Gold Standard Treatment for Moderate to Severe Multi-Pelvic Organ Descent
For moderate to severe multi-pelvic organ descent, abdominal sacral colpopexy is the gold standard treatment, not sacrospinous colpopexy or isolated rectocele/cystocele repair. Sacral colpopexy achieves superior anatomic correction with the lowest recurrence rates and should be combined with repair of coexisting pelvic floor defects in a single operation 1, 2.
Why Sacral Colpopexy is Superior
Sacral colpopexy is considered the gold standard for vaginal vault suspension throughout the literature due to its superior effectiveness and durability 1. The procedure involves suspension of the vaginal cuff to the sacrum using fascia or synthetic mesh, providing robust long-term support 2.
Key Advantages Over Sacrospinous Colpopexy:
- Better anatomic correction: Sacral colpopexy restores normal vaginal axis and provides superior apical support compared to sacrospinous suspension 2
- Lower recurrence rates: Abdominal approaches achieve dramatically better outcomes than vaginal approaches for vault prolapse 3
- Addresses multi-compartment defects: The procedure should always be accompanied by enterocele repair and cul-de-sac obliteration, allowing simultaneous correction of multiple pelvic floor defects 2
When Sacrospinous Colpopexy May Be Considered
Sacrospinous suspension has good safety and efficacy profiles but is less anatomically correct than sacral colpopexy 3. This vaginal approach should be reserved for:
- Elderly patients with significant medical comorbidities who cannot tolerate abdominal surgery 3
- Patients where the surgeon must balance anatomic correction against safety concerns 3
However, for moderate to severe multi-organ prolapse in appropriate surgical candidates, the less invasive approach should not compromise the superior anatomic outcomes achieved with sacral colpopexy 3.
Addressing Coexisting Rectocele and Cystocele
Multi-pelvic organ descent requires comprehensive repair of all defects simultaneously, not isolated rectocele or cystocele repair 4, 2. The evidence demonstrates:
- Rectal prolapse frequently coexists with other pelvic floor defects in 52 of 55 patients (95%) in one series 4
- Internal rectal prolapse may simulate a rectocele or enterocele, requiring defecography to establish the correct diagnosis 4
- Sacral colpopexy can be combined with rectopexy (with or without sigmoid resection), rectopubic urethropexy, and other reconstructive procedures in a single operation 4
Laparoscopic Approach
The laparoscopic approach to sacral colpopexy is highly effective with minimal morbidity when performed by experienced surgeons 1. This minimally invasive technique offers:
- Reduced postoperative complications compared to open surgery 1
- Shorter hospital stays 1
- Equivalent long-term anatomic outcomes 1
Critical Surgical Considerations
When performing sacral colpopexy for multi-organ prolapse:
- Always perform concurrent enterocele repair and cul-de-sac obliteration to prevent postoperative enterocele formation 2
- Assess for stress urinary incontinence (symptomatic or latent) and perform concurrent anti-incontinence procedures as needed 2
- Use meticulous technique to avoid complications including mesh infection, mesh erosion, bowel obstruction, and presacral venous bleeding 2
Special Consideration for Rectal Prolapse Component
If rectal prolapse is present as part of the multi-organ descent:
- Perform rectopexy (with or without sigmoid resection) combined with sacral colpopexy 4
- Add sigmoid resection if the patient has significant pre-existing constipation to reduce postoperative constipation rates 5
- Avoid bowel resection if the patient has pre-existing diarrhea or severe fecal incontinence, as symptoms may worsen 5
Common Pitfall to Avoid
Do not perform isolated rectocele or cystocele repair when multi-compartment prolapse is present 4. The mean number of failed surgical procedures before correct diagnosis of rectal prolapse was 1.5 in one series, highlighting the importance of comprehensive evaluation and definitive repair 4. Video defecography should be obtained when internal rectal prolapse is suspected to avoid misdiagnosis 4.