Complications of Female Incontinence and Pelvic Reconstructive Surgery (Current Clinical Urology) 2nd ed.

6. Complications of Abdominal Sacrocolpopexy

Michelle Koski1 and J. Christian Winters 

(1)

Department of Urology, Medical University of South Carolina, Charleston, SC 29425, USA

(2)

Department of Urology, Louisiana State University, 1542 Tulane Avenue, 5th Floor, Room 547, New Orleans, LA 70112, USA

J. Christian Winters

Email: cwinte@lsuhsc.edu

Abstract

With the aging of our population, pelvic organ prolapse is an increasingly common condition that negatively affects patient quality of life. Vaginal vault prolapse has been reported to occur in as many as 18.2% of all women with prolapse [1], and many would suggest that vaginal vault prolapse is a component of most high-grade anterior compartment descensus. Several repairs exist that reconstitute support to the vaginal vault, and certainly there is no single procedure that is optimal for all patients. Abdominal sacral colpopexy (ASC) offers an effective and durable repair for vaginal vault prolapse [2]. It maximizes functional vaginal length and approximates the normal vaginal axis [3]. ASC should be considered especially in patients with failed prior vaginal repairs, isolated high-grade apical prolapse, and in younger patients with apical prolapse who would like to maintain sexual function [4]. The procedure may be performed open, laparoscopically, or robotically. In our experience, the key components of the operation though the open or robotic approach include utilization of a permanent, type I macroporous mesh, secure suture fixation of the graft to the sacral promontory and vaginal cuff (Fig. 6.1), complete enterocele reduction and culdoplasty, and the addition of concomitant anti-incontinence procedures as indicated [4]. We affix the vaginal portion of the graft with multiple sutures to distribute the tension evenly over the vaginal apex (Fig. 6.2), and avoid excessive tension between the apex and sacrum (Fig. 6.3). We routinely close the peritoneum over the mesh arm. In this chapter we will address the recognition and management of complications potentially associated with this method of the repair, as well as outline complications that have arisen from other variations.

Introduction

With the aging of our population, pelvic organ prolapse is an increasingly common condition that negatively affects patient quality of life. Vaginal vault prolapse has been reported to occur in as many as 18.2% of all women with prolapse [1], and many would suggest that vaginal vault prolapse is a component of most high-grade anterior compartment descensus. Several repairs exist that reconstitute support to the vaginal vault, and certainly there is no single procedure that is optimal for all patients. Abdominal sacral colpopexy (ASC) offers an effective and durable repair for vaginal vault prolapse [2]. It maximizes functional vaginal length and approximates the normal vaginal axis [3]. ASC should be considered especially in patients with failed prior vaginal repairs, isolated high-grade apical prolapse, and in younger patients with apical prolapse who would like to maintain sexual function [4]. The procedure may be performed open, laparoscopically, or robotically. In our experience, the key components of the operation though the open or robotic approach include utilization of a permanent, type I macroporous mesh, secure suture fixation of the graft to the sacral promontory and vaginal cuff (Fig. 6.1), complete enterocele reduction and culdoplasty, and the addition of concomitant anti-incontinence procedures as indicated [4]. We affix the vaginal portion of the graft with multiple sutures to distribute the tension evenly over the vaginal apex (Fig. 6.2), and avoid excessive tension between the apex and sacrum (Fig. 6.3). We routinely close the peritoneum over the mesh arm. In this chapter we will address the recognition and management of complications potentially associated with this method of the repair, as well as outline complications that have arisen from other variations.

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Fig. 6.1

Type 1 macroporous mesh is sutured to the sacral promontory and the vaginal cuff

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Fig. 6.2

The mesh graft is affixed to the apex of the vagina with multiple sutures for even tension distribution

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Fig. 6.3

Intraoperative view: graft in final position. A space of two fingerbreadths between the graft and the rectum prevents compression of the rectum under the graft. Incised peritoneum will be closed over graft

Intraoperative Complications

In a large meta-review by Nygaard et al. [2], intraoperative complications included hemorrhage or transfusion (0.18–16.9%), cystotomy (0.4–15.8%), enterotomy or proctotomy (0.4–2.5%), and ureteral injury (0.8–1.9%). In patients undergoing the laparoscopic or robotic approach, intraoperative complications associated with pneumoperitoneum and port access may occur which are not unique to colpopexy.

Hemorrhage

Presacral hemorrhage incurred during the dissection of the sacral promontory is one of the most feared complications of ASC, as well as one of the more commonly reported in the literature [2]. Bleeding from the presacral space may be large volume because the bleeding vessels may retract into the sacrum. Historically, in the 1970s, the operation was described with fixation of the mesh graft to the level of S3–S4 below the sacral promontory in an attempt to create a more natural vaginal axis [5]. After a life-threatening hemorrhage at this site, Sutton advocated for fixation higher on the sacral promontory at the S1–S2 level [6]. This site allows better visualization of the middle sacral artery and the slight difference in vaginal axis has not resulted in negative outcomes. Careful dissection at the sacral promontory should be used to avoid laceration of unseen presacral vessels. Excessive blunt dissection should be avoided to prevent shearing of the presacral veins. Monopolar cautery should be used precisely, and diathermy cautery may be helpful as well. If bleeding occurs in the laparoscopic or robotic approach, increasing the intra-abdominal pressure to 20 cm H2O may slow the bleeding enough to see the vessel to cauterize. If uncontrollable bleeding is incurred which is not amenable to direct cautery, it may be managed with stainless steel thumbtacks [7], bone wax, or a figure of eight stitch [8].

Cystotomy, Enterotomy, and Ureteral Injury

Injury to the bladder or bowel may occur during dissection or inadvertently. Care should be taken at all points of bladder dissection to maintain a full thickness dissection and avoid cystotomy. Additionally, we try to avoid excessive cautery in the dissection of the bladder from the vagina. If a bladder injury is detected, it should be closed in two layers with absorbable suture and an adequately sized urethral catheter should be left for bladder drainage. At this point, it would be at the discretion of the surgeon whether to proceed with mesh attachment to the vaginal apex. Mesh should not be placed adjacent to or in proximity to the cystotomy as it might predispose to erosion of mesh into the bladder or fistula formation [9]. If vesical injury is missed, patients may present with fever, pain secondary to urinoma or urinary ascites.

Enterotomy with any fecal or enteric soilage precludes placement of mesh. The bowel injury should be repaired and the case concluded. This illustrates the benefit of preoperative bowel preparation. If enterotomy is missed, patients with unrecognized bowel injuries often present 1–2 days postoperatively and may lack the typical signs of peritonitis. Patients may present with low grade fever and leucopenia with a left shift. If the injury was incurred in a laparoscopic case, they may have severe pain at one of the trocar sites. The clinician should maintain a high index of suspicion to order a computed tomography (CT) scan in these patients.

The ureters should be identified early on in the case to avoid injury from dissection or entrapment or kinking in the culdoplasty sutures. To insure patency of the ureter we perform cystoscopy after the conclusion of the case with administration of indigo carmine or methylene blue to clearly visualize ureteral efflux.

Postoperative Complications

Postoperative complications in a comprehensive review included urinary tract infection ­(2.5–25.9%), wound infection or separation (0.4–19.8%), ileus (1.1–9.3%), deep venous thrombosis or pulmonary embolism (0.4–5.0%), and small bowel obstruction (SBO) (0.6–8.6%), and incisional hernia requiring repair (0.4–15%). Additionally, mesh erosion was noted at an overall rate of 3.4% in the 2,178 patients reviewed in this meta-analysis [2].

Vaginal Mesh Erosion

Key signs and symptoms of vaginal mesh erosion include persistent pain, discharge, and occasionally dyspareunia for the woman and/or her partner. Suture erosions are typically asymptomatic [1011]. A comprehensive review of ASC quoted an overall mesh erosion rate of 3.4% [2], although rates of erosion quoted in the literature vary [101214]. While mesh erosions after ASC typically occur 4–24 months after surgery [1012], they may also present several years later [15]. Because of this, determining an accurate erosion rate in series is complicated by length of follow-up. Additionally, mesh type, surgical technique, and modifiable factors may affect the rate of erosion.

Mesh type appears to affect erosion rates based on comparison of the literature, although there have been no standardized trials comparing different materials. In the Nygaard meta-analysis, polypropylene carried an erosion rate of 0.5% in comparison to 3.1% for polyethylene terephthalate (Mersilene; Johnson & Johnson), 3.4% for polytetrafluoroethylene (Gore-Tex; W.L. Fore, Flagstaff, AZ), 5.0% for polyethylene (Phillips Sumika, Polypropylene Co., Houston, TX) and 5.5% for Teflon (E.I. DuPont de Nemours and Co.) [2]. No conclusions were made in this review regarding whether certain mesh types predispose to erosion because in this setting they could not control for other variables (method of graft placement, concurrent hysterectomy, etc.). However, certainly, particular mesh materials are more at risk for erosion. Govier et al. found a 23.8% graft complication rate (mesh erosion or infection) in a retrospective review of 21 patients who underwent ASC using a silicone coated polyethylene preformed graft [13]. A subanalysis of the Colpopexy and Urinary Reduction Efforts (CARE) study found a nearly fourfold increased risk of mesh erosion if Gore-Tex mesh was used compared to non-Gore-Tex mesh, which reached statistical significance and altered their use of Gore-Tex mesh [14].

Biologic materials are not without complication. Allograft fascia lata has been described as a biologic alternative to mesh. This material precludes the risk of mesh erosion. However, reports of failures associated with attenuation or absence of the fascia lata graft in reoperation [1617], presumably secondary to autolysis, have led to decreased use of this material. A retrospective cohort study comparing polypropylene mesh to Pelvicol (CR Bard, Murray Hill, NJ) and autologous fascia found a higher rate of failures as well as erosions and other graft-related complications in the Pelvicol group (although it should be noted that Pelvicol was used more frequently in patients undergoing concomitant hysterectomy) [18]. Similar findings of high rates of graft-related complications and unacceptable failure rates were found with porcine grafts [19].

A modifiable risk factor for erosion after ASC identified by the CARE trial analysis was tobacco use [14]. In their group of 322 patients, smoking was associated with a fivefold increased risk of erosion. A retrospective study of 499 patients undergoing ASC found a nonsignificant trend of smokers requiring more than one surgery for effective treatment of vaginal mesh erosion [20]. The dominant theory is that microvascular vasospasm with associated hypoxia may lead to poor wound healing and vaginal mesh erosion in smokers [15].

Approach and technique affect mesh erosion rates. If graft or suture is introduced through the vagina in sacral colpoperineopexy, erosion rates are increased. In a retrospective review of 273 patients, there was no statistically significant difference in mesh erosion rates for patients undergoing ASC (3.2%) or purely abdominal sacral colpoperineopexy (4.5%). In patients undergoing sacral colpoperineopexy with vaginal introduction of mesh or sutures, the erosion rates increased to 16% (vaginal placement of sutures) and 40% (vaginal mesh), which maintained statistical significance on multivariate analysis. These patients exhibited a shorter time to mesh erosion as well, with median time to erosion 15.6 months for ASC, 12.4 months for abdominal sacral colpoperineopexy, 9.0 months in the suture group (P  <  0.005), and 4.1 months in the vaginal mesh group (P  <  0.0001) [21].

The role of concomitant hysterectomy in mesh erosion after ASC has been debated. In the CARE subanalysis [15], concurrent abdominal hysterectomy was performed in 26% of the patients, who incurred a 14% risk of erosion as compared to 4% in women who had undergone prior hysterectomy. This represented a fivefold increased risk of erosion. Culligan et al. found a statistically significant increase in erosion rates in patients undergoing concomitant hysterectomy in a retrospective review of 245 patients (27.3% erosion in those undergoing hysterectomy, 1.3% erosion without hysterectomy) [22]. A retrospective review of 313 patients found a statistically significant fivefold risk of mesh erosion in women on estrogen with concomitant hysterectomy [23]. Of note, they found no significant difference in erosion rates in those undergoing concurrent hysterectomy in the non estrogen group, or in the overall group as well. This data implies that either estrogen or hysterectomy may increase erosion rates. In our experience, it seems hysterectomy would be the most likely risk factor. In contrast, in a retrospective review of 124 patients undergoing ASC (60 with hysterectomy and 64 without), Brizzolara et al. found a low overall mesh erosion rate of 0.8% and no significant difference in mesh erosions in the hysterectomy group [12]. They attributed their success to two-layer closure of the cuff, careful handling of tissues and use of antibiotic irrigation [12]. Based on these findings, if a small vaginal laceration is encountered during colpopexy, we close the laceration in two layers as described in the previous study. In reviewing outcomes of colpopexy following hysterectomy, the significance of the CARE subanalysis, as opposed to retrospective reviews, is that it was prospectively designed to capture complications, including mesh and suture erosions, at regular study intervals in the first 2 years.

In cases of mesh erosion after combined hysterectomy and ASC, the erosion site is usually at the cuff. This may be secondary to potential vaginal bacterial contamination of the mesh from the opened vagina during hysterectomy. Alternatively, poor healing may occur at the cuff secondary to a devascularizing effect of cuff closure combined with mesh vaginal attachment sutures [15]. Some authors advocate supra-cervical hysterectomy as an alternative to total hysterectomy at the time of ASC [13]. Currently, the practice of concomitant hysterectomy and ASC remains controversial.

In cases of erosion of Type I mesh (Dacron, Marlex, Prolene), treatment with antibiotics and trimming and covering of the mesh is sufficient [11]. Because of the macroporous nature of the mesh, it is expected that macrophages will pass, making complete removal of the graft unnecessary. Additionally, eroded Type III mesh (combinations of multifilament and macroporous components: Teflon, Mersilene) may be treated with partial removal and reclosure of vaginal flaps [11]. However, infected Type II mesh (microporous material: Gore-Tex) must almost always be removed completely, as its microporous nature creates a bacterial sanctuary where access to antibiotics and the immune response is reduced [1115].

Conservative therapy with observation and topical estrogen may be initially attempted in small mesh erosions of type I or III mesh (<1 cm). Local excision of mesh is utilized as first line therapy as well, or in cases of failed conservative therapy. In a series of vaginal erosions of Ethibond (Ethicon, Somerville, NJ) suture and Marlex and Mersilene mesh, patients presented at an average of 14 months postoperatively (range 4–24). All patients were initially treated with vaginal estrogen and 8 weeks of pelvic rest. Two patients with suture erosions resolved with this regimen, but all five patients with mesh erosion required surgical intervention and were successfully treated with vaginal mesh excision and flap advancement [10]. In another series, local surgical excision of exposed mesh carried a reported efficacy rate of 50% [20]. If the upper portion of the mesh is infected, it must be removed [15]. In the CARE subanalysis, 6% of patients experienced mesh/suture erosion. Most of the women with mesh erosion (13/17) underwent at least one surgery for partial or total mesh removal. Two patients completely resolved, 6 had persistent problems, and 5 were lost to follow-up [15]. Of the four women who elected observation, none experienced resolution [15].

Well-circumscribed areas of mesh extrusion may be approached vaginally. We excise only the exposed area with an additional margin of 1–2 cm; not all of the mesh needs to be excised. Surgical exposure of apical mesh extrusions in the postsacrocolpopexy patient is more challenging than in distal vaginal extrusions. When the apex is well supported, it may be difficult to pull the apex into the forefront of the surgical field. We use a Lone Star retractor (Cooper Surgical, Trumbull, CT) with sharp hooks placed proximal to the mesh to expose as well as possible. Hydrodissection may be utilized around the area of the extrusion. We grasp the edge of the vaginal margin and dissect laterally between the vaginal margin and the mesh with Metzenbaum scissors to create vaginal flaps that extend about 2 cm circumferentially. If the edge of the mesh is available, we grasp that edge and begin our dissection underneath the mesh. If an edge is not accessible, we incise the mesh and isolate each resultant edge in an Allis clamp. Oftentimes, the mesh will peel off the underlying tissue with a combination of blunt and sharp dissection. We keep the scissor tips pointing toward the mesh. Once the mesh has been separated back to the edges of the initial dissection we inspect the quality of the edges of our vaginal margins. If there is any question about the quality of the tissue, we will excise or debride the edges. Finally, we reapproximate the vaginal flaps with absorbable suture in a tension-free closure with no mesh under the suture line. Other authors have advocated a partial colpocleisis type approach [20]. If the initial extrusion is extensive or if prior vaginal approaches have failed, an abdominal approach may be attempted. Abdominal excisions are associated with higher blood loss, longer hospitalization, and additional morbidity [20].

In all cases, the approach to extrusions is vaginal unless there is other intra-abdominal pathology warranting correction. In an abdominal approach, extensive scarring and adhesions will be encountered. A full bowel preparation is recommended and vaginal localization can be assisted with the use of an EEA sizer and or a Lucite vaginal stent. Partial removal of offending mesh is acceptable unless gross infection is ­present. The vaginal defect should be repaired in two layers using absorbable sutures. In cases of poor tissue quality, a biologic interposition over the vaginal cuff or omentum may be utilized to assist in cuff healing.

Erosion of Mesh into Bladder or Bowel

Patients with mesh erosion into the bladder after ASC may present with hematuria, irritative voiding symptoms, recurrent urinary tract infections, or chronic bladder stones. Diagnosis of this problem hinges on a high index of suspicion and a low threshold to perform cystoscopy. Maintaining a full thickness of the bladder without cystotomy during dissection, or alternatively, minimizing bladder mobilization may help in avoiding this complication.

Patsner reported a case of erosion of polypropylene mesh and Prolene suture into the bladder base presenting 4 months after ASC who was treated with open excision after two failed cystoscopic attempts [24]. Yamamoto et al. report a vesicovaginal fistula after abdominal hysterectomy and ASC which occurred adjacent to the edge of the mesh and required abdominal repair [9]. In our experience, we have not had a mesh or suture erosion into the bladder secondary to ASC, but we have acquired a skill set from dealing with vesical mesh erosions from other causes (Fig. 6.4). Depending on the site of erosion and the amount of mesh, a cystoscopic approach may be attempted. If this fails or is precluded by position or mesh volume, an open cystorrhaphy may be necessary. If the mesh is near the ureteral orifice, the surgeon should consider a retrograde pyelogram or a ureteral stent to delineate the ureter. In a retrospective review of intravesical mesh management cases (from various causes), Frenkl et al. concluded that, in their experience, sutures were managed most successfully with endoscopic techniques, where mesh was best managed with cystorrhaphy [25].

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Fig. 6.4

Cystoscopic view of mesh erosion into the bladder

There have been only three reported incidences of mesh erosion into the bowel. In a rare report of mesh erosion into the sigmoid colon 8 years after ASC, the patient was noted to have stool in her vagina and was ultimately treated with sigmoid colon resection with a low colorectal reanastamosis and omental J-flap placement [26]. Kenton et al. described a Gore-Tex graft erosion into the rectum with spontaneous passage of the graft 7 years post-ASC without fistula formation [27]. Hopkins and Rooney describe a small bowel fistula secondary to adhesion of a loop of terminal ileum to an exposed mesh that had been “minimally retroperitonealized” [28]. Based on this, they advocate retroperitonealization of the mesh as a way to prevent adhesion of bowel. Most early descriptions of sacrocolpopexy describe closing the peritoneum over the graft. Other authors question the utility of this step. In a small study of 35 women, 3 had postoperative bowel obstructions, all resulting from intestine trapped under the mesh, despite careful retroperitonealization [29]. Due to the low incidence of bowel mesh erosions, it is unlikely that this question will be addressed in a standardized fashion. In order to prevent these complications, we would advise meticulous placement of the mesh with careful attention to ensure an adequate space between the mesh and the sigmoid colon. We routinely close the peritoneum over the mesh.

Ileus and Small Bowel Obstruction

The reported incidence of postoperative ileus is a median 3.6% (range 1.1–9.3%) of patients and reoperation for SBO is a median 1.1% (range 0.6–8.6%) after ASC in meta-analysis [2]. This review was comprised mostly of retrospective reports. The findings from a subanalysis of the CARE trial supported these findings in the framework of a large prospective trial [30]. Of their 322 patients, 5.9% had postoperative gastrointestinal conditions resulting in reoperation, prolonged hospitalization, or readmission. Four patients (1.2%) required reoperation and all were found to have small bowel entrapment in, or adhesion to, the abdominal wall incision (Fig. 6.5). Overall, the rate of SBO was 1.9–2.5% and the rate of ileus was 2.2–2.8%. Age was found to have a significant association with ileus [30]. Prior abdominal surgery was not significantly associated, but the study was not sufficiently powered to rule this out. Of note, 18% of their patients experienced nausea, vomiting and bloating postoperatively and they make note that 20–30% of patients may experience these symptoms after general anesthesia for any surgery [31].

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Fig. 6.5

Radiographic images of a patient with partial small bowel obstruction after abdominal sacral colpopexy. The CT scan shows distended loops of bowel with a transition point marked with an arrow

Recurrence

Recurrent vaginal vault prolapse after ASC with permanent mesh is rare. The success rate, when defined as lack of apical prolapse postoperatively, ranges from 78 to 100% [2]. Baessler et al. proposed that rare cases of symptomatic apical recurrence are usually secondary to detachment of the mesh from the vagina and that separation of the mesh from the sacrum is much less common [11]. If the mesh is still secured to the sacrum, they describe attaching a new mesh to it, which is then sutured to the vagina. They warn against removal of the original mesh due to the high risk of hazard to the ureter and bowel in a potentially difficult dissection. Addison et al. reiterate this in their series of recurrences, all resulting from disruption of the mesh from the vaginal apex (one of these cases secondary to a dissection of an enterocele beneath the mesh, causing disruption) [32]. They advocate performing a meticulous culdoplasty with permanent sutures and attachment of the mesh to the vaginal vault with multiple permanent sutures placed through the entire thickness of the vagina over a broad area as methods to help prevent recurrence [32].

Unmasking of Occult Stress Incontinence

We routinely assess for occult SUI preoperatively with either urodynamics or cough stress test with the prolapse reduced. Rates of urodynamic SUI with prolapse reduction have been reported ranging from 25 to 100% in symptomatically continent women using various methods of reduction [33]. Patients undergoing ASC are at significant risk for developing bothersome stress urinary incontinence, even in the absence of preoperative symptoms. This was well illustrated in the CARE study [34]. In a prospective, controlled trial of 322 previously stress-continent women, 23.8% who underwent Burch colposuspension at the time of ASC showed postoperative SUI compared to 44.1% who underwent ASC alone. Those in the ASC alone group were also more likely to report bothersome SUI symptoms as compared to the Burch group (24.5% vs. 6.1%) [34]. Women who demonstrated preoperative SUI with prolapse reduction were more likely to report postoperative SUI, regardless of concurrent colposuspension (controls 58% vs. 38% (P  =  0.04) and Burch 32% vs. 21% (P  =  0.19)) [33]. In this study, the majority of women who did not leak with prolapse reduction did not leak after prolapse surgery (60%). In addition, women who did have a Burch procedure still experienced an approximately 30% rate of recurrent SUI. Based on these findings, we use urodynamics to counsel our patients and identify who might best benefit from concurrent anti-incontinence procedures, but we also inform our patients that a negative test does not preclude postoperative incontinence. We prefer midurethral sling concurrently in patients undergoing ASC with symptomatic or occult SUI detected on screening. If women have significant obstructive symptoms on urodynamics with the prolapse reduced, we will perform ASC without sling. If a woman has no occult SUI or symptoms of SUI, patients choose whether or not to undergo concomitant sling. Our bias is to not place a sling at that time. If patients develop SUI after ASC alone, a midurethral sling can be placed at a later date with minimal difficulty.

Osteomyelitis

Osteomyelitis after ASC is rare, and is generally heralded by persistent new low back pain. Weidner et al. described two cases of lumbosacral osteomyelitis after ASC, both treated successfully and definitively with prolonged parenteral antibiotic therapy guided by aspirated cultures and neither requiring mesh removal [35]. One patient presented with unremitting severe low back pain 5 years after ASC, and the second patient presented 2 months postoperatively. Both sacral fixations were performed with Ticron (Davis and Geck, Wayne, NJ) suture. Both were diagnosed on MRI, which is the most sensitive method for detecting osteomyelitis and defining the extent of the infection. Plain films and bone scan may be diagnostic, but are less sensitive than MRI. The authors suggest maintaining a higher level of suspicion for osteomyelitis in patients with a history of degenerative disc disease [35], as patients with degenerative disc disease are predisposed to infection due to disruption of the vertebral endplate and neovascularization of disc spaces, which allows bacteria into a normally avascular space [36]. In the rheumatologic literature, Cailleux et al. reported on five cases of sacral osteomyelitis after ASC (of a retrospective review of 45 patients with sacral osteomyelitis) [37]. Initial symptoms occurred at an average of 38 days postoperatively. In three of the patients, the same bacterial species was identified in urine cultures 1–4 days postoperatively as in the biopsy of the infected bone.

Since these initial series, there have been more reports, usually in the form of case report. Nosseir et al. reported a case secondary to titanium tacks that resolved with parenteral antibiotics [38]. Muffly et al. reported a case of osteomyelitis and infected mesh with a sinus tract after robotic hysterectomy and ASC which required discectomy, sacral debridement, and mesh removal [39]. Another case of sacral osteomyelitis with concomitant mesh erosion and sinus formation required mesh removal and tract resection [40]. Taylor et al. described a case that presented with vaginal erosion of mesh and osteomyelitis with progressive neurologic symptoms requiring a decompressive laminectomy [41].

We advocate empiric routine preoperative IV antibiotics and meticulous surgical technique with mesh and other permanent implants. Patients with degenerative disc disease may be at increased risk of osteomyelitis and should be treated with care as well as a higher index of suspicion postoperatively. MRI should be used to rule out osteomyelitis in the carefully selected patient, and if possible, CT-guided aspiration and culture should be performed to guide antibiotic therapy. Isolated osteomyelitis may respond to prolonged antibiotics alone. In cases that fail antibiotics or in patients with mesh erosion, infection, or sinus tracts, surgery may be required. The urologist should maintain a low threshold to consult infectious disease, orthopedics, and/or neurosurgery as indicated by the patient’s presentation.

Conclusion

Sacrocolpopexy is a well-established standard of care for the surgical correction of vaginal vault prolapse. It has become minimally invasive with the robotic and laparoscopic approach. In many ways it is now a more comparable alternative to vaginal apical repair operations. Complications occur at a low incidence [2]. For the vast majority of patients, this procedure provides a gratifying outcome which is durable and anatomic. A thorough knowledge of anatomy, graft biology, and potential complications is optimal in order to assure this procedure may be performed as safely and efficiently as possible.

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