(Video Poster 29) Laparoscopic Salvage Surgery After Failed Robotic Sacrocolpopexy

Objectives: This video aims to achieve the following: 1) describe possible etiologies of early sacrocolpopexy failure, 2) Discuss intraoperative decision-making and surgical approach to a laparoscopic salvage sacrocolpopexy in a patient with a failed robotic sacrocolpopexy.

Methods: A 55-year-old G4P2 woman presented with Stage III pelvic organ prolapse. She had undergone a robotic supracervical hysterectomy and sacrocervicopexy 2 years earlier but noted recurrence of the prolapse within 4 weeks after the index surgery. On exam, point C was noted to be +7. Urodynamic testing with prolapse reduction demonstrated potential stress urinary incontinence. Laparoscopic inspection demonstrated that the previous mesh was retroperitoneal and firmly attached to the sacrum, but the anterior and posterior mesh segments were completely detached from the cervix. The case was started by freeing the distal end of the mesh from the right pelvic sidewall with care to avoid ureteral injury. The bladder was sharply dissected off the cervix and anterior vaginal wall with laparoscopic scissors and judicious use of monopolar electrosurgery and similarly, the rectovaginal septum was entered to gain access to the posterior vaginal fascia. It was noted that no mesh was encountered during the dissection. A new lightweight polypropylene Y-mesh was inserted and attached to the cervix and anterior and posterior vaginal walls with interrupted CV-2 and CV-3 Gore-Tex sutures respectively. The sacral tail of the new Y-mesh was sutured to the proximal portion of the pre-existing mesh close to the sacral attachment with CV-2 Gore-Tex sutures. The entire mesh was then re-peritonealized with a barbed absorbable suture.

Clinical Relevance: Sacrocolpopexy is widely recognized as an effective reconstructive procedure for the treatment of apical prolapse. This video reviews the potential etiologies of a failed sacrocolpopexy and the surgical approach to recurrent prolapse. While it is usually impossible to determine pre-operatively the cause of sacrocolpopexy failure, intraoperative evaluation will demonstrate whether the mesh detached from the sacrum, the vagina / cervix or whether there was a break in the sacral mesh segment. As demonstrated in this video, utilizing the existing sacral mesh attachment, when feasible, avoids a potentially difficult and risky repeat dissection at the sacrum. In addition, attaching a new mesh to the cervix and vaginal fascia is a viable technique when previous mesh has failed.