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Cervicosacropexy and Vaginosacropexy (CESA/VASA)

Cervicosacropexy (CESA) and vaginosacropexy (VASA) are laparoscopic bilateral apical suspension techniques, described by Jäger, in which the paired uterosacral ligaments are replaced by two narrow polyvinylidene fluoride (PVDF) mesh strips running from the cervix (CESA) or vaginal vault (VASA) to the prevertebral fascia at the level of S1.[1][2] They were developed as a surgical alternative for women with apical prolapse and coexisting mixed or urgency urinary incontinence, on the theory that lax uterosacral ligaments contribute to both conditions.[2] For the general framework and the more established apical options, see Prolapse Repair and Sacrocolpopexy.

Technique​

CESA includes a subtotal (supracervical) hysterectomy, with the bladder left attached to the cervix, before mesh placement; VASA is performed at the vaginal vault, typically after a prior hysterectomy.[1] Jäger's description uses two PVDF mesh strips, each with an estimated length of 8.8 to 9.3 cm, in place of the native uterosacral ligaments. The central mesh segment is secured to the cervix or vaginal vault with nonabsorbable suture, and each lateral arm is fixed at S1 with tacks.[1] In a 120-patient laparoscopic series using this bilateral technique, restoration of apical vaginal support was achieved in 97% (116/120); it failed in the first 4 patients, attributed to the use of fast-absorbing suture at the mesh-to-cervix/vault fixation, after which a nonabsorbable or slow-absorbing suture was used.[3]

Unlike sacrocolpopexy, which attaches mesh to both the anterior and posterior vaginal walls, the CESA/VASA construct as described has no routine anterior or posterior vaginal mesh attachment and is not designed to reinforce those compartments directly.[1] Both open abdominal and laparoscopic approaches to this bilateral apical fixation have been described; a comparative series of 145 women (75 open, 70 laparoscopic) reported comparable efficacy and safety between routes, with the laparoscopic approach showing shorter operative time, hospital stay and recovery.[4]

Evidence for Urinary Incontinence​

CESA/VASA is distinguished from most other apical suspension techniques by being studied specifically as a treatment for urgency and mixed urinary incontinence, not only for prolapse. In the 120-patient series above, 78 of 120 patients (65%) with preoperative mixed or urgency incontinence symptoms achieved continence after surgery, with a mean hospital stay of 3 days and no major intraoperative complications.[3]

A 2022 systematic review of CESA/VASA for urinary incontinence and apical prolapse found cure rates, pooled across heterogeneous studies with a mean follow-up of 9.7 ± 7.3 months, of 47.5% for mixed urinary incontinence, 73.8% for urgency urinary incontinence and 97% to 100% for apical prolapse. Additional incontinence surgery was performed in 38.9% (216/555) of women who had preoperative urinary incontinence, and concomitant or subsequent prolapse surgery in 4.4% (13/299). The review's authors rated the included studies as having moderate-to-high risk of bias and low certainty of evidence overall, concluding that CESA/VASA may relieve urgency and mixed urinary incontinence and appears to correct apical prolapse in the short term, but called for trials with better-defined patient selection and validated outcome measures before the technique can be compared with established options.[2]

Limitations​

CESA/VASA is not an AUA-, SUFU-, ICS- or AUGS-endorsed first-line apical suspension; it has not been directly compared with sacrocolpopexy, sacrospinous fixation or uterosacral ligament suspension in a randomized trial, and the evidence base consists of case series and one systematic review rated as low-certainty.[2] The PVDF mesh and fixation tacks described by Jäger are not the macroporous polypropylene mesh used in standard sacrocolpopexy; separate attention to a different mesh material's own exposure and erosion profile is warranted before adopting the technique outside the centers that have published this early experience.[1][3][4] Several of the published outcome series on this technique come from groups whose surgeons disclose a financial or consulting relationship with the mesh manufacturer.[3][4]

See Also​

References​

1. Jeffery ST, Jere KT. New Techniques in Laparoscopic Pelvic Floor Surgery. In: Cardozo L, Staskin D, eds. Textbook of Female Urology and Urogynecology. Vol 2: Surgical Perspectives. 5th ed. CRC Press; 2023:1124-1133.

2. Page AS, Page G, Deprest J. Cervicosacropexy or vaginosacropexy for urinary incontinence and apical prolapse: A systematic review. Eur J Obstet Gynecol Reprod Biol. 2022;279:60-71. doi:10.1016/j.ejogrb.2022.10.004

3. Rexhepi S, Rexhepi E, Stumm M, Mallmann P, Ludwig S. Laparoscopic Bilateral Cervicosacropexy and Vaginosacropexy: New Surgical Treatment Option in Women with Pelvic Organ Prolapse and Urinary Incontinence. J Endourol. 2018;32(11):1058-1064. doi:10.1089/end.2018.0474

4. Ludwig S, Pfleiderer M, Püchel J, et al. Comparison of Open Abdominal and Laparoscopic Bilateral Uterosacral Ligament Replacement: A One-Year Follow-Up Study. J Clin Med. 2025;14(6):1880. doi:10.3390/jcm14061880