Sacral colpopexy / hysteropexy using synthetic mesh

Laparoscopic or robot-assisted surgery for vaginal prolapse

This information has been prepared by the specialists at Urogynaecology Specialists. It is intended to help you understand your planned procedure. Please speak with your surgeon if you have any questions.

What is vaginal prolapse?

Vaginal prolapse happens when the walls of the vagina lose their support and drop out of position. It is very common. Symptoms can include:

  • A feeling of a bulge or lump in the vagina
  • Difficulty emptying your bladder or bowel
  • Constipation
  • Problems with sexual intercourse

Surgery is only recommended when prolapse is causing symptoms. Most women feel significantly better after an operation.

About this surgery

A sacral colpopexy or sacral hysteropexy is an operation to lift and support the upper vagina by attaching it to the bone at the base of your spine (the sacrum). This is done through small keyhole incisions in the abdomen using either a laparoscope or a surgical robot.

The name of the operation depends on whether you have a uterus:

  • Sacral hysteropexy — if your uterus is being kept in place. The uterus is supported and lifted without being removed.
  • Sacral colpopexy — if you have already had a hysterectomy, or if you are having a hysterectomy at the same time. In this case, the top of the vagina (the vault) is what is being supported.

Your surgeon will have discussed which procedure applies to you. If you are also having an incontinence procedure, this will be listed on your hospital consent form. Please contact your surgeon’s rooms if you have any questions.

Illustrations: Figure 1 — sacral hysteropexy; Figure 2 — sacral colpopexy. (Add your anatomical diagrams here using a Squarespace Image block.)

For this surgery, a strip of synthetic mesh is used as the graft. It is stitched to the vagina or cervix and attached to the sacrum, lifting and supporting the prolapse. Research shows that sacral colpopexy/hysteropexy using mesh has better prolapse outcomes than many alternative non-mesh operations.

How successful is this surgery?

Our experience is that long-term support of the vault or uterus is achieved in over 95% of patients. Most women also report significant improvement in quality of life and bladder, bowel and sexual symptoms. Long-term follow-up data show that approximately 90% of women remain free from repeat prolapse surgery at 6 years.

Sacral hysteropexy — where the uterus is kept in place — has been shown in research to produce comparable outcomes to performing a hysterectomy at the same time. For women who wish to preserve their uterus, this is a well-supported option.

About TiLENE mesh

TiLENE is a titanised polypropylene mesh manufactured in Germany. It is TGA (Therapeutic Goods Administration) approved and is used for soft tissue support, including hernia repair. It has been used in Europe to treat women with prolapse and has a well-established safety profile.

Why is this considered ‘off-label’ use?

In Australia, mesh companies have voluntarily withdrawn their pelvic floor mesh products from the market. This was a commercial decision made by the manufacturers — it was not a TGA withdrawal or ban. As a result, no mesh product is currently marketed or endorsed by its manufacturer specifically for pelvic reconstructive surgery in Australia.

TiLENE mesh is TGA approved, but the manufacturer has chosen not to endorse its use for pelvic reconstructive surgery in Australia. Using it for this purpose is therefore considered ‘off-label’ — meaning the product is being used for a condition beyond the scope of its current Australian endorsement, not because it is unsafe or unapproved as a product.

It is important to understand that there is robust evidence supporting the use of synthetic mesh for sacral colpopexy and hysteropexy. This surgery uses mesh placed through the abdomen rather than through the vagina — this is an important distinction. The mesh complications that received public attention (including the Senate inquiry) related primarily to mesh inserted through the vaginal wall. Abdominal sacrocolpopexy has a substantially lower rate of mesh-related problems and has continued to be endorsed by international guidelines including the UK’s NICE and the Cochrane Collaboration.

Your surgeon has carefully assessed the benefits and risks of mesh-augmented surgery in your individual case, and has discussed the non-mesh and non-surgical alternatives with you. The decision to proceed has been made together.

A published study of 217 women who had sacral colpopexy using TiLENE equivalent mesh found it to be safe and effective, with a reduction in mesh-related complications at 1 year after surgery.

Cost

Your health fund may not cover the cost of the mesh. If not covered, you will be required to pay approximately $850–950 for the mesh. In many cases health funds do cover this cost — please check with your fund in advance.

What happens during the operation?

The operation is performed under general anaesthetic — you will be completely asleep.

Your surgeon makes 4 small cuts in the abdomen (5–12 mm each) and uses keyhole instruments to carefully separate the bladder and bowel from the upper vagina.

  • If you are having a hysterectomy at the same time, this is performed first. When hysterectomy is combined with mesh sacral colpopexy, the UGS surgeons recommend a subtotal hysterectomy — removing the body of the uterus but leaving the cervix in place. This is because retaining the cervix is associated with a significantly lower risk of mesh erosion compared to total hysterectomy.
  • If you have already had a hysterectomy, your surgeon works directly with the top of the vagina (the vault).
  • If your uterus is being kept (hysteropexy), the uterus remains in place and the mesh is attached to support it.

A strip of TiLENE mesh is introduced into the abdomen, stitched to the outside of the vagina or cervix, and attached to a strong ligament on the sacrum. This lifts and supports the prolapse. The mesh is then covered with a layer of tissue (peritoneum) to prevent bowel becoming trapped in the repair.

At the end of the operation, a small camera is passed into your bladder (cystoscopy) to check that the bladder, urethra and ureters have not been injured. A bladder catheter is placed and is usually removed 1–2 days later.

What are the risks?

General surgical risks

  • Anaesthetic risks
  • Bleeding (rarely requiring a blood transfusion)
  • Infection in the pelvis or wound (antibiotics are given to help prevent this)
  • Blood clots in the legs or lungs (DVT/PE) — you will be given medication and compression stockings to reduce this risk
  • Rarely, the keyhole approach may need to be converted to open surgery

Risks specific to mesh

  • Mesh exposure or erosion — this occurs in approximately 2% of cases. If it occurs in the vagina (the most common site), it is usually treated with oestrogen cream if the vaginal skin is thin, or a small vaginal procedure to cover the mesh
  • Mesh placed through the abdomen (as in this surgery) carries a much lower risk of mesh-related complications than mesh placed through the vagina

Risks specific to prolapse surgery

  • Bladder problems such as difficulty emptying, urinary tract infection, or leakage — these usually settle. If leakage persists, further treatment may be needed.
  • Pain after surgery — this usually resolves within days to weeks. Long-term pain is rare.
  • Injury to nearby structures (bladder, bowel, ureter, or nerves) — rare. A cystoscopy at the end of surgery checks for bladder injury.
  • Bowel obstruction or hernia — rare, and may need further surgery
  • Bladder urgency — some women notice new or worsened urgency (a sudden strong need to urinate) after surgery. This affects a small proportion of women and in most cases settles over time. If it persists, it can usually be treated.
  • Sexual intercourse: most women notice improvement, but around 2% experience pain with sex after surgery, which may require further treatment
  • Prolapse recurrence

Recovery

Most women stay 2–3 nights in hospital after this procedure and can return to work after 6 weeks. Detailed information about your recovery is provided in the UGS Recovery Information page, which you will be given a link to or can request from our rooms.

What are the alternatives?

  • No treatment — you may choose to manage your symptoms without surgery
  • Pelvic floor muscle training
  • Vaginal pessary — your surgeon may recommend trying this before surgery
  • Suture support surgery — an alternative where sutures are used to lift the vault or uterus up to either the sacrospinous or uterosacral ligaments. This can be performed vaginally or laparoscopically. It is associated with less success than a graft-based surgery.
  • Laparoscopic/robotic sacral colpopexy using your own tissue (fascia lata) — a mesh-free alternative. Note that long-term evidence for this approach is still being gathered.

Please also refer to the RANZCOG Sacrocolpopexy Clinical Guidance Statement.

References

  1. Schlager et al. (2020). TiLENE mesh for sacral colpopexy — safety and efficacy in 217 women. International Urogynecology Journal 31:763–768. https://doi.org/10.1007/s00192-019-04146-x
  2. Maher et al. (2023). Surgery for women with apical vaginal prolapse. Cochrane Database of Systematic Reviews. https://doi.org/10.1002/14651858.CD012376.pub2
  3. NICE Interventional Procedures Guidance IPG 558 — Laparoscopic sacrocolpopexy for vaginal vault prolapse and uterine prolapse. https://www.nice.org.uk/guidance/ipg558
  4. Nygaard et al. (2013). Long-term outcomes following abdominal sacrocolpopexy for pelvic organ prolapse. JAMA 309(19):2016–2024. https://doi.org/10.1001/jama.2013.4919
  5. Gutman RE et al. (2017). Uterine-preserving POP surgery. Current Opinion in Obstetrics and Gynecology. https://doi.org/10.1097/GCO.0000000000000367
  6. RANZCOG Sacrocolpopexy Clinical Guidance Statement. https://ranzcog.edu.au/wp-content/uploads/2022/08/Sacrocolpopexy-clinical-guidance-statement-C-Gyn-37.pdf