Critical Anatomy for Robotic Sacrocolpopexy: A Long-term Follow-up Study.

OBJECTIVE: This study aimed to assess anatomy relative to sacral sutures 20 to 24 months after robotic sacrocolpopexy. METHODS: This was an institutional review board-approved prospective anatomy study of women undergoing robotic sacrocolpopexy. After placement of suture into the anterior longitudinal ligament, a small vascular clip was secured on the base of the suture. Subjects were imaged at 6 weeks and between 20 and 24 months after surgery. Measurements were calculated by the primary investigator and radiologist coinvestigator. RESULTS: Of the 11 subjects enrolled in the initial 6-week postoperative study, 5 (45%) completed the long-term follow-up. Regarding the vascular anatomy, no significant changes were documented. Similarly, the major urologic structure, the right ureter, was stable at 16 mm from the clip. A significant change was noted, however, in the distance from the apex of the vagina to the sacral suture. At 6 weeks postoperatively, the mean (SD) distance from the vaginal apex to the clip was 69.3 (14) mm; this increased to 85.2 (11.3) mm at the long-term follow-up (P = 0.004). CONCLUSIONS: Reassuringly, the position of the clip remained stable, which is reflected in the constancy of the measurements to the vascular landmarks. Nevertheless, alteration in the distance to the vaginal apex suggests elongation of the mesh or vaginal tissue with time. Although the increase in length was greater than 1.5 cm, it may bear clinical relevance in certain patients. This information may help guide surgeons regarding appropriate mesh tensioning during this critical step of the procedure.

Uterosacral Ligament Suspension: A Radiographic Study of Suture Location in Live Subjects.

OBJECTIVES: This study aimed to describe uterosacral ligament suspension (USLS) suture location relative to the surrounding anatomy in a living model using computed tomographic imaging. METHODS: This was an institutional review board-approved prospective descriptive study. Women aged 18 to 85 years undergoing vaginal hysterectomy with USLS were eligible. A size 'small' titanium vascular clip was applied to the base of each USLS suture. Computed tomography of the pelvis was performed on postoperative day 1. Preoperative and postoperative neurologic questionnaires and physical examinations were performed. A sample size of 15 subjects was deemed appropriate for this pilot study. RESULTS: Seventeen subjects were enrolled: 2 excluded and 15 analyzed. The median (interquartile range) age of the subjects was 57 (22) years. The closest branch of the internal iliac complex was 2.6 (0.9) cm (median [interquartile range]) from the proximal suture on the right and 2.6 (0.5) cm on the left. The right ureter was 2.1 (0.7) cm from the right proximal suture. The left ureter was 2.3 (1.0) cm from the left proximal suture. The rectal lumen were 3.0 (1.6) cm from the right proximal suture and 2.8 (1.4) cm from the left proximal suture. No subjects were found to have neurologic involvement of the sutures based on neurologic questionnaire responses and physical examination. CONCLUSIONS: In live subjects, our study confirms that the vasculature, ureter, and rectum of the pelvic side wall are near suture placement for USLS. This information highlights the importance of careful dissection and awareness of anatomic landmarks.

Critical Anatomy Relative to the Sacral Suture: A Postoperative Imaging Study After Robotic Sacrocolpopexy.

OBJECTIVE: This study aimed to characterize pertinent anatomy relative to the sacral suture placed at time of robotic sacrocolpopexy using postoperative computed tomography and magnetic resonance imaging. METHODS: A vascular clip was placed at the base of the sacral suture at the time of robotic sacrocolpopexy. Six weeks postoperatively, subjects returned for a computed tomography scan and magnetic resonance imaging. RESULTS: Ten subjects completed the study. The middle sacral artery and vein coursed midline or to the left of midline in all the subjects. The left common iliac vein was an average of 26 mm from the sacral suture. To the right of the suture, the right common iliac artery was 18 mm away. Following the right common iliac artery to its bifurcation, the right internal iliac was on average 10 mm from the suture. The bifurcations of the inferior vena cava and the aorta were 33 mm and 54 mm further cephalad, respectively.The right ureter, on average, was 18 mm from the suture. The thickness of the anterior longitudinal ligament was 2 mm.The mean angle of descent of the sacrum was 70 degrees. Lastly, we found that 70% of the time, a vertebral body was directly below the suture; the disc was noted in 30%. CONCLUSIONS: We describe critical anatomy surrounding the sacral suture placed during robotic sacrocolpopexy. Proximity of both vascular and urologic structures within 10 to 18 mm, as well as anterior ligament thickness of only 2 mm highlights the importance of adequate exposure, careful dissection, and surgeon expertise.