Vaginal Mesh Augmented Bilateral Sacrospinous Cerclage Cervicopexy

Objectives: To describe a novel mesh based vaginal prolapse repair in a patient with a history of bladder exstrophy and multiple prior abdominal prolapse repairs.

Methods: This video highlights a vagina mesh based prolapse repair using a transobturator midurethral sling trocar kit to correct recurrent prolapse in a patient with a history of bladder exstrophy and multiple previous sacrocopopexies. To begin the procedure, the cervix is placed on traction and the bladder is dissected from the cervical tissue. A posterior incision is then made at the uterovaginal junction and the vaginal epithelium is then dissected from the cervix. Blunt dissection is then performed into the bilateral pararectal spaces until the ischial spine is palpated. Using a suture capture device, two delayed absorbable sutures are placed at the middle of the sacrospinous ligament bilaterally. Next, using the mesh and trocars from an in to out transobturator sling, the mesh is placed around the cervix in a circumferential cerclage. The trocars are placed from the anterior to posterior dissection to the bring mesh in the same direction in an inverted U orientation. The mesh arms are then anchored to the anterior and posterior cervix with delayed absorbable suture. The cervix and mesh are then elevated towards the sacrospinous ligaments in order to decide where to place the sutures on the mesh. Based on this distance, the sutures were then threaded through the mesh and the sutures were then tied down. The anterior and posterior incisions were then closed. An exam at the conclusion showed excellent vaginal support.

Clinical Relevance: This technique described in the video demonstrates a vaginal approach with a durable prolapse repair for a patient with a complex surgical history as well as complex pelvic anatomy. As the risk of significant complications would have been very high with attempting another abdominal prolapse repair, this technique allows for a safe extra-peritoneal surgical approach with a low complication risk. In addition, this procedure utilizes a commonly available midurethral sling kit, which will allow for a urogynecologist to offer this procedure to any patient with a complex history and recurrent prolapse.