Laparoscopic mesh hysteropexy for recurrent uterine prolapse after felled laparoscopic mesh sacrocopohysteropexy, International Urogynecology Associates of Beverly Hills in Atlanta. The uterus sacral ligaments are the primary support structure of the uterus and vaginal vault. Attenuation, stretching, or breaking of the uterus sacral ligaments can ultimately result in uterine prolapse. The gold standard operation for uterine prolapse is either hysterectomy with sacrocopexy or sacrocopohysteropexy. A 52-year-old Gravita 2, Para 2 female presented with uterine prolapse. She underwent a mesh hysteropexy eight years ago and was told within a week that her surgery had felled. Her surgeon suggested her prolapse was the result of an elongated cervix. Before examination revealed uterine prolapse beyond the hymenal ring by 2 and 1⁄2 centimeters. The vaginal vault and uterus were easily reducible, suggesting she did not have an elongated cervix. The differential diagnosis for felled hysteropexy includes 1, failure at the points of suture attachment, 2, compromised mesh, and 3, inadequate surgical support due to surgical technique. Our patient presents with obvious uterine prolapse. The reason for recurrent uterine prolapse can be made at the time of laparoscopy. Here we see the mesh and sutures are uncompromised. However, the mesh is no longer attached to the uterus. Uterine prolapse is seen from the vaginal laparoscopic view. Elevation of the vaginal vault and the uterus reveals the cervix is not elongated, as it can be completely reduced. Further laparoscopic inspection reveals the mesh is not attached to the uterus or cervix. The mesh is only attached to the vaginal apex. This will result in recurrence of her uterine prolapse. The mesh is completely intact between the vagina and the sacrum, and there is no evidence of mesh or suture avulsion from the sacrum. It appears the original hysteropexy either was never attached to the cervix and or body of the uterus, or the mesh had avulsed from the uterus. Inadequate mesh attachment to the cervix and uterus has resulted in recurrent uterine prolapse. Type 1 soft polypropylene mesh is introduced into the pelvis. The mesh is positioned at the level of the cervix and over the fundus of the uterus. A 0-0 braided polyester suture is utilized to attach the synthetic mesh to the cervix, lower uterine segment, and the body of the uterus. The first suture is placed in the right lower lateral aspect of the isthmus of the cervix. Four to five extracorporeal knots are tied to secure each and every suture into place. The first suture is cut using hooked scissors, and the excess suture removed. A series of sutures usually placed in two columns along the vertical axis of the uterine body and cervix are placed. We usually place our sutures working from the distal aspect of the cervix to the more proximal aspect of the uterine body. This sequence of suture placement allows for us to cover the greatest amount of uterine surface area and maximize our efficiency during this surgical procedure. Sutures are usually placed in four to five rows of two sutures each, working from the cervix towards the body of the uterus. It has been our experience that poor suture and mesh attachment to the cervix and body of the uterus can result in recurrent uterine prolapse. More commonly, we have seen cases similar to this case, where either the mesh was never attached to the uterus or cervix, but instead attached only to the posterior vaginal vault, or the mesh was not shortened enough to give appropriate uterine suspension. Both of these scenarios can result in recurrent early uterine prolapse. Surgical suture and mesh distribution on the uterus minimizes suture pullout and mesh detachment. These two techniques, coupled with appropriate suspension of the uterus and vaginal vault, will reduce short-term and long-term recurrent prolapse. The point of mesh attachment at the sacrum is identified. The mesh is pulled cephalide, so the uterus is elevated to the appropriate level. The needle in the 00 synthetic polyester suture is passed through the mesh at the level of the sacral promontory. The needle is retrieved and removed, and then four knots are tied to secure the newly placed mesh to the old mesh at the level of the sacrum. A second suture is passed distal to the first suture, securing the previously placed mesh to the newly placed mesh. Note the needle is not going through the sacral promontory, but instead of the secured previously The excess mesh above the point of attachment at the level of the sacrum is cut and subsequently removed. It is not necessary to retroperitonealize this mesh. Before and after video of the cervix support is shown. Preoperatively, the patient's cervix was two and a half centimeters beyond the level behind And after a second laparoscopic hysterephexy, her cervix was elevated to a point 7.5 centimeters above the hymeral ring. This medical illustration shows the previously attached mesh in green at the level of the posterior vaginal apex, and the recently placed mesh in blue, where the majority of the mesh is attached to the cervix and the body of the uterus. In conclusion, we can see that recurrent uterine prolapse can be due to a number of mechanical reasons. Identification of the specific etiology is essential in offering the appropriate surgical correction. Correction of recurrent prolapse may require replacement, sutures, mesh, or both. And finally, recurrent uterine prolapse does not necessarily warrant a hysterectomy.

recurrent uterine prolapse

mesh hysteropexy

uterus sacral ligaments

laparoscopic examination

surgical procedure