Best Placement of the Sacrocolpopexy Stitch

Positioning sutures away from an intervertebral disc at the promontory may help reduce the risk of disc-related sequelae after sacrocolpopexy, concluded a review of spinal MRIs of women undergoing surgical repair of pelvic organ prolapse.¹
   
During a sacrocolpopexy procedure, the top of the vagina or the cervix is stitched with nonabsorbable sutures or with a synthetic mesh material to the back of the sacrum, or tail bone, providing significant support to the vagina or uterus by recreating the natural anatomic structure that the uterosacral and cardinal ligaments provide.² The typical placement of sacrocolpopexy presacral sutures is at or just above the sacral promontory. However, these sutures usually are placed without knowledge of the location of intervertebral discs, explained the study authors. Of concern is that any suture placed too near an intervertebral disc at the promontory has the potential to cause or increase the risk of disc-related sequelae, such as infective lumbar discitis or lumbosacral spondylodiscitis.
   
Sagittal T1-weighted fluid-attenuated inversion recovery sequence images of the lumbosacral spine were obtained for all study participants-a total of 73 women.¹ The MRI scans, obtained at the midline of the spinal cord, were used to identify the promontory as the most prominent point where S1 intersected with the superior anatomic structures. The findings indicated that most women (73%) had an intervertebral disc at the promontory. The average distance between the promontory and the next bony structure (L5) was 13 millimeters. The median distance between the promontory and the base of the L5 disc was 1.29 millimeters for women without a disc at the promontory. Age was not associated with structure prominence or correlated to disc height or distance to L5; the mean age of the women in this study was 59 years.
   
Currently, obtaining an MRI scan for disc-mapping purposes is not standard practice in the surgical repair of pelvic organ prolapse. However, the study authors suggest that in consideration of the high percentage of women who have an intervertebral disc at the promontory, use of imaging studies to help avoid placing sutures at this location may help reduce or avoid disc-related sequelae after sacrocolpopexy.

Pertinent Points:
- Of 73 women who underwent surgery for repair of pelvic organ prolapse, nearly 75% had an intervertebral disc at the promontory, increasing the risk of disc-related sequelae.
- Use of an MRI scan to help avoid suture placement too near an intervertebral disc may be useful before sacrocolpopexy.
 

References:

1. Abernathy 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;19:31-33.
2. Rajamaheswari N, Agarwal S, Seethalakshmi K. Lumbosacral spondylodiscitis: an unusual complication of abdominal sacrocolpopexy. Int Urogynecol J. 2012;23:374-377.