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Sacrocolpopexy

Sacrocolpopexy is the gold-standard surgical procedure for apical vaginal prolapse repair. A Y-shaped synthetic mesh is attached to the anterior and posterior vaginal walls and suspended to the anterior longitudinal ligament of the sacrum, restoring apical support along a near-anatomic axis. It can be performed open, laparoscopically, or with robotic assistance — laparoscopic and robotic approaches are now standard at most contemporary centers, with comparable outcomes.[1][2][3]

For the supracervical hysterectomy that is preferred when concomitant hysterectomy is performed at sacrocolpopexy, see Supracervical Hysterectomy at Sacrocolpopexy. For uterus-preserving abdominal-mesh variants, see Sacrohysteropexy / Sacrocervicopexy and Pectopexy. For the broader prolapse decision framework, see Prolapse Repair.

Definition and Mesh​

The bladder and rectum are dissected off the vagina, mesh is fixed along the anterior and posterior vaginal walls, and the mesh tail is suspended to the sacral promontory; peritoneum is closed over the mesh.[4][5]

Sacrocolpopexy Y-mesh in sagittal view: anterior and posterior arms sutured to the vaginal walls join into a stem fixed to the anterior longitudinal ligament at the sacral promontory

The Y-mesh in sagittal section. An anterior arm and a posterior arm are sutured along the vaginal walls (after the bladder and rectum are dissected off) and join into a single stem carried retroperitoneally to the sacral promontory, where it is fixed to the anterior longitudinal ligament just below S1. The mesh should bridge tension-free along the natural vaginal axis — overtensioning causes pain/dyspareunia, undertensioning risks recurrence. Stay clear of the right ureter and the presacral (middle sacral) vessels; re-peritonealize the mesh. (Original WARWIKI schematic)

ComponentRecommendation
Mesh materialType 1 monofilament polypropylene — multifilament and small-pore meshes have higher complication rates and are no longer used[1][2][3]
Mesh weightLightweight polypropylene — long-term graft-related complications 7.3% vs 22.8% for heavier-weight (HR 3.3)[14]
Vaginal-side suturesAbsorbable — eliminates suture-erosion risk without compromising anatomic outcome[3][9]
Sacral-side suturesPermanent (non-absorbable) sutures or tackers[3]
PeritonealizationClose peritoneum over the mesh[3]
Synthetic vs biologic graftSynthetic mesh is superior — 93% vs 62% anatomic cure at 5 yr with cadaveric fascia lata[7][1]

Indications and Patient Selection​

Per ACOG and AUGS:[1][7]

  • Post-hysterectomy vaginal vault prolapse — best-established indication.
  • Shortened vaginal length or intra-abdominal pathology requiring concurrent management.
  • Risk factors for recurrent prolapse: younger age, advanced stage, BMI ≥ 26 kg/m².
  • Recurrent prolapse after prior vaginal repair.

For women at increased risk of mesh complications (chronic steroid use, current smokers), biologic grafts or alternative procedures should be considered.[1][7]

Surgical Approaches — Open vs Laparoscopic vs Robotic​

Laparoscopic is the preferred technique (Grade B); robotic assistance is equivalent.[3][2]

ParameterOpenLaparoscopicRobotic-Assisted
Operative timeShorter (~222 min)Moderate (~296 min)Longer than laparoscopic[1]
Blood lossHigher (~187 mL)Lower (~122 mL)Lowest[1][2]
Hospital stayLonger (~2.9 d)Shorter (~1.3 d)Similar to laparoscopic[1][3]
Anatomic outcomesEquivalentEquivalentEquivalent[4][5]
Conversion to laparotomyN/AHigherLower (OR 0.2)[2][5]
CostLowerLowerHigher[1][4]

A 2026 meta-analysis (5 RCTs + 24 observational studies) confirmed equivalent anatomical and clinical outcomes between robotic and laparoscopic approaches; robotic may be advantageous in technically demanding cases due to lower conversion.[9]

Robotic Sacrocolpopexy — Technique​

The robotic platform offers wristed instrumentation, 3D visualization, tremor filtration, and facilitated intracorporeal suturing — particularly suited to the deep pelvic suturing demands of sacrocolpopexy.[1][13]

Positioning and port placement​

Dorsal lithotomy with steep Trendelenburg.[4][5][1]

  • Camera port: 12 mm, at or above umbilicus (higher in obese patients).
  • Two robotic arm ports: 8 mm, lateral to rectus muscles bilaterally.
  • One or two assistant ports: 5–12 mm, lateral.
  • Three-arm robotic configuration common; some surgeons use a fourth arm for retraction.[6]
  • Intravaginal retractor / manipulator (EEA sizer or vaginal stent) is essential for elevating the apex and delineating dissection planes.[5][1]

Step-by-step​

  1. Sacral-promontory exposure. Peritoneum incised over the promontory; identify and preserve the right ureter and presacral vessels (middle sacral artery / vein). Keep dissection superficial — only enough to expose the anterior longitudinal ligament for suture / tacker placement; extend the peritoneal incision caudally toward the vaginal apex in a retroperitoneal tunnel.[4][1]
  2. Anterior vaginal dissection. Reflect the bladder off the anterior vaginal wall (sharp + blunt dissection); the intravaginal manipulator delineates the vesicovaginal plane. Dissect distally to the level of the trigone for adequate anterior support.[6][4]
  3. Posterior vaginal dissection. Dissect the rectum off the posterior vaginal wall; the deepest row of sutures should extend down to the levator-ani plane for posterior support.[6]
  4. Mesh attachment to vagina (Y-shaped Type-1 lightweight polypropylene). Standardized Giannini 2022 suturing pattern (yielded 0% mesh exposure and 6.7% retreatment at 24 months):[6]
    • Apex / cervix: 3 non-absorbable stitches (cervicosacropexy) or 3 absorbable stitches (vault colpopexy)
    • Anterior vaginal wall: 6 long-term absorbable sutures extending to the trigone base
    • Posterior vaginal wall: 6 long-term absorbable sutures extending to the levator-ani plane
  5. Mesh fixation to sacral promontory. Bring the mesh tail to the promontory and secure to the ALL — typically 2–3 non-absorbable sutures (Ethibond or Gore-Tex). Permanent tackers are faster but carry a theoretical risk of discitis / osteomyelitis. Tension the mesh to allow the apex to sit at the level of the ischial spines — overtensioning causes pain / dyspareunia, undertensioning risks recurrence.[6][1]
  6. Retroperitonealization. Close peritoneum over the mesh with a running absorbable suture to prevent bowel adhesion to mesh.[4][1]
  7. Cystoscopy. Confirm ureteral patency and bladder integrity at conclusion.[7][4]

Vaginal-attachment suture options​

TechniqueNotes
Interrupted non-barbed absorbableTraditional; slowest (mesh attachment ~42 min)[1]
Running barbed absorbable (Quill)11–16 min faster than interrupted; slightly lower surgeon-satisfaction scores[1][2]
Absorbable anchors (SureClose)Fastest (12 min vs 21 min); limited long-term data[3]
Delayed-absorbable suture (PDS) to vaginaEliminates suture-erosion risk; equivalent anatomic outcomes; preferred over non-absorbable on the vaginal side[4][9]
Non-absorbable suture to vaginaTraditional; 9 suture erosions requiring excision in one series[4]

Non-absorbable sutures remain standard for the sacral promontory.[6]

Single-port vs multi-port​

An RCT (n = 70) of robotic single-site (LESS) vs multi-port:[10]

  • Multi-port was 24 minutes faster overall (157 vs 181 min, p = 0.018).
  • Console time 33 minutes shorter with multi-port.
  • Anatomic outcomes equivalent.

The articulating single-port platform offers advantages in narrow spaces (single 2.5 cm incision).[11][12]

Robotic learning curve​

  • Operative-time efficiency stabilizes after 20–30 cases (25% decrease after first 10).[4][3]
  • Complication-based proficiency at 55–84 cases.[15][16]
  • Overall proficiency at ~78 cases by CUSUM.[15]
  • For surgeons with extensive laparoscopic experience, the curve may shorten to 10–20 procedures.[18][13]
  • ACOG notes ongoing improvement throughout the first 100 surgeries.[3]

Technical pearls​

  1. Sigmoid retraction is critical — suture through sigmoid mesentery, fourth-arm bowel grasper, or magnetic retraction.[7]
  2. Use a 30° scope alternating "up" and "down" facing for optimal visualization across phases.[2]
  3. Avoid excessive presacral dissection — only expose enough ALL for 2–3 suture bites; minimizes presacral hemorrhage.
  4. Peritoneal tunneling between promontory incision and vaginal apex simplifies retroperitonealization and reduces operative time.[8][12]
  5. Always perform cystoscopy — bladder injury rate ~2.5%.[4]

Efficacy and Outcomes​

SourceEndpointResult
NICHD PFDN RCT (Menefee 2024)36-mo composite failure28% SCP vs 43% NTR (aHR 0.57, p = 0.01); TVM noninferior to SCP at 29%[10]
Pooled meta-analysisAnatomic success vs NTROR 2.04 (95% CI 1.12–3.72)[7][1]
CARE 7-yr extensionComposite POP failure27–48% depending on definition; apical success remains high; anterior / posterior recurrence more common[11]
Pacquée 86-mo prospective cohortPatient-reported improvement82.5%; apical anatomic failure 8.6%[12]

Complications​

Compared with native-tissue vaginal repair, sacrocolpopexy carries higher rates of:[1][7]

ComplicationSCPNTR
Ileus / SBO2.7%0.2%
Thromboembolic events0.6%0.1%
Mesh / suture complications4.2%0.04%

Mesh exposure — long-term concern​

  • Contemporary minimally invasive series: ~3.5%.[13]
  • CARE 7-yr: 10.5% mesh erosion (many cases used non-Type-1 mesh).[11]
  • Lightweight polypropylene reduces graft complications vs heavier mesh (7.3% vs 22.8%, HR 3.3).[14]
  • Mesh exposure rates are comparable across open, laparoscopic, and robotic approaches (~5.3% overall).[15]

Concomitant Hysterectomy​

A critical decision point.

  • Concomitant total hysterectomy is associated with significantly higher mesh exposure vs supracervical (pooled OR 0.26 favoring supracervical; 3.8% vs 0.36% mesh erosion).[16][17]
  • A population-based study (n = 12,189): reoperation for mesh complications 0.7% supracervical vs 3.1% total (8.9% vs 2.1% with ≥ 4 yr follow-up).[17]
  • Supracervical hysterectomy is preferred when hysterectomy is performed concurrently — though some large database studies show similar rates.[2][16][18][19]
  • Uterine preservation (sacrohysteropexy) is an emerging option; further RCT data needed.[2][3]

See Supracervical Hysterectomy at Sacrocolpopexy for the dedicated atlas page.

Concomitant Anti-Incontinence Procedures​

Approximately 40% of continent women develop de novo SUI after prolapse repair due to unmasking of occult incontinence.[20]

The CARE trial demonstrated that adding Burch colposuspension at sacrocolpopexy reduced postoperative SUI from 44% to 24% in women without preoperative SUI symptoms.[5] A 2026 Cochrane review confirmed concomitant Burch probably reduces new-onset SUI; long-term effects less certain.[21]

Commonly performed concomitant procedures:[4][3]

  • Burch colposuspension or midurethral sling — for SUI
  • Paravaginal repair — for lateral cystocele defects
  • Posterior colporrhaphy or perineorrhaphy
  • Rectopexy — when concurrent rectal prolapse

Postoperative Recovery​

Emerging evidence supports expedited return to activity after sacrocolpopexy. A 2023 RCT and a 2025 retrospective study both demonstrated that moderate-to-high physical activity does not compromise anatomic outcomes at 2 years, challenging traditional prolonged activity restrictions.[22] Minimally invasive approaches allow hospital discharge within 1–2 days.[1]

Key Principles​

  • Sacrocolpopexy is the preferred procedure for apical prolapse (Grade A); the durability benchmark for vault repair.[3][10]
  • Use Type-1 lightweight monofilament polypropylene mesh — heavier mesh and non-Type-1 mesh drive complication rates.[1][3][14]
  • Laparoscopic and robotic approaches are equivalent; choose based on surgeon experience and case complexity.[9]
  • Avoid concomitant total hysterectomy when possible; supracervical hysterectomy or uterine preservation is preferred.[2][16][17]
  • Delayed-absorbable suture on the vaginal side eliminates suture-erosion risk without compromising outcome; non-absorbable remains standard at the sacral promontory.[6][9]
  • Mesh tensioning matters — apex should sit at the level of the ischial spines; over-tension causes pain, under-tension recurrence.[6]
  • Cystoscopy is mandatory — bladder injury rate ~2.5%.[4]
  • 40% de novo SUI risk without concomitant anti-incontinence procedure — Burch reduces this to 24% (CARE).[5][20]
  • Robotic learning curve: efficiency at 20–30 cases; full proficiency at ~78 cases.[15][3]
  • Long-term follow-up is essential — late mesh complications and progressive failure rates extend beyond 5 years.[11]

References​

1. Committee on Practice Bulletins—Gynecology and American Urogynecologic Society. Pelvic organ prolapse: ACOG Practice Bulletin, Number 214. Obstet Gynecol. 2019;134(5):e126-e142. doi:10.1097/AOG.0000000000003519.

2. Shahid U, Chen Z, Maher C. Sacrocolpopexy: the way I do it. Int Urogynecol J. 2024;35(11):2107-2123. doi:10.1007/s00192-024-05922-0.

3. Costantini E, Brubaker L, Cervigni M, et al. Sacrocolpopexy for pelvic organ prolapse: evidence-based review and recommendations. Eur J Obstet Gynecol Reprod Biol. 2016;205:60-5. doi:10.1016/j.ejogrb.2016.07.503.

4. Yeung E, Baessler K, Christmann-Schmid C, et al. Transvaginal mesh or grafts or native tissue repair for vaginal prolapse. Cochrane Database Syst Rev. 2024;3:CD012079. doi:10.1002/14651858.CD012079.pub2.

5. Brubaker L, Cundiff GW, Fine P, et al. Abdominal sacrocolpopexy with Burch colposuspension to reduce urinary stress incontinence. N Engl J Med. 2006;354(15):1557-66. doi:10.1056/NEJMoa054208.

6. Giannini A, Russo E, Misasi G, et al. Technical features, perioperative and anatomical outcomes of a standardized suturing pattern for robotic sacrocolpopexy. Int Urogynecol J. 2022;33(11):3085-3092. doi:10.1007/s00192-021-05049-6.

7. American Urogynecologic Society. Pelvic organ prolapse. Female Pelvic Med Reconstr Surg. 2019;25(6):397-408. doi:10.1097/SPV.0000000000000794.

8. Guan X, Ma Y, Gisseman J, Kleithermes C, Liu J. Robotic single-site sacrocolpopexy using barbed suture anchoring and peritoneal tunneling technique: tips and tricks. J Minim Invasive Gynecol. 2017;24(1):12-13. doi:10.1016/j.jmig.2016.06.012.

9. Ferrari A, Borrelli M, Moretti G, et al. Laparoscopic versus robot-assisted sacrocolpopexy: a systematic review and meta-analysis. BJOG. 2026. doi:10.1111/1471-0528.70218.

10. Menefee SA, Richter HE, Myers D, et al. Apical suspension repair for vaginal vault prolapse: a randomized clinical trial. JAMA Surg. 2024;159(8):845-855. doi:10.1001/jamasurg.2024.1206.

11. Nygaard I, Brubaker L, Zyczynski HM, et al. Long-term outcomes following abdominal sacrocolpopexy for pelvic organ prolapse. JAMA. 2013;309(19):2016-24. doi:10.1001/jama.2013.4919.

12. Pacquée S, Nawapun K, Claerhout F, et al. Long-term assessment of a prospective cohort of patients undergoing laparoscopic sacrocolpopexy. Obstet Gynecol. 2019;134(2):323-332. doi:10.1097/AOG.0000000000003380.

13. Deblaere S, Hauspy J, Hansen K. Mesh exposure following minimally invasive sacrocolpopexy: a narrative review. Int Urogynecol J. 2022;33(10):2713-2725. doi:10.1007/s00192-021-04998-2.

14. Page AS, Cattani L, Pacquée S, et al. Long-term data on graft-related complications after sacrocolpopexy with lightweight compared with heavier-weight mesh. Obstet Gynecol. 2023;141(1):189-198. doi:10.1097/AOG.0000000000005021.

15. van Zanten F, Schraffordt Koops SE, Pasker-De Jong PCM, Lenters E, Schreuder HWR. Learning curve of robot-assisted laparoscopic sacrocolpo(recto)pexy: a cumulative sum analysis. Am J Obstet Gynecol. 2019;221(5):483.e1-483.e11. doi:10.1016/j.ajog.2019.05.037.

16. Nassif J, Yadav GS, Orejuela FJ, Turrentine MA. Rate of mesh erosion after sacrocolpopexy with concurrent supracervical compared with total hysterectomy: a systematic review and meta-analysis. Obstet Gynecol. 2022;140(3):412-420. doi:10.1097/AOG.0000000000004901.

17. Dallas K, Taich L, Kuhlmann P, et al. Supracervical hysterectomy is protective against mesh complications after minimally invasive abdominal sacrocolpopexy: a population-based cohort study of 12,189 patients. J Urol. 2022;207(3):669-676. doi:10.1097/JU.0000000000002262.

18. Kikuchi JY, Yanek LR, Handa VL, et al. Prolapse and mesh reoperations following sacrocolpopexy: comparing supracervical hysterectomy, total hysterectomy, and no hysterectomy. Int Urogynecol J. 2023;34(1):135-145. doi:10.1007/s00192-022-05263-w.

19. Glass Clark S, Bretschneider CE, Bradley MS, et al. Risk of postoperative mesh exposure following sacrocolpopexy with supracervical versus total concomitant laparoscopic hysterectomy. Int Urogynecol J. 2024;35(1):207-213. doi:10.1007/s00192-023-05658-3.

20. Committee on Practice Bulletins—Gynecology and American Urogynecologic Society. ACOG Practice Bulletin No. 155: Urinary incontinence in women. Obstet Gynecol. 2015;126(5):e66-e81. doi:10.1097/AOG.0000000000001148.

21. Baessler K, Christmann-Schmid C, Haya N, et al. Surgery for women with pelvic organ prolapse with or without stress urinary incontinence. Cochrane Database Syst Rev. 2026;2:CD013108. doi:10.1002/14651858.CD013108.pub2.

22. Morciano A, Pecorella G, Tinelli A, et al. To rest or not to rest after sacral colpopexy? Dispelling an old custom in the ERAS time. Arch Gynecol Obstet. 2025;311(3):863-870. doi:10.1007/s00404-024-07904-5.