(Video Poster 03) Missed the Mark: Addressing Overlooked Vaginal Prolapse Post-Rectopexy

Objectives: To present intraoperative findings from two revision surgeries in patients with pelvic organ prolapse after prior rectopexy.

To highlight key surgical considerations and decision-making strategies for optimal repair in patients with recurrent pelvic organ prolapse following prior rectopexy.

Methods: Two patients who presented with pelvic organ prolapse after prior rectopexy. The first case is a 73 y/o multipara with pelvic organ prolapse status post robotic ventral mesh rectopexy (VMR), rectocele repair, sacrocolpopexy and mid urethral sling for rectal intussusception and vaginal prolapse. Preoperative physical examination revealed stage 2 prolapse. During surgery, mesh was seen to be loosely attached to posterior vaginal wall providing minimal support. For this reason, a sacrocolpopexy was performed including anterior and posterior vaginal wall mesh. The second case is a 55 y/o G3P3 with uterine prolapse, cystocele, and full thickness rectal prolapse s/p robotic rectopexy with mesh in 2023 at outside facility. Preoperative physical examination revealed a stage I prolapse though significant prolapse was noted in defecography. During surgical repair the prior mesh was found folded and detached. The prior mesh was removed and a repeat VMR and sacrocolpopexy was performed. Both patients reported significant improvement in symptoms without recurrence of prolapse up 6 weeks post op.

Clinical Relevance: Our evaluation begins with a comprehensive physical examination, including the POP-Q assessment, to identify the compartments requiring surgical correction. During the procedure, we assess areas where the previous mesh has become detached, determining whether to remove and replace it with a new mesh or to reinforce the existing mesh. We presented two patients that were treated for rectal prolapse; however, their pelvic organ prolapse was not adequately treated and patients required second invasive surgery to correct untreated compartment. For this reason we encourage patients be assessed for multi-compartment prolapse prior to surgery. To better serve our patients, we must encourage a multi-disciplinary team approach to ensure all prolapses are addressed and treated to improve surgical outcomes and quality of life