Lowest colpopexy sacral fixation point alters vaginal axis and cul-de-sac depth.

OBJECTIVE: To determine the variation in vaginal axis and posterior cul-de-sac depth when the lowest suture used to attach the sacrocolpopexy mesh to the anterior longitudinal ligament is anchored at different levels. STUDY DESIGN: At five lumbosacral mesh attachment sites, the anterior vaginal wall axis angle was measured relative to a line between the lowest border of the pubic symphysis and fourth sacral (S4) foramen in 9 unembalmed cadavers. The vertical distance from S4 to the posterior mesh was measured as a surrogate of cul-de-sac depth. RESULTS: From a mesh fixation point at the lower border of S2 to a point at the lower border of L5, there was a 3-fold increase in both vaginal axis angle (13.04 +/- 3.19 vs 42.88 +/- 4.16 cm) and distance from S4 to the posterior mesh (2.50 +/- 0.61 vs 7.38 +/- 1.30 cm) between these points. CONCLUSION: During sacrocolpopexy, progressively cephalad sacral attachment increases vaginal axis angle and cul-de-sac depth.