This video demonstrates the surgical treatment of a patient who presented to our office with dyspironia, pelvic pain, and recurrent prolapse. She had previously undergone an anterior and posterior trans-operator prolapse repair with mesh, and on examination, she was noted to have well-supported anterior and posterior vaginal walls, but she had a gap failure with stage 2 vaginal wall prolapse. Laparoscopic examination revealed extensive omental and bowel adhesions that were lysed prior to the sacrocopalpexy. Dissection anteriorly was performed until the dense scar tissue indicating the proximal edge of her previous mesh was encountered. Similarly, dissection was performed in the rectovaginal space until the previous mesh was palpable laparoscopically. The peritoneum was incised over the sacral promontory, and dissection was performed until the anterior ligament was identified. The peritoneum was incised along the pelvic sidewall until it met the incision from the rectovaginal dissection. A lightweight polypropylene Y-shaped mesh was introduced through a suprapubic 10mm port and positioned over the vaginal vault. CV-2 GORE-TEX SUTURES CV-2 GORE-TEX SUTURES CV-2 GORE-TEX SUTURES were used to affix the mesh to the anterior vaginal wall with the most distal sutures picking up the proximal edges of the previous mesh. The same procedure was performed posteriorly with extracorporeal knot tying used for each stitch. After determining the proper tension, the proximal arm of the mesh was sutured to the sacral promontory with CV-0 GORE-TEX SUTURES. CV-2 GORE-TEX SUTURES After trimming excess mesh, the peritoneum was closed over the mesh using a delayed absorbable unidirectional barbed suture. CV-2 GORE-TEX SUTURES CV-2 GORE-TEX SUTURES The next part of the procedure addressed the intravescal mesh erosion that was noted on the preoperative cystoscopy. We felt that the best way to approach this erosion was through a cystotomy using a retropubic approach. After dissecting into the space of retzius, laparoscopic scissors were used to make an intentional cystotomy at the dome of the bladder. CV-2 GORE-TEX SUTURES Exploration of the bladder revealed the mesh erosion above the trigone and the position of the ureteral orifices, which were sufficiently far from the erosion so that ureteral stents were not needed. CV-2 GORE-TEX SUTURES After placing traction on the mesh, the mesh erosion was excised, leaving a defect in the base of the bladder. CV-2 GORE-TEX SUTURES A delayed absorbable suture was then used to place a figure-of-eight stitch to re-approximate the bladder wall mucosa. CV-2 GORE-TEX SUTURES An intracorporeal knot tying technique was used due to the delicate nature of the bladder wall. CV-2 GORE-TEX SUTURES The cystotomy was then closed with several interrupted stitches of absorbable suture, again using an intracorporeal knot tying technique. CV-2 GORE-TEX SUTURES The peritoneal incision was then closed using barbed suture. CV-2 GORE-TEX SUTURES CV-2 GORE-TEX SUTURES Intraoperative cystoscopy demonstrated bilateral ureteral patency and the bladder base repair without any residual mesh fibers. The cystotomy repair at the dome could also be seen and appeared intact. A transurethral Foley catheter was kept in place for seven days, followed by a retrograde cystogram that showed a normal bladder contour.

surgical procedure

pelvic pain

mesh repair

vaginal wall prolapse

laparoscopic examination