What are the indications for sacrospinous (sacrospinous ligament) colpopexy?

Sacrospinous Colpopexy Indications

Sacrospinous colpopexy is indicated for vaginal vault prolapse following hysterectomy, marked uterovaginal prolapse (especially in women desiring uterine preservation), and pelvic floor abnormalities including enteroceles, cystoceles, and rectoceles when performed in conjunction with other pelvic reconstructive procedures. 1

Primary Indications

Vaginal Vault Prolapse

• Post-hysterectomy vaginal vault prolapse is the most established indication for sacrospinous colpopexy 2, 3, 4
• The procedure demonstrates high long-term success rates, with vault support maintained in 96% of patients at mean 57-month follow-up 4
• Particularly effective in elderly patients with massive vaginal eversion, where it can be performed safely under regional anesthesia 5

Uterovaginal Prolapse

• Marked (grade 3-4) uterovaginal prolapse requiring surgical intervention 1, 3
• Especially valuable as primary treatment in young women who wish to preserve fertility, as the procedure allows uterine conservation 3
• Can be performed simultaneously with vaginal hysterectomy or with uterine preservation depending on patient goals 2, 4

Associated Pelvic Floor Defects

• Pouch of Douglas protrusion (often confused with rectal intussusception) is best addressed with sacrocolpopexy, typically performed with other gynecologic procedures 1
• Pelvic floor abnormalities including cystoceles, rectoceles, and enteroceles when vaginal vault support is needed 1
• The procedure allows simultaneous correction of coincident anterior and posterior vaginal wall defects 2, 6, 4

Key Advantages Supporting These Indications

Technical Benefits

• Avoids major abdominal surgery while achieving comparable or superior outcomes to abdominal vault supporting procedures 2
• Allows correction of coexistent cystocele and rectocele in the same operative setting 2, 6
• Quick procedure with mean operative time of 65.6 minutes and low blood loss (mean 81.8 ml) 4

Patient-Centered Outcomes

• Maintains sexual function in all sexually active women, with 43% reporting improvement 4
• Restores relatively normal vaginal depth (mean 7.8-8 cm at long-term follow-up) and axis 6, 4
• High success rate with low recurrence: only 4% vault prolapse recurrence at 5-year follow-up 4

Clinical Context and Patient Selection

Preferred Patient Populations

• Elderly patients with significant medical comorbidities who may not tolerate abdominal surgery 1, 5
• Patients with contraindications for abdominal approaches 1
• Women desiring maintenance of coital function 6

Common Pitfalls to Avoid

• Do not confuse Pouch of Douglas protrusion with rectal intussusception or full-thickness rectal prolapse—the former requires sacrocolpopexy while the latter requires rectopexy 1
• Be aware that symptomatic cystocele formation occurs in approximately 5% of patients postoperatively and may require additional intervention 4
• The procedure should be performed two fingerbreadths medial to the ischial spine to avoid injury to pudendal vessels, pudendal nerve, sciatic nerve, and rectum 3

Concurrent Procedures Commonly Indicated

• Anterior colporrhaphy (performed in 60-88% of cases) 4, 5
• Posterior colpoperineorrhaphy (performed in 88% of cases) 5
• Enterocele sac obliteration (performed in 72% of cases) 2, 5
• Vaginal hysterectomy when uterine preservation is not desired 2, 3, 4

Important Considerations

The evidence strongly supports sacrospinous colpopexy as a first-line surgical option for vaginal vault prolapse and marked uterovaginal prolapse, with success rates of 96-97.3% and low complication rates 3, 4. The procedure is particularly valuable because it addresses the primary indication while allowing simultaneous correction of associated pelvic floor defects through a single vaginal approach, avoiding the morbidity of laparotomy 2, 6.