Evaluation of Presacral Vascular Anatomy Using Contrast-Enhanced 3D-CT for Surgical Planning in Endoscopic Sacrocolpopexy

Background: Endoscopic sacrocolpopexy (ESC) is a widely performed procedure for pelvic organ prolapse, with laparoscopic sacrocolpopexy (LSC) and robotic-assisted sacrocolpopexy (RSC) approaches. However, suturing to the anterior longitudinal ligament at the sacral promontory carries a risk of massive hemorrhage due to presacral vascular injury. This study aimed to determine the frequency of presacral venous variations considered clinically relevant during suturing at the promontory and to explore their association with perioperative outcomes using contrast-enhanced three-dimensional computed tomography (3D-CT). Methods: Among 319 consecutive ESC cases performed between 2014 and 2025, 265 patients who underwent preoperative contrast-enhanced CT were retrospectively analyzed in this single-center cohort study. Two vascular findings were defined as clinically significant: (1) anomalous drainage of the internal iliac vein into the contralateral common iliac vein and (2) a clearly visualized median sacral vein on 3D reconstruction. The clinical impact of vascular abnormalities was evaluated using surgical time, blood loss, and perioperative complication rates as indicators. Student’s t-test was used for comparing continuous variables, and the chi-squared test was used for comparing categorical variables. The data for this study were retrospectively collected from electronic medical records, anonymized, and then analyzed. Results: Anomalous internal iliac vein drainage was observed in 11.3% (30/265), and a visible median sacral vein was observed in 10.2% (27/265). Overall, 17.7% (47/265, CI: 13.2–22.2%) of patients had at least one clinically significant variation. There were no significant differences between the groups in terms of age, parity, BMI, operative time, blood loss, or perioperative complication rates. No cases required transfusion. Conclusions: Clinically significant presacral vein mutations were present in approximately 1 in 6 patients. The main findings of this study are that clinically significant presacral vascular mutations are relatively frequent (17.7%) in ESC and that there was no significant difference in perioperative outcomes between patients with and without vascular mutations. Clinically relevant presacral vascular variations are relatively common in ESC. Preoperative contrast-enhanced 3D-CT may support risk assessment and surgical planning.