If performing a combined abdominal and vaginal approach, the graft is secured to the perineal body vaginally. The posterior vaginal wall is opened, and a defect-directed rectocele repair is performed. Sacral colpopexy is accomplished in the usual fashion except that the vaginal dissection is opened superiorly, creating a window to the abdominal dissection. The graft can then be passed down from the abdominal field to the vaginal field and anchored inferiorly to the perineal body and laterally to the arcus tendineus fascia rectovaginalis (Fig. 28.8).
Short-term outcomes for 19 patients who underwent sacral colpoperineopexy indicated good anatomic results for apical and posterior support as well as for perineal descent (39). Complete cessation of defecatory dysfunction symptoms was accomplished in 66% of patients. In a report of outcomes for a slightly different variation of the sacral colpoperineopexy, the authors’ technique involved attachment of Marlex mesh to the perineal body using a needle carrier (222). The failure rate was 25% and mesh erosion rate was 5% for 205 patients with up to 10-year follow-up. A study of Mersilene mesh erosion rates related to sacral colpopexy and sacral colpoperineopexy noted similar erosion rates between sacral colpopexy and colpoperineopexy when the vagina was not opened (3.2% vs. 4.5%, respectively) (223). However, the erosion rate was 16% with vaginal suture placement and 40% when the mesh was placed vaginally. The use of nonsynthetic grafts such as dermal allograft and xenograft may help prevent high erosion rates. In a case series of 11 patients, researchers performed sigmoid resection (if indicated) and suture rectopexy in conjunction with sacral colpoperineopexy using AlloDerm for women with coexistent rectal prolapse, perineal descent, and defecatory dysfunction. Early follow-up (12.5 ± 7.7 months) revealed excellent improvement of defecatory dysfunction symptoms and quality-of-life considerations, with an 82% cure of perineal descent (224). A recently published retrospective cohort of 38 women revealed high satisfaction following abdominal sacral colpoperineopexy, despite the persistence of obstructed defecation symptoms 5 years after surgery (225). Sacral colpoperineopexy may have value for a select group of patients, but larger prospective series with long-term anatomic and symptomatic outcomes are necessary to evaluate the durability of this procedure.
Rectal Prolapse Numerous surgical procedures have been described for the treatment of rectal prolapse and are broadly categorized into perineal or abdominal approaches. Most surgeons prefer an abdominal procedure because of lower recurrence rates, reserving perineal procedures for more debilitated patients.
Figure 28.8 Abdominal sacral colpoperineopexy with sigmoid resection and suture rectopexy. This sagittal view shows the posterior graft sutured to the rectovaginal fascia and perineal body after defect-directed rectocele repair. The anterior graft is sutured to the pubocervical fascia. Both sheets will be secured to the sacral periosteum to the right of the rectum. Rectopexy sutures (left) have not yet been tied and secured. (Courtesy of Geoffrey W. Cundiff, M.D.)