for Graduate Medical Education recognized subspecialty of Female Pelvic Medicine and Reconstructive Surgery has energized a cadre of young urologists and gynecologists to address numerous unanswered scientific and technical challenges of this field. In addition, during the last few years the issue of managing the altered anatomy of the female pelvis that has had previous surgery, including the
2094
PERITONEOCOLPOPEXY TECHNIQUE
use of mesh, has presented itself as a challenge to many female pelvic surgeons, demanding new innovations in how to handle the altered anatomy. It is in this environment that this seemingly simple and relevant procedure carries importance. This technique, in which the prolapsed cuff of the vagina is loosely fixated to loose tissue, challenges the old thinking that the cuff of the vagina has to be anchored to a hard point of fixation such as the sacrum promontory. For many years female pelvic surgeons have used the perirectal fascia and tissue
for plication through a vaginal route or other methods to assist in the repair of POP. It seems that this new technique could be added to our surgical armamentarium to be used in particular cases in which access to well established and time-tested anatomical sites may not be available.
The authors are to be congratulated on the description of a technical alternative to sacrocolpopexy for proximal mesh anchorage at apical prolapse repair. With this technique mesh is not fixated to the sacral promontory, thereby eliminating potential complications such as bleeding and osteomyelitis. The authors note this complication is rare, as is the inability to safely identify these anatomical locations. Therefore, it is not clear how often and why one would choose to perform peritoneocolpopexy. The durability of this procedure is unclear, with an average followup of 19.6 months. With longer followup the gold standard, sacrocolpopexy, shows
greater failure rates (although the majority of patients did not require repeat surgery) (reference 11 in article). Similar findings are seen with autologous fascial sling and urethropexy with greater followup.1 So, are long-term “failures” that are not bothersome and do not require further intervention truly failures, and what is the optimal definition of long-term “success” for a surgical procedure?
Firouz Daneshgari Department of Urology Case Western Reserve University Cleveland, Ohio
David A. Ginsberg USC Institute of Urology Keck School of Medicine of USC Los Angeles, California
REFERENCE 1. Brubaker L, Richter HE, Norton PA et al: 5-Year continence rates, satisfaction and adverse events of Burch urethropexy and fascial sling surgery for urinary incontinence. J Urol 2012; 187: 1324.
REPLY BY AUTHORS Although rare, the complications of mesh sacrocolpopexy can be disastrous. The impetus to consider developing an alternative approach to the standard mesh sacrocolpopexy came from hearing a case report by Dr. C. Nager on osteomyelitis and discitis requiring major corrective spinal surgery (reference 6 in article). Recent anatomical and magnetic resonance imaging studies of the promontory area have since highlighted the risks of operating in its vicinity (reference 11 in article).1
Our approach allows us to stay clear of the promontory yet provide good securement of the vaginal apex. Apical support is still dependent on mesh incorporation into surrounding tissues and strong fibrosis formation. This technical variant would have been unthinkable without the lasting and strong V-Loc 180 sutures which fix the apex in place while this fibrotic process unfolds. However, we agree that time will tell if this repair holds durably. So far it has done so sufficiently well to justify sharing this limited experience with others.
REFERENCE 1. Brubaker L, Richter HE, Norton PA et al: 5-Year continence rates, satisfaction and adverse events of Burch urethropexy and fascial sling surgery for urinary incontinence. J Urol 2012; 187: 1324.
