Neurourology and Urodynamics
Anatomical Insights Into Sacrocolpopexy for Multicompartment Pelvic Organ Prolapse Alfredo Ercoli,1,2* Giuseppe Campagna,3 Vincent Delmas,2,4 Stefania Ferrari,1 Andrea Morciano,3 Giovanni Scambia,2 and Mauro Cervigni2 1
Policlinico Abano Terme–Urogynaecology Unit, Piazza Cristoforo Colombo, 1 , Abano Terme (PD), Italy 2 Institute of Anatomy, Descartes University URDIA EA4465, Paris, France 3 Department of Obstetrics and Gynaecology, Catholic University of the Sacred Heart, Rome, Italy 4 Department of Urology, Bichat Cloude Bernard Hospital, Paris Diderot University Medical School, Paris, France Aims: Pelvic organ prolapse occurs in 50% of parous women. Laparoscopic sacrocolpopexy (LSCP) is a common surgical procedure for restoring pelvic anatomy and function. The aim of this study is to evaluate surgical anatomy and anatomical modifications induced by standardized LSCP. Methods: Ten fresh female cadavers underwent LSCP, six subsequently underwent standard anatomical dissection, and four had sagittal anatomical dissection. Four cadavers were used as control subjects; two of them underwent standard anatomical dissection, and two had sagittal anatomical dissection. Results: Vesicovaginal space dissection resulted in an arrow-shaped space limited by the trigone and vesical branches of the uterine artery. Rectovaginal space dissection resulted in an inverted V-shaped space marked by the utero-sacral and rectovaginal ligaments, the cranial end of the perineal body and the levator ani muscle. Exposing the longitudinal vertebral ligament through a peritoneal and presacral fascia incision along the medial border of the right common iliac artery allowed the identification and the preservation of the right hypogastric nerve. The anterior mesh stretched across the proximal half of the anterior vaginal wall, and the cervix towards the sacral promontory provided excellent cervix suspension and anterior-vaginal wall support with a concomitant stretch of the pubocervical fascia. The median angle formed by the axis of the infra-levatorial vagina with the axis of the supra-levatorial vagina changed from 1428 to 1718 and determined the linearization-ventralization of the vaginal canal. Conclusions: LSCP can be performed in a nervesparing, standardized fashion, providing excellent apical suspension and anterior vaginal wall support. Neurourol. Urodynam. 9999:1–6, 2015. # 2015 Wiley Periodicals, Inc. Key words: laparoscopic sacrocolpopexy; pelvic organ prolapse; surgical anatomy INTRODUCTION
Female pelvic organ prolapse (POP) is reported to be present in 50% of parous women1 and represents one of the most frequent causes for pelvic surgery in women. Many surgical procedures for restoring normal pelvic anatomy and functions have been described to date.2 Among them, laparoscopic sacrocolpopexy (LSCP) is one of the most widely used because it combines the high efficacy of reconstructive surgery using non-absorbable mesh with the fast recovery and lowcomplication rate resulting from minimal tissue trauma and laparoscopical procedure precision.3,4 However, there is a relative paucity of studies analyzing the surgical anatomy of LSCP, and there is essentially a lack of studies investigating the anatomical modifications induced by this procedure. The aim of this study is to gain further insight into the surgical anatomy and the anatomical alterations induced by the LSCP procedure for multicompartment POP we actually perform. This procedure is characterized by a complete dissection of the avascular spaces between the anterior vaginal wall and the bladder and between the posterior vaginal walls and the rectum5,6 to provide support and suspension to a large portion of the vagina and adjacent pelvic organs. Moreover, we adopt specific protocols of surgical dissection resulting from our previous studies of radical pelvic surgery performed to spare the nerve structures that could be injured during our dissections, such as the superior hypogastric plexus and the hypogastric nerves, which run in close proximity to the sacral promontory and the rectum and the uterosacral ligaments.7,8 The specific goals of our research are (i) to define the anatomical boundaries of the vesicovaginal and rectovaginal spaces, ii) to #
2015 Wiley Periodicals, Inc.
study the surgical anatomy of the dissections performed to insert the meshes to effectively verify that our procedure is truly nerve-sparing and (iii) to analyze the consequent anatomical alterations induced by LSCP. For this study, we performed LSCP followed by macroscopic anatomical dissection on 10 fresh female cadavers, and we compared our results with those obtained from the dissection of four fresh female cadavers that had never undergone surgery that were used as control subjects. MATERIALS AND METHODS
For this study, we utilized 14 fresh female cadavers showing no previous pelvic operations. All subjects were adult Caucasian. The mean age at death was 67.4 9.8 years (range 51–87). All subjects underwent total body vascular injection by the femoral vessels, as previously described,8 and 10 of them underwent LSCP. Six of the subjects undergoing LSCP and two of the control subjects underwent macroscopic anatomical dissection using a standard abdominal approach, while four of the subjects undergoing LSCP and two of the control subjects Potential conflicts of interest: Nothing to disclose. Dr. Mickey Karram led the peer-review process as the Associate Editor responsible for the paper. Correspondence to: Alfredo Ercoli, Policlinico Abano Terme - Urogynaecology Unit, Piazza Cristoforo Colombo, 1 , Abano Terme (PD), Italy 35031. E-mail: [email protected] Received 19 October 2014; Accepted 21 May 2015 Published online in Wiley Online Library (wileyonlinelibrary.com). DOI 10.1002/nau.22806
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Ercoli et al.
were frozen at 808C and then cut longitudinally on the midline in order to perform the dissection and evaluate the LSCP-induced anatomical modifications from the latero-lateral point of view. Macroscopic anatomical dissections were carried out by removing the abdominal wall, as well as the lower abdominaland pelvic-parietal peritoneum. The retroperitoneal areolar connective tissue was then gently dissected in a cranio-caudal fashion starting from the origin of the inferior mesenteric artery where the aortic sympathetic fibers fuses in order to expose the superior hypogastric plexus and the hypogastric nerves. Furthermore, we defined the vesicovaginal and rectovaginal spaces, identified the pubo-cervical fascia/anterior vaginal wall, the tendinous arch of endopelvic fascia, the rectovaginal fascia/posterior vaginal wall and the pelvic parietal fascia covering the levator ani muscle. The visceral branches of the hypogastric vessels and the muscles forming the pelvic floor were then completely dissected. All preparation of subjects and LSCP and anatomical dissections were performed at the ‘‘Centre du Don des Corps’’ of the ParisDescartes University (Paris - France) between January 2009 and June 2012. In this study, we adopted anatomical terms conforming to the ‘‘Terminologia Anatomica’’ 9 and modifications we previously proposed8 unless otherwise specified. Surgical Technique
The LSCP began with a subtotal hysterectomy using a classic technique. Then, the sacral promontory was identified by palpation of the lumbar-sacral convexity with the midline laparoscopic instrument inserted in the middle between the pubis and umbilicus with the subject in a steep Trendelenburg position and exposed with the nerve-sparing approach we developed. The peritoneum overlying the right common iliac artery was incised along the axis of the artery itself for 3–4 cm starting from the promontory. The underlying presacral fascia containing the hypogastric nerve was identified and penetrated with scissors, and the resulting foramen was gently enlarged and dislocated medially by blunt dissection to expose the longitudinal anterior vertebral ligament for at least 15 mm in both the cranio-caudal and latero-lateral directions. An inverted L–shaped peritoneal incision extending from the sacral promontory up to the left uterosacral ligament was completed while ensuring that the presacral fascia containing the right hypogastric nerve on the lateral parietal side was left to avoid accidental nerve injuries. Then, the rectovaginal space was fully dissected, and at its caudal edge, the dissection was carried out lateral to the rectum upwards to identify the pelvic parietal fascia covering the levator ani muscle. This dissection area was covered by an adequately shaped synthetic mesh fixed with a total of five no. 3–0 non-absorbable sutures. Two sutures were placed on the fascia covering the pelvic floor, two were applied approximately 2–3 cm distal from the uterine cervix along the left and right uterosacral ligaments, and the last one was placed centrally on the dorsal area of the uterine cervix. Subsequently, the vesicouterine peritoneum was opened, and the vesicovaginal space was fully dissected. A second synthetic mesh fitted to cover the entire dissection area was inserted and fixed to the anterior vaginal wall with five no. 3–0 non-absorbable sutures. The first suture was placed centrally on the most ventral point of the dissected space, while two sutures per side were placed on the most lateral edges of the same space. The anterior mesh was then threaded up towards the promontory with the lowest amount of tension necessary to form a linear connection between the most caudal mesh fixation point over the anterior vaginal wall and the Neurourology and Urodynamics DOI 10.1002/nau
Fig. 1. Left hemipelvis, median sagittal section. Planes of vesicovaginal and rectovaginal dissection. B, bladder; V, vagina; R, rectum; U, uterus. Red line: plane of vesicovaginal space dissection; yellow line: plane of rectovaginal space dissection.
promontory, and it was fixed to the longitudinal vertebral ligament previously exposed with one no. 0 non-absorbable suture. This procedure was performed under visual and palpation control from the surgeon by checking the degree of tension of the mesh that could be deduced by the morphology of the mesh and its resistance against pressure applied by a laparoscopic instrument. RESULTS
While performing the dissection of the vesicovaginal space, we found that in 14 out of 14 (100%) cases, the most caudal point cleavable by blunt dissection without the need to cut vessels or fibrous structure in order to proceed with the dissection was the dorsal end of the bladder trigone (Fig. 1). The complete dissection of the vesicovaginal space created a triangular-shaped vesicovaginal space with the apex at the dorsal end of the bladder trigone and the lateral limits
Fig. 2. Entire pelvis, view from above. Vesicovaginal space. White triangle: vesicovaginal space, dashed line: length of space (mean Standard Deviation). VUL (red circles): superficial layer of Vesico-Uterine Ligament formed by the descending branch of the uterine artery, the superficial vesical vein and the cervicovesical vessels. RtR: Retro-trigonal Region. U, uterus. FC, Foley’s Catheter.
Anatomical Insights Into Sacrocolpopexy
Fig. 3. Right hemipelvis, median sagittal section: mesh fixation over the anterior and posterior vaginal walls. U, urethra; B, bladder; R, rectum; PB, perineal body. Blue tube: ureteral stent. Red arrow: vaginal portion not covered by mesh; blue arrow: vaginal portion covered by the mesh.
represented by the superficial layer of the vesicouterine ligament formed by (a) the descending branch of the uterine artery, (b) the superficial vesical vein (branch of the superficial uterine vein), and (c) the cervicovesical vessels (Fig. 2). In particular, we found that the avascular, easily cleavable, vesicovaginal space that we dissected measured 37 6 mm (mean SD) (range: 31–47) of the total anterior-vaginal wall length of 76 8 mm (mean SD) (range: 70–86) (Fig. 3) in the cranio-caudal direction. No nerve structures were identified during this dissection, while the branches of the bladder nerves
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from the inferior hypogastric plexus were identified in the deep portion of the vesicouterine ligament (data not shown). While performing the dissection of the rectovaginal space, we found that in 14 out of 14 (100%) cases, the most caudal point cleavable by blunt dissection without the need to cut vessels or fibrous structure in order to proceed with the dissection was the cranial end of the perineal body (Fig. 1). At this level, lateral to the posterior vaginal wall, the rectal fascia is easily cleavable from the pelvic parietal fascia covering the puborectal/pubococcygeal portion of the levator ani muscle. The complete dissection of the rectovaginal space resulted in an inverted V-shaped space with the apex at the convergence of the left and right uterosacral ligaments. The lateral limits were defined by the vessels running into the uterosacral and rectovaginal ligaments, and the base was represented by the cranial end of the perineal body in the middle, left and right puborectal/pubococcygeal portions of the levator ani muscle, which hugs the lateral vaginal walls on both sides. In particular, we found that the avascular, easily cleavable, rectovaginal area we were able to dissect measured 75 8 mm (range: 65–84) of the total posterior vaginal wall length of 94 11 mm (range: 75–109) in the craniocaudal direction (Fig. 3). During our dissections, we found that in 11 out of 14 cases (78%), the middle rectal vessels and the rectal nervous branch of the inferior hypogastric plexus ran in close proximity to the puborectal/pubococcygeal portions of the levator ani muscle, immediately below the rectal fascia (Fig. 4). The dissection of the retroperitoneal tissue at the level of the promontory showed the presence of two layers of connective tissue superposed on the longitudinal anterior vertebral ligament. In all the cases examined, the first layer consisted of the peritoneum along with its accompanying areolar tissue,
Fig. 4. Left hemipelvis, paramedian section (main picture); right hemipelvis median section (auxiliary picture). B, bladder; V, vagina; R, rectum; HA, hypogastric artery; US, uterosacral ligament; PR-LAM, pubo-rectal portion of Levator ani muscle. Blue circle: Kelly forceps in uretra; green circle: vascular forceps at the vaginal entry; yellow circle: lateral rectal ligament composed by middle rectal artery and vein and rectal nervous branches from the inferior hypogastric plexus.
Neurourology and Urodynamics DOI 10.1002/nau
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while the second layer was formed by the presacral fascia containing the superior hypogastric plexus and nerves. During the exposure of the longitudinal vertebral ligament, in 14 out of 14 (100%) cases, the incision of the peritoneum and of the subjacent presacral fascia along the medial border of the right common iliac artery followed by its medial displacement allowed for the identification and preservation of the right hypogastric nerve, which was consistently located medial to our incision, thus verifying our assumption (Fig. 5). The area exposed by the incision and medial displacement of the presacral fascia consists of a triangle formed by the right common iliac artery, the left common iliac vein, and the edge of sacral promontory. This area contains the middle sacral artery and vein, which run longitudinally in the middle of the fifth lumbar vertebra over the longitudinal anterior vertebral ligament. The sagittal sections showed that when the anterior mesh is placed with the lowest amount of tension necessary to form a linear connection between the most caudal mesh fixation point over the anterior vaginal wall and the promontory, it stretches the proximal half of the anterior vaginal wall and the cervix towards the sacral promontory. With this degree of mesh tension applied, the median angle formed by the axis of the infra- and trans-levatorial portions of the vagina with the axis of the supralevatorial portion of the vagina changed from 1428 (range: 139–144) to 1718 (range: 165–173) after LSCP (Fig. 6). The results of this modification of the vaginal axis consisted of the suspension of the cervix, linearization and ventralization of the vaginal canal and enlargement of the pelvic space situated
Fig. 5. Dissection of the sacral promontory. AA, aorta artery; RCIA, right common iliac artery; LCIA, Left common iliac artery; RHN, right hypogastric nerve; IMA, Inferior mesenteric artery: SP, sacral promontory. White circle: presacral fascia; blue dots: line of peritoneal incision; yellow dots: peritoneum.
Neurourology and Urodynamics DOI 10.1002/nau
dorsally to the posterior vaginal wall (Fig. 6). Moreover, as a consequence of the cranial stretch of the vagina towards the sacral promontory determined by the tension applied to the mesh, a cranial stretch of the portion of the pubocervical fascia between the tendinous arch of the endopelvic fascia and the vagina was observed in 10 out of 10 (100%) cases examined (Fig. 7). DISCUSSION
To the best of our knowledge, this is the first study to investigate LSCP from the anatomical surgical point of view and analyze the anatomical modifications induced by this procedure. Our results showed that the dissection of the vesicovaginal space could be performed in a reproducible fashion using well-defined, easily recognizable, anatomical landmarks, such as the vessels forming the superficial layer of the vesicouterine ligament and the dorsal end of the bladder trigone. No risk of nerve injury is foreseen if the procedure is carried out respecting these anatomical boundaries because the bladder nerve branches are located lateral and mostly caudal to this dissection plane. The arrow-shaped space resulting from this dissection measures approximately 50% of the total length of the vaginal wall. Regarding the rectovaginal space dissection, our results also showed that this surgical step is reproducible using specific anatomical landmarks. In particular, these were the uterosacral and rectovaginal ligaments laterally, the cranial end of the perineal body and the left and right puborectal/ pubococcygeal portions of the levator ani muscle. The resulting rectovaginal dissection space consists of a V-shaped area covering about two-thirds of the posterior vaginal wall. Attention should be paid during this dissection to avoid penetration into the rectal fascia in order to avoid possible lesions in the middle rectal vessels and the rectal branches of the inferior hypogastric plexus, which run close to the pelvic floor in more than 80% of the cases in our series report. We have previously described a nerve-sparing procedure for exposing the sacral promontory and dissecting the peritoneum needed for exposing the longitudinal anterior vertebral ligament and inserting the mesh. Interestingly, by using this technique, there is complete visibility of the right hypogastric nerve all the way from the promontory down to the right uterosacral ligament and rectovaginal space to avoid accidental lesions and/or coagulation of this nerve during the exposure of the promontory and/or the preparation of the subperitoneal tunnel for the mesh. From an anatomical point of view, we observed that the mesh fixed on the vesicovaginal dissection area and the cervix stretched across the proximal half of the anterior vaginal wall and the cervix towards the sacral promontory. This effect facilitates excellent apical support and the preservation of vaginal length described in the literature as characteristics of LSCP.10 Moreover, it is our opinion that the upward stretch of the lateral portion of the pubocervical fascia observed after LSCP could play a relevant role in cystocele correction that is a specific characteristic of this type of LSCP.11 However, we showed that only the proximal half of the anterior vaginal wall could be dissected and directly anchored by the mesh. This implies that the support and suspension produced by LSCP on the proximal half of the vagina, which support the bladder base, could be more evident than that obtained over the distal half of the vagina, which supports the bladder neck and the urethra, not directly suspended by the mesh. Thus, it is possible that the anatomical correction provided by LSCP might not be adequate in patients characterized by a marked ptosis of the bladder neck and urethra with associated
Anatomical Insights Into Sacrocolpopexy
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Fig. 6. Right and left hemipelvis, median sagittal sections. Vaginal axis: before and after LSCP. B, bladder, P, pubes, R, rectum, S1, sacral vertebra, L5, lumbar vertebra. Yellow circle: posterior compartment before LSCP; blue circle: posterior compartment after LSCP; red line: vaginal axis.
voiding dysfunction. This hypothesis is supported by the CARE studies showing that Burch colposuspension, which specifically suspends the distal half of the anterior vaginal wall, combined with colposacropexy is able to significantly reduce the rate of voiding obstructive symptoms postoperatively in both continent and incontinent patients.12–14 We observed that the mesh fixed along the rectovaginal space completely eliminates this space, theoretically avoiding the possibility of enterocele formation and containing the ventral pulsion and/or enlargement of the pelvic portion of the rectum. We observed after LSCP that the effect of the linearizationventralization of the vaginal axis is evident, considering that the normal vaginal axis is directed towards the second-third
sacral vertebras,15 while after LSCP, it points towards its fixation point situated at the level of S1-L5 and is in complete agreement with in vivo10 and cadaveric16 studies. The consequential enlargement of the pelvic space is situated dorsally to the posterior vaginal wall, i.e., the rectovaginal pouch could offer the opportunity to dislocate the bowel into the pelvis, implying a higher susceptibility to enterocele formation if no specific cautionary measures are taken. Observations support the hypothesis that patients submitted to Burch colposuspension, which could determine a change in the vaginal axis similar to that observed after LSCP, show a high risk of developing post-operative enterocele.17 These observations justify the necessity of placing a posterior mesh, even in the absence of such a posterior vaginal support defect, as recommended by us4 and other authors.16,18–20 Future radiological and functional in vivo studies are needed to fully evaluate the clinical potential of LSCP and, possibly, further standardize the surgical procedure and improve the results for our patients. CONCLUSIONS
Our study confirms the importance of a comprehensive anatomical knowledge of the pelvic cavity not only macroscopically but also at the time of fine dissection during laparoscopy. For a modern approach to POP repair, it is essential to realize the fundamental role of the ‘‘nerve-sparing‘‘ technique to avoid functional sequelae in the post-op period of a pelvic organ. ACKNOWLEDGMENTS
Fig. 7. Entire pelvis, view from above. Pubocervical fascia stretch. Green point: ischial spine; red arrows: tendinous arch of the pubocervical fascia; red tubes: ureteral stents; blue arrows: area of stretching of the pubocervical fascia; white arrow: direction of the tension applied to the mesh.
Neurourology and Urodynamics DOI 10.1002/nau
We gratefully acknowledge Kathryn Carlisle for editing the manuscript; Mr. Maurice Harasse, Mr. Dominique Lefevre, and Mr. Jean-Remy Hadadou for their outstanding technical help; and Mme. Edith Bordereaux and Mr. Daniel Esperandieu for their administrative assistance.
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1. Nygaard IE,Bradely C, Brandt D. Pelvic organ prolapse in older women: prevalence and risk factors. Obstet Gynecol 2004;104:489–97. 2. Olsen AL, Smith VJ, Bergstrom JO, et al. Epidemiology of surgically managed pelvic organ prolapse and urinary incontinence. Obstet Gynecol 1997;89:501–6. 3. Nygaard IE, McCreery R, Brubacker L, et al. Abdominal sacrocolpopexy: A comprehensive review. Obstet Gynecol 2004;104:804–23. 4. Gadonneix P, Ercoli A, Scambia G, et al. The use of laparoscopic sacrocolpopexy in the management of pelvic organ prolapse. Curr Opin Obstet Gynecol 2005;17:376–80. 5. Gadonneix P, Ercoli A, Salet-Lizee D, et al. Laparoscopic sacrocolpopexy with two separate meshes along the anterior and posterior vaginal walls for multicompartment pelvic organ prolapse. J Am Assoc Gynecol Laparosc 2004;11:29–35. 6. Rozet F, Mandron E, Arroyo C, et al. Laparoscopic sacral colpopexy approach for genitor-urinary prolapse: Experience with 363 cases. Eur Urol 2005;47:230–6. 7. Ercoli A, Delmas V, Gadonneix P, et al. Classical and nerve-sparing radical hysterectomy: An evaluation of the risk of injury to the autonomous pelvic nerves. Surg Radiol Anat. 2003; ; 25:200–6. 8. Ercoli A, Delmas V, Fanfani F, et al. Terminologia Anatomica versus unofficial descriptions and nomenclature of the fasciae and ligaments of the female pelvis: A dissection-based comparative study. Am J Obstet Gynecol 2005;193:1565–73. 9. Terminologia Anatomica. International anatomical terminology/Federative Committee on Anatomical Terminology (FCAT). Stuttgart/New York: Thieme; 1998. 10. Ginath S, Garely AD, Luchs JS, et al. Magnetic resonance imaging of abdominal versus vaginal prolapse surgery with mesh. Int Urogynecol J 2012;23: 1569–76.
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11. Sergent F, Resch B, Loisel C, et al. Mid-term outcome of laparoscopic sacrocolpopexy with anterior and posterior polyester mesh for treatment of genito-urinary prolapse. Eur J Obstet Gynecol Reprod Biol 2011;156:217–22. 12. Brubaker L, Cundiff GW, Fine P, et al. Pelvic Floor Disorders Network. Abdominal sacrocolpopexy with Burch colposuspension to reduce urinary stress incontinence. N Engl J Med 2006;354:1557–66. 13. Burgio KL, Nygaard IE, Richter HE, et al. Bladder symptoms 1 year after abdominal sacrocolpopexy with and without Burch colposuspension in women without preoperative stress incontinence symptoms. Am J Obstet Gynecol 2007;197:647. 14. Brubaker L, Nygaard I, Richter HE, et al. Two-year outcomes after sacrocolpopexy with and without burch to prevent stress urinary incontinence. Obstet Gynecol 2008;112:49–55. 15. Gutman RE, Pannu HK, Cundiff GW, et al. Anatomic relationship between the vaginal apex and the bony architecture of the pelvis: A magnetic resonance imaging evaluation. Am J Obstet Gynecol 2005;192:1544–8. 16. Balgobin S, Good MM, Dillon SJ, et al. Lowest colpopexy sacral fixation point alters vaginal axis and cul-de-sac depth. Am J Obstet Gynecol 2013;208:e1–6. 17. Paraiso MF, Falcone T, Walters MD. Laparoscopic surgery for enterocele, vaginal apex prolapse and rectocele. Int Urogynecol J Pelvic Floor Dysfunct 1999;10:223–9. 18. Costantini E, Zucchi A, Giannantoni A, et al. Must colposuspension be associated with sacropexy to prevent postoperative urinary incontinence? Eur Urol 2007;51:788–94. 19. Costantini E, Lazzeri M, Bini V, et al. Burch colposuspension does not provide any additional benefit to pelvic organ prolapse repair in patients with urinary incontinence: A randomized surgical trial. J Urol 2008;180:1007–12. 20. Costantini E, Lazzeri M, Bini V, et al. Pelvic organ prolapse repair with and without concomitant burch colposuspension in incontinent women: A randomised controlled trial with at least 5-year follow-up. Obstet Gynecol Int 2012;967923.
Anatomical Insights Into Sacrocolpopexy for Multicompartment Pelvic Organ Prolapse Alfredo Ercoli,1,2* Giuseppe Campagna,3 Vincent Delmas,2,4 Stefania Ferrari,1 Andrea Morciano,3 Giovanni Scambia,2 and Mauro Cervigni2 1
Policlinico Abano Terme–Urogynaecology Unit, Piazza Cristoforo Colombo, 1 , Abano Terme (PD), Italy 2 Institute of Anatomy, Descartes University URDIA EA4465, Paris, France 3 Department of Obstetrics and Gynaecology, Catholic University of the Sacred Heart, Rome, Italy 4 Department of Urology, Bichat Cloude Bernard Hospital, Paris Diderot University Medical School, Paris, France Aims: Pelvic organ prolapse occurs in 50% of parous women. Laparoscopic sacrocolpopexy (LSCP) is a common surgical procedure for restoring pelvic anatomy and function. The aim of this study is to evaluate surgical anatomy and anatomical modifications induced by standardized LSCP. Methods: Ten fresh female cadavers underwent LSCP, six subsequently underwent standard anatomical dissection, and four had sagittal anatomical dissection. Four cadavers were used as control subjects; two of them underwent standard anatomical dissection, and two had sagittal anatomical dissection. Results: Vesicovaginal space dissection resulted in an arrow-shaped space limited by the trigone and vesical branches of the uterine artery. Rectovaginal space dissection resulted in an inverted V-shaped space marked by the utero-sacral and rectovaginal ligaments, the cranial end of the perineal body and the levator ani muscle. Exposing the longitudinal vertebral ligament through a peritoneal and presacral fascia incision along the medial border of the right common iliac artery allowed the identification and the preservation of the right hypogastric nerve. The anterior mesh stretched across the proximal half of the anterior vaginal wall, and the cervix towards the sacral promontory provided excellent cervix suspension and anterior-vaginal wall support with a concomitant stretch of the pubocervical fascia. The median angle formed by the axis of the infra-levatorial vagina with the axis of the supra-levatorial vagina changed from 1428 to 1718 and determined the linearization-ventralization of the vaginal canal. Conclusions: LSCP can be performed in a nervesparing, standardized fashion, providing excellent apical suspension and anterior vaginal wall support. Neurourol. Urodynam. 9999:1–6, 2015. # 2015 Wiley Periodicals, Inc. Key words: laparoscopic sacrocolpopexy; pelvic organ prolapse; surgical anatomy INTRODUCTION
Female pelvic organ prolapse (POP) is reported to be present in 50% of parous women1 and represents one of the most frequent causes for pelvic surgery in women. Many surgical procedures for restoring normal pelvic anatomy and functions have been described to date.2 Among them, laparoscopic sacrocolpopexy (LSCP) is one of the most widely used because it combines the high efficacy of reconstructive surgery using non-absorbable mesh with the fast recovery and lowcomplication rate resulting from minimal tissue trauma and laparoscopical procedure precision.3,4 However, there is a relative paucity of studies analyzing the surgical anatomy of LSCP, and there is essentially a lack of studies investigating the anatomical modifications induced by this procedure. The aim of this study is to gain further insight into the surgical anatomy and the anatomical alterations induced by the LSCP procedure for multicompartment POP we actually perform. This procedure is characterized by a complete dissection of the avascular spaces between the anterior vaginal wall and the bladder and between the posterior vaginal walls and the rectum5,6 to provide support and suspension to a large portion of the vagina and adjacent pelvic organs. Moreover, we adopt specific protocols of surgical dissection resulting from our previous studies of radical pelvic surgery performed to spare the nerve structures that could be injured during our dissections, such as the superior hypogastric plexus and the hypogastric nerves, which run in close proximity to the sacral promontory and the rectum and the uterosacral ligaments.7,8 The specific goals of our research are (i) to define the anatomical boundaries of the vesicovaginal and rectovaginal spaces, ii) to #
2015 Wiley Periodicals, Inc.
study the surgical anatomy of the dissections performed to insert the meshes to effectively verify that our procedure is truly nerve-sparing and (iii) to analyze the consequent anatomical alterations induced by LSCP. For this study, we performed LSCP followed by macroscopic anatomical dissection on 10 fresh female cadavers, and we compared our results with those obtained from the dissection of four fresh female cadavers that had never undergone surgery that were used as control subjects. MATERIALS AND METHODS
For this study, we utilized 14 fresh female cadavers showing no previous pelvic operations. All subjects were adult Caucasian. The mean age at death was 67.4 9.8 years (range 51–87). All subjects underwent total body vascular injection by the femoral vessels, as previously described,8 and 10 of them underwent LSCP. Six of the subjects undergoing LSCP and two of the control subjects underwent macroscopic anatomical dissection using a standard abdominal approach, while four of the subjects undergoing LSCP and two of the control subjects Potential conflicts of interest: Nothing to disclose. Dr. Mickey Karram led the peer-review process as the Associate Editor responsible for the paper. Correspondence to: Alfredo Ercoli, Policlinico Abano Terme - Urogynaecology Unit, Piazza Cristoforo Colombo, 1 , Abano Terme (PD), Italy 35031. E-mail: [email protected] Received 19 October 2014; Accepted 21 May 2015 Published online in Wiley Online Library (wileyonlinelibrary.com). DOI 10.1002/nau.22806
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were frozen at 808C and then cut longitudinally on the midline in order to perform the dissection and evaluate the LSCP-induced anatomical modifications from the latero-lateral point of view. Macroscopic anatomical dissections were carried out by removing the abdominal wall, as well as the lower abdominaland pelvic-parietal peritoneum. The retroperitoneal areolar connective tissue was then gently dissected in a cranio-caudal fashion starting from the origin of the inferior mesenteric artery where the aortic sympathetic fibers fuses in order to expose the superior hypogastric plexus and the hypogastric nerves. Furthermore, we defined the vesicovaginal and rectovaginal spaces, identified the pubo-cervical fascia/anterior vaginal wall, the tendinous arch of endopelvic fascia, the rectovaginal fascia/posterior vaginal wall and the pelvic parietal fascia covering the levator ani muscle. The visceral branches of the hypogastric vessels and the muscles forming the pelvic floor were then completely dissected. All preparation of subjects and LSCP and anatomical dissections were performed at the ‘‘Centre du Don des Corps’’ of the ParisDescartes University (Paris - France) between January 2009 and June 2012. In this study, we adopted anatomical terms conforming to the ‘‘Terminologia Anatomica’’ 9 and modifications we previously proposed8 unless otherwise specified. Surgical Technique
The LSCP began with a subtotal hysterectomy using a classic technique. Then, the sacral promontory was identified by palpation of the lumbar-sacral convexity with the midline laparoscopic instrument inserted in the middle between the pubis and umbilicus with the subject in a steep Trendelenburg position and exposed with the nerve-sparing approach we developed. The peritoneum overlying the right common iliac artery was incised along the axis of the artery itself for 3–4 cm starting from the promontory. The underlying presacral fascia containing the hypogastric nerve was identified and penetrated with scissors, and the resulting foramen was gently enlarged and dislocated medially by blunt dissection to expose the longitudinal anterior vertebral ligament for at least 15 mm in both the cranio-caudal and latero-lateral directions. An inverted L–shaped peritoneal incision extending from the sacral promontory up to the left uterosacral ligament was completed while ensuring that the presacral fascia containing the right hypogastric nerve on the lateral parietal side was left to avoid accidental nerve injuries. Then, the rectovaginal space was fully dissected, and at its caudal edge, the dissection was carried out lateral to the rectum upwards to identify the pelvic parietal fascia covering the levator ani muscle. This dissection area was covered by an adequately shaped synthetic mesh fixed with a total of five no. 3–0 non-absorbable sutures. Two sutures were placed on the fascia covering the pelvic floor, two were applied approximately 2–3 cm distal from the uterine cervix along the left and right uterosacral ligaments, and the last one was placed centrally on the dorsal area of the uterine cervix. Subsequently, the vesicouterine peritoneum was opened, and the vesicovaginal space was fully dissected. A second synthetic mesh fitted to cover the entire dissection area was inserted and fixed to the anterior vaginal wall with five no. 3–0 non-absorbable sutures. The first suture was placed centrally on the most ventral point of the dissected space, while two sutures per side were placed on the most lateral edges of the same space. The anterior mesh was then threaded up towards the promontory with the lowest amount of tension necessary to form a linear connection between the most caudal mesh fixation point over the anterior vaginal wall and the Neurourology and Urodynamics DOI 10.1002/nau
Fig. 1. Left hemipelvis, median sagittal section. Planes of vesicovaginal and rectovaginal dissection. B, bladder; V, vagina; R, rectum; U, uterus. Red line: plane of vesicovaginal space dissection; yellow line: plane of rectovaginal space dissection.
promontory, and it was fixed to the longitudinal vertebral ligament previously exposed with one no. 0 non-absorbable suture. This procedure was performed under visual and palpation control from the surgeon by checking the degree of tension of the mesh that could be deduced by the morphology of the mesh and its resistance against pressure applied by a laparoscopic instrument. RESULTS
While performing the dissection of the vesicovaginal space, we found that in 14 out of 14 (100%) cases, the most caudal point cleavable by blunt dissection without the need to cut vessels or fibrous structure in order to proceed with the dissection was the dorsal end of the bladder trigone (Fig. 1). The complete dissection of the vesicovaginal space created a triangular-shaped vesicovaginal space with the apex at the dorsal end of the bladder trigone and the lateral limits
Fig. 2. Entire pelvis, view from above. Vesicovaginal space. White triangle: vesicovaginal space, dashed line: length of space (mean Standard Deviation). VUL (red circles): superficial layer of Vesico-Uterine Ligament formed by the descending branch of the uterine artery, the superficial vesical vein and the cervicovesical vessels. RtR: Retro-trigonal Region. U, uterus. FC, Foley’s Catheter.
Anatomical Insights Into Sacrocolpopexy
Fig. 3. Right hemipelvis, median sagittal section: mesh fixation over the anterior and posterior vaginal walls. U, urethra; B, bladder; R, rectum; PB, perineal body. Blue tube: ureteral stent. Red arrow: vaginal portion not covered by mesh; blue arrow: vaginal portion covered by the mesh.
represented by the superficial layer of the vesicouterine ligament formed by (a) the descending branch of the uterine artery, (b) the superficial vesical vein (branch of the superficial uterine vein), and (c) the cervicovesical vessels (Fig. 2). In particular, we found that the avascular, easily cleavable, vesicovaginal space that we dissected measured 37 6 mm (mean SD) (range: 31–47) of the total anterior-vaginal wall length of 76 8 mm (mean SD) (range: 70–86) (Fig. 3) in the cranio-caudal direction. No nerve structures were identified during this dissection, while the branches of the bladder nerves
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from the inferior hypogastric plexus were identified in the deep portion of the vesicouterine ligament (data not shown). While performing the dissection of the rectovaginal space, we found that in 14 out of 14 (100%) cases, the most caudal point cleavable by blunt dissection without the need to cut vessels or fibrous structure in order to proceed with the dissection was the cranial end of the perineal body (Fig. 1). At this level, lateral to the posterior vaginal wall, the rectal fascia is easily cleavable from the pelvic parietal fascia covering the puborectal/pubococcygeal portion of the levator ani muscle. The complete dissection of the rectovaginal space resulted in an inverted V-shaped space with the apex at the convergence of the left and right uterosacral ligaments. The lateral limits were defined by the vessels running into the uterosacral and rectovaginal ligaments, and the base was represented by the cranial end of the perineal body in the middle, left and right puborectal/pubococcygeal portions of the levator ani muscle, which hugs the lateral vaginal walls on both sides. In particular, we found that the avascular, easily cleavable, rectovaginal area we were able to dissect measured 75 8 mm (range: 65–84) of the total posterior vaginal wall length of 94 11 mm (range: 75–109) in the craniocaudal direction (Fig. 3). During our dissections, we found that in 11 out of 14 cases (78%), the middle rectal vessels and the rectal nervous branch of the inferior hypogastric plexus ran in close proximity to the puborectal/pubococcygeal portions of the levator ani muscle, immediately below the rectal fascia (Fig. 4). The dissection of the retroperitoneal tissue at the level of the promontory showed the presence of two layers of connective tissue superposed on the longitudinal anterior vertebral ligament. In all the cases examined, the first layer consisted of the peritoneum along with its accompanying areolar tissue,
Fig. 4. Left hemipelvis, paramedian section (main picture); right hemipelvis median section (auxiliary picture). B, bladder; V, vagina; R, rectum; HA, hypogastric artery; US, uterosacral ligament; PR-LAM, pubo-rectal portion of Levator ani muscle. Blue circle: Kelly forceps in uretra; green circle: vascular forceps at the vaginal entry; yellow circle: lateral rectal ligament composed by middle rectal artery and vein and rectal nervous branches from the inferior hypogastric plexus.
Neurourology and Urodynamics DOI 10.1002/nau
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while the second layer was formed by the presacral fascia containing the superior hypogastric plexus and nerves. During the exposure of the longitudinal vertebral ligament, in 14 out of 14 (100%) cases, the incision of the peritoneum and of the subjacent presacral fascia along the medial border of the right common iliac artery followed by its medial displacement allowed for the identification and preservation of the right hypogastric nerve, which was consistently located medial to our incision, thus verifying our assumption (Fig. 5). The area exposed by the incision and medial displacement of the presacral fascia consists of a triangle formed by the right common iliac artery, the left common iliac vein, and the edge of sacral promontory. This area contains the middle sacral artery and vein, which run longitudinally in the middle of the fifth lumbar vertebra over the longitudinal anterior vertebral ligament. The sagittal sections showed that when the anterior mesh is placed with the lowest amount of tension necessary to form a linear connection between the most caudal mesh fixation point over the anterior vaginal wall and the promontory, it stretches the proximal half of the anterior vaginal wall and the cervix towards the sacral promontory. With this degree of mesh tension applied, the median angle formed by the axis of the infra- and trans-levatorial portions of the vagina with the axis of the supralevatorial portion of the vagina changed from 1428 (range: 139–144) to 1718 (range: 165–173) after LSCP (Fig. 6). The results of this modification of the vaginal axis consisted of the suspension of the cervix, linearization and ventralization of the vaginal canal and enlargement of the pelvic space situated
Fig. 5. Dissection of the sacral promontory. AA, aorta artery; RCIA, right common iliac artery; LCIA, Left common iliac artery; RHN, right hypogastric nerve; IMA, Inferior mesenteric artery: SP, sacral promontory. White circle: presacral fascia; blue dots: line of peritoneal incision; yellow dots: peritoneum.
Neurourology and Urodynamics DOI 10.1002/nau
dorsally to the posterior vaginal wall (Fig. 6). Moreover, as a consequence of the cranial stretch of the vagina towards the sacral promontory determined by the tension applied to the mesh, a cranial stretch of the portion of the pubocervical fascia between the tendinous arch of the endopelvic fascia and the vagina was observed in 10 out of 10 (100%) cases examined (Fig. 7). DISCUSSION
To the best of our knowledge, this is the first study to investigate LSCP from the anatomical surgical point of view and analyze the anatomical modifications induced by this procedure. Our results showed that the dissection of the vesicovaginal space could be performed in a reproducible fashion using well-defined, easily recognizable, anatomical landmarks, such as the vessels forming the superficial layer of the vesicouterine ligament and the dorsal end of the bladder trigone. No risk of nerve injury is foreseen if the procedure is carried out respecting these anatomical boundaries because the bladder nerve branches are located lateral and mostly caudal to this dissection plane. The arrow-shaped space resulting from this dissection measures approximately 50% of the total length of the vaginal wall. Regarding the rectovaginal space dissection, our results also showed that this surgical step is reproducible using specific anatomical landmarks. In particular, these were the uterosacral and rectovaginal ligaments laterally, the cranial end of the perineal body and the left and right puborectal/ pubococcygeal portions of the levator ani muscle. The resulting rectovaginal dissection space consists of a V-shaped area covering about two-thirds of the posterior vaginal wall. Attention should be paid during this dissection to avoid penetration into the rectal fascia in order to avoid possible lesions in the middle rectal vessels and the rectal branches of the inferior hypogastric plexus, which run close to the pelvic floor in more than 80% of the cases in our series report. We have previously described a nerve-sparing procedure for exposing the sacral promontory and dissecting the peritoneum needed for exposing the longitudinal anterior vertebral ligament and inserting the mesh. Interestingly, by using this technique, there is complete visibility of the right hypogastric nerve all the way from the promontory down to the right uterosacral ligament and rectovaginal space to avoid accidental lesions and/or coagulation of this nerve during the exposure of the promontory and/or the preparation of the subperitoneal tunnel for the mesh. From an anatomical point of view, we observed that the mesh fixed on the vesicovaginal dissection area and the cervix stretched across the proximal half of the anterior vaginal wall and the cervix towards the sacral promontory. This effect facilitates excellent apical support and the preservation of vaginal length described in the literature as characteristics of LSCP.10 Moreover, it is our opinion that the upward stretch of the lateral portion of the pubocervical fascia observed after LSCP could play a relevant role in cystocele correction that is a specific characteristic of this type of LSCP.11 However, we showed that only the proximal half of the anterior vaginal wall could be dissected and directly anchored by the mesh. This implies that the support and suspension produced by LSCP on the proximal half of the vagina, which support the bladder base, could be more evident than that obtained over the distal half of the vagina, which supports the bladder neck and the urethra, not directly suspended by the mesh. Thus, it is possible that the anatomical correction provided by LSCP might not be adequate in patients characterized by a marked ptosis of the bladder neck and urethra with associated
Anatomical Insights Into Sacrocolpopexy
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Fig. 6. Right and left hemipelvis, median sagittal sections. Vaginal axis: before and after LSCP. B, bladder, P, pubes, R, rectum, S1, sacral vertebra, L5, lumbar vertebra. Yellow circle: posterior compartment before LSCP; blue circle: posterior compartment after LSCP; red line: vaginal axis.
voiding dysfunction. This hypothesis is supported by the CARE studies showing that Burch colposuspension, which specifically suspends the distal half of the anterior vaginal wall, combined with colposacropexy is able to significantly reduce the rate of voiding obstructive symptoms postoperatively in both continent and incontinent patients.12–14 We observed that the mesh fixed along the rectovaginal space completely eliminates this space, theoretically avoiding the possibility of enterocele formation and containing the ventral pulsion and/or enlargement of the pelvic portion of the rectum. We observed after LSCP that the effect of the linearizationventralization of the vaginal axis is evident, considering that the normal vaginal axis is directed towards the second-third
sacral vertebras,15 while after LSCP, it points towards its fixation point situated at the level of S1-L5 and is in complete agreement with in vivo10 and cadaveric16 studies. The consequential enlargement of the pelvic space is situated dorsally to the posterior vaginal wall, i.e., the rectovaginal pouch could offer the opportunity to dislocate the bowel into the pelvis, implying a higher susceptibility to enterocele formation if no specific cautionary measures are taken. Observations support the hypothesis that patients submitted to Burch colposuspension, which could determine a change in the vaginal axis similar to that observed after LSCP, show a high risk of developing post-operative enterocele.17 These observations justify the necessity of placing a posterior mesh, even in the absence of such a posterior vaginal support defect, as recommended by us4 and other authors.16,18–20 Future radiological and functional in vivo studies are needed to fully evaluate the clinical potential of LSCP and, possibly, further standardize the surgical procedure and improve the results for our patients. CONCLUSIONS
Our study confirms the importance of a comprehensive anatomical knowledge of the pelvic cavity not only macroscopically but also at the time of fine dissection during laparoscopy. For a modern approach to POP repair, it is essential to realize the fundamental role of the ‘‘nerve-sparing‘‘ technique to avoid functional sequelae in the post-op period of a pelvic organ. ACKNOWLEDGMENTS
Fig. 7. Entire pelvis, view from above. Pubocervical fascia stretch. Green point: ischial spine; red arrows: tendinous arch of the pubocervical fascia; red tubes: ureteral stents; blue arrows: area of stretching of the pubocervical fascia; white arrow: direction of the tension applied to the mesh.
Neurourology and Urodynamics DOI 10.1002/nau
We gratefully acknowledge Kathryn Carlisle for editing the manuscript; Mr. Maurice Harasse, Mr. Dominique Lefevre, and Mr. Jean-Remy Hadadou for their outstanding technical help; and Mme. Edith Bordereaux and Mr. Daniel Esperandieu for their administrative assistance.
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11. Sergent F, Resch B, Loisel C, et al. Mid-term outcome of laparoscopic sacrocolpopexy with anterior and posterior polyester mesh for treatment of genito-urinary prolapse. Eur J Obstet Gynecol Reprod Biol 2011;156:217–22. 12. Brubaker L, Cundiff GW, Fine P, et al. Pelvic Floor Disorders Network. Abdominal sacrocolpopexy with Burch colposuspension to reduce urinary stress incontinence. N Engl J Med 2006;354:1557–66. 13. Burgio KL, Nygaard IE, Richter HE, et al. Bladder symptoms 1 year after abdominal sacrocolpopexy with and without Burch colposuspension in women without preoperative stress incontinence symptoms. Am J Obstet Gynecol 2007;197:647. 14. Brubaker L, Nygaard I, Richter HE, et al. Two-year outcomes after sacrocolpopexy with and without burch to prevent stress urinary incontinence. Obstet Gynecol 2008;112:49–55. 15. Gutman RE, Pannu HK, Cundiff GW, et al. Anatomic relationship between the vaginal apex and the bony architecture of the pelvis: A magnetic resonance imaging evaluation. Am J Obstet Gynecol 2005;192:1544–8. 16. Balgobin S, Good MM, Dillon SJ, et al. Lowest colpopexy sacral fixation point alters vaginal axis and cul-de-sac depth. Am J Obstet Gynecol 2013;208:e1–6. 17. Paraiso MF, Falcone T, Walters MD. Laparoscopic surgery for enterocele, vaginal apex prolapse and rectocele. Int Urogynecol J Pelvic Floor Dysfunct 1999;10:223–9. 18. Costantini E, Zucchi A, Giannantoni A, et al. Must colposuspension be associated with sacropexy to prevent postoperative urinary incontinence? Eur Urol 2007;51:788–94. 19. Costantini E, Lazzeri M, Bini V, et al. Burch colposuspension does not provide any additional benefit to pelvic organ prolapse repair in patients with urinary incontinence: A randomized surgical trial. J Urol 2008;180:1007–12. 20. Costantini E, Lazzeri M, Bini V, et al. Pelvic organ prolapse repair with and without concomitant burch colposuspension in incontinent women: A randomised controlled trial with at least 5-year follow-up. Obstet Gynecol Int 2012;967923.
