24% of U.S. women have some degree of pelvic organ prolapse. Surgery is often used to treat pelvic organ prolapse and it is estimated that more than 200,000 surgical procedures are performed each year. Women with complicating medical problems are often seen as less desirable surgical candidates and are relegated to plausibly less effective non-surgical treatments for their pelvic organ prolapse symptoms. In this video, a 71-year-old woman, having failed years of conservative therapy for stage 3 uterovaginal prolapse, undergoes a hysterectomy and mesh sacrocopalpexy. The woman's past surgical history is remarkable for having undergone a right nephrectomy and cadaveric kidney transplant into the preperitoneal space of the left pelvis. The high prevalence of kidney disease in the United States, which is estimated to be approximately 12%, is due to the increasing prevalence of the underlying causes including cardiovascular disease, diabetes, and hypertension. Kidney transplantation has become the treatment of choice for end-stage renal disease. As the number of patients who develop kidney disease continues to rise and the treatment outcomes continue to improve, the gynecologic surgeon will encounter women with a history of previous kidney transplantation. Ordinarily, preperitoneal kidney transplantation is not a contraindication for hysterectomy or pelvic organ prolapse surgery. We will review the pre-, intra-, and post-operative considerations for the gynecologic surgeon for this type of patient, as well as important surgical concepts such as port placement and the anatomy of a renal transplant graft. The most common placement for a renal graft is preperitoneal with anastomosis to the external iliac vessels and implantation of the ureter into the dome of the bladder. The ureteral insertion of an extravestical kidney transplant is typically directly into the dome and far from the area of dissection. Cystoscopic examination of the bladder reveals the graft ureter insertion into the dome of the bladder and atrophic ureteral orifices in the typical anatomical area. Often, however, the intraperitoneal cavity is entered and a portion of the kidney capsule is intraperitoneal and more susceptible to injury. Intra-abdominal kidney placement occurs when renal graft is combined with a pancreatic transplant, but this is beyond the scope of this video. It is important for the gynecologic surgeon to obtain and review operative reports from the transplant surgery to know kidney placement and its blood supply. If operative reports cannot be obtained or are not conclusive, a non-contrast CAT scan can be helpful to determine placement. Laparotomy incisions should be carefully planned to avoid the renal graft and its blood supply. With a pelvic kidney, a vertical midline incision would be appropriate. Self-retaining retractors should be used with great care and pressure on the kidney carefully avoided. Laparoscopic entry into the abdomen with a varice needle should be done, again, with great care to avoid the kidney or capsule. In our case, we utilize an Ethicon OptiView trocar initially placed in the left upper quadrant. This site was chosen to avoid injury to the kidney, allow visualization of the pelvis, and deliver safe insufflation. One can see the layers of the abdominal wall clearly as the OptiView trocar passes into the abdominal cavity. An orogastric tube should always be in place and to suction prior to insertion of a left upper abdominal port. After intraperitoneal placement is visually confirmed, the abdomen is then insufflated. A maximum pressure of 15 millimeters of mercury or less is maintained to avoid vascular compression of the renal graft. A survey of the pelvis is performed and one can see the left-sided renal graft and its surrounding peritoneal capsule. Port placement should maintain sufficient distance from the graft kidney so that it sustains no trauma from instrumentation. The uterus and the areas of dissection for the hysterectomy are unencumbered by the transplanted kidney. Based on these findings, a vaginal hysterectomy for a known preperitoneal kidney could also be considered. Planning for additional ports takes into account the need for passing diverse laparoscopic instrumentation for sacrocopalpexy dissection and suturing. Not only did port sites need to avoid the renal graft itself, but the trajectory of instruments was considered so that the kidney would not be hit, potentially causing a subcapsular hemorrhage or hematoma formation. Maintenance of abdominal wall vasculature and adequate instrument manipulation to perform the intended procedure was also considered. After consideration of pelvic anatomy with the retroperitoneal kidney, an 11-millimeter versus step port is placed 3 centimeters left lateral of the umbilicus and a 5-millimeter PD port 3 centimeters right lateral of the umbilicus. In this picture, one can see the port placement during this procedure as seen on the patient's abdomen. A drawing shows our typical port sites for this procedure in red with modifications for this particular procedure in yellow. The laparoscopic assisted portion of the hysterectomy is then performed after a bladder flap is created in the usual fashion. The ovaries are spared at the patient's request. A cystoscopy is performed after the vaginal portion of the hysterectomy and midurethral trans-obturator sling. During the hysterectomy, attention is turned to the sacrococopexy. With a Breisky retractor within the vagina, the posterior cul-de-sac is dissected to the perineal body. The anterior dissection is then performed with an end-to-end anastomosis or EEA sizer sharply along the distal 4 to 5 centimeters of the anterior surface of the vagina. American Medical Systems Intipro Y-mesh is then sutured to the anterior and posterior surfaces of the vagina with 12-3-0 non-absorbable polypropylene sutures placed using laparoscopic technique and extracorporeal knot time. Care is taken to avoid the left-sided kidney graft with the knot pusher as it enters the abdomen. The mesh is then trimmed and the excess removed. The mesh is appropriately tensioned and after again clearing the sacral promontory so it is easily and adequately visible, the mesh is sutured to the anterior longitudinal ligament with care taken to avoid nearby vascular structures. After copious irrigation, the peritoneum is then closed over the mesh. After all laparoscopic ports are closed and a vaginal exam confirms excellent support of the vagina and pelvic floor, a cystoscopy confirms no evidence of bladder or ureteral injury. Postoperatively, non-steroidal anti-inflammatory drugs or NSAIDs are contraindicated in the patient with a renal transplant and continuation of their anti-rejection drugs is very important. Ileus, prolonged hospitalization or other complications could be an indication for consultation with transplant surgeon for assistance in monitoring these drug levels. In summary, this case demonstrates that typically a transplanted renal graft is not a problem during laparoscopic gynecologic pelvic floor reconstruction surgery. Typically the kidney is retroperitoneal as is its blood supply, so adhesive disease and abnormal intra-abdominal vasculature is not a problem. The implanted ureter is typically short and inserts into the dome of the bladder well away and protected from the area of dissection. However, the gynecologic surgeon must be flexible and adapt usual technique to avoid injury to the transplanted kidney. For more information visit www.FEMA.gov

71-year-old woman

stage 3 uterovaginal prolapse

hysterectomy

mesh sacrocopalpexy

laparoscopic procedure