If mesh is used, hemostasis should be ensured when the vagina is closed using interrupted suture with little or no mucosal excision, thereby minimizing tension at the suture line and hopefully reducing the risk of postoperative mesh exposure.
A rectal exam should be done to exclude rectal injury/stitch penetration. In addition, it's important to assess the tissue bridge spanning the sacrospinous ligaments to make sure this is not too tight. A tight bridge may cause significant postoperative pain as well as defecatory dysfunction by partially obstructing the rectosigmoid. When using a mesh, this bridge can be minimized by cutting the apical transverse distance to at least 10 cm.
Cystoscopy with IV indigo carmine is performed at the end of the procedure to exclude unintentional urethral extraction/kinking. The vagina is packed at the surgeon's discretion.
Preventing, Managing Complications
With proper technique, complications associated with the sacrospinous suspension are relatively uncommon.
They can be broadly categorized as occurring intraoperatively and postoperatively, and can be largely avoided by minimizing wide dissection, by placing sutures at least 2 cm medial to the ischial spine to avoid injury to the pudendal neurovascular bundle, and by always performing a rectal exam as well as cystoscopy with IV indigo carmine following the surgical procedure.
Intraoperative Complications
Intraoperative complications can be associated with dissection into the sacrospinous space and placement of the suspension suture. Dissection-related complications include injury to the rectosigmoid as well as bleeding during dissection. It is important to make sure that dissection of the endopelvic fascia is performed sharply until a relatively avascular and areolar space is created; at this time, blunt dissection with the surgeon's finger can be easily accomplished.
Hugging the lateral side wall on each side should minimize risk of injury to the bowel. Rectal exam after placement of the suture is essential to the diagnosis of any unintentional bowel injury or suture penetration. Any confirmed rectal injury would need repair at the time of surgery.
Use of finger dissection in a back-and-forth motion rather than a sweeping up-down or side-side motion will minimize injury to the surrounding vasculature while still creating a tract large enough to place the suture. Placement of the suture can occasionally be associated with bleeding if there is any injury to the pudendal neurovascular bundle or its associated branches.
Oftentimes, tie-down of the suspension suture will control the bleeder. If there is persistent and uncontrollable bleeding, it is best not to be overly aggressive with hemostatic sutures or surgical clips, as these may result in increasing injury to the pudendal neurovascular bundle. Adequate exposure and suction are essential. Initial control of the hemostasis with pressure and tapenade for several minutes is usually successful. Placement of hemostatic agents such as Surgicel or Flo-Seal is often effective, followed by suture/clip placement if needed. Postoperative embolization for persistent bleeders has also been reported.
Placement of the suture also can sometimes be associated with ureteral kinking/obstruction. Following tie-down of the suspension sutures, cystoscopy with IV indigo carmine is recommended. If the ureter fails to spill on either side, repeat IV indigo carmine followed by ureteral stent placement is suggested. Stent placement will allow one to determine the relative site of obstruction based on how far the stent can be inserted. Typically, obstruction associated with sacrospinous sutures allows the stent to be passed 5-9 cm.
Removal of the suspension suture almost always results in resolution of the obstruction with resulting ureteral spill. A repeat suspension suture could then be placed slightly more medial at the surgeon's discretion. Repeat cystoscopy should be performed to confirm continued ureteral patency.
Postoperative Complications
Postoperative complications include hematoma/bleeding and complaints of buttock pain secondary to the involvement of the pudendal nerve branches. Bleeding should be banished accordingly. If bleeding is significant, reoperation or embolization is generally the best option. Small self-limited hematomas can be expectantly managed or drained via vaginal access as needed. It may be best to drain hematomas in cases in which mesh was placed at the time of sacrospinous suspension so as to prevent significant abscess and postoperative infection.
Mild buttock discomfort following sacrospinous suspension is not uncommon, and it is usually managed conservatively with observation, nonsteroidals, and muscle relaxants such as baclofen. The patient should be monitored on a weekly basis to ensure continued improvement.
For severe or persistent pain, removal of the suture should be considered; this is easiest if the suture was tied transvaginally rather than with the traditional pulley stitch technique. (In the latter case, suture removal involves opening the vagina.) Transvaginal excision of the suspension sutures can often be performed in the office or at the bedside with a lighted speculum and long scissors. Most patients report almost immediate relief after removal of the suture.
