Patient Factors Associated with Presacral Space Depth: A Pelvic MRI Study

Sacrocolpopexy is the most durable surgical repair for advanced pelvic organ prolapse, but dissection of the presacral space can be technically challenging. Variation in presacral space depth may affect surgical exposure and operative risk. Limited data exist regarding patient-specific factors associated with variation in presacral anatomy and presacral space depth. We hypothesized that body mass index (BMI) would not meaningfully predict variation in presacral space depth.

This retrospective cohort study evaluated presacral anatomic measurements using pelvic magnetic resonance imaging (MRI) in women. Presacral anatomic measurements, including presacral depth, anterior longitudinal ligament thickness, and sacral vertebral dimensions, were obtained between L5 and S3 using a standardized midsagittal MRI technique. Patient demographics, clinical characteristics, and medical history were collected. Descriptive statistics, correlation analyses, and effect sizes were calculated.

A total of 209 pelvic MRIs were reviewed, of which 167 had complete data. BMI demonstrated only weak correlations with presacral space depth. A history of hysterectomy was associated with increased presacral depth at S1 compared with women with an intact uterus (24% increase; p = 0.01). Postmenopausal status and exogenous estrogen use were associated with increased L5-S1 disc space height (p = 0.03 and p = 0.02, respectively). Presacral space depth was significantly shallower at the sacral promontory than at more caudal levels, while anterior longitudinal ligament thickness was greatest at the promontory. Presacral depth was also moderately correlated with sacral vertebral body height.

Presacral space depth was not associated with BMI but was modestly increased in women with a history of hysterectomy. These findings suggest that prior pelvic surgery, rather than BMI, may influence presacral anatomy and could be relevant for surgical planning.