Robotic-Assisted Paravaginal Repair at the Time of Sacrocopalpexy as a Case Series. Current literature reports nearly one-third of women having anatomic or symptomatic treatment failure within five years of having a sacrocopalpexy. Addressing paravaginal defects at the time of sacrocopalpexy may improve failure rates of the anterior vaginal compartment. This video serves to demonstrate a robotic-assisted paravaginal repair and space of Retzius dissection, as well as evaluate the effectiveness of these concurrent procedures for the prevention of recurrent anterior compartment prolapse. Sacrocopalpexy has already been performed, and attention is turned to the anterior abdominal wall to begin our space of Retzius dissection. The uracus is identified in the midline and is followed from its broad attachment at the bladder dome cephalad to its tapered apex. The lateral border of our dissection will be at the obliterated umbilical ligaments bilaterally. The space of Retzius is accessed through a transperitoneal incision with the monopolar scissors at the apex of the uracus. At this level, the uracus is more firmly attached and applied to both peritoneum and fascia. Using both blunt and electrocautery dissection in the midline, loose areolar tissue is identified. The uracus is attached to both peritoneum and fascia. The uracus is attached to both peritoneum and fascia. Using both blunt and electrocautery dissection in the midline, loose areolar tissue is identified. Complete dissection to the rectus abdominis muscles assures access to the loose areolar tissue of the prevesical space. The loose areolar tissue of the prevesical space is dissected down the anterior abdominal wall to the pubic symphysis and ramus. The boundaries of the space of Retzius are the symphysis pubis anteriorly, the pubic rami laterally, and the sidewalls composed of pubic bone and obturator internus muscle. Along the pubic rami, Cooper's ligament is also identified. Adipose tissue behind the symphysis pubis between the bladder and the pubic bone is gently dissected to expose the retropubic space. Here, the anterior aspects of the proximal urethra and bladder neck are visualized. The floor of the retropubic space is composed of a fibrofatty outer lining of the vaginal wall called the endopelvic fascia and the paravesical fascia. This trapezoid-shaped structure provides support for the proximal urethra and bladder. Lateral blunt dissection in this space exposes the arcus tendineus fascia pelvis and its associated obturator internus muscle. The obturator neurovascular bundle can be visualized by the visualization of the obturator neurovascular bundle and its associated obturator internus muscle. The obturator neurovascular bundle can be visualized The obturator neurovascular bundle can be visualized entering the obturator canal at the anterior superior border of the obturator foramen. Further blunt dissection on the patient's right side exposes the arcus tendineus fascia pelvis, or white line, running in an arcing fashion from the ischial spine posteriorly to the pubis anteriorly. A probe is placed in the distal vagina for exposure of the lateral vagina. The fibrofatty endopelvic and paravesical fascia are dissected medially off of the lateral vagina to protect the bladder and proximal urethra. The paravaginal defect, or detached lateral fascia, from its point of insertion on the sidewall is clearly visualized. The paravaginal defect, or detached lateral fascia, from its point of insertion on the sidewall is clearly visualized. Using the lighted vaginal distension probe, Using the lighted vaginal distension probe, interrupted permanent sutures of 2-oproline are placed sequentially to re-approximate the detached lateral vagina to the arcus tendineus fascia pelvis on the sidewall. Approximately 3-4 sutures are placed on each side depending on the size of the defect. The lateral vagina is now attached at its normal point of insertion on the lateral sidewall at the arcus tendineus fascia pelvis. If an anti-incontinence procedure was required, the space of Retzius dissection was utilized to perform a Birch-Coppo suspension. The space of Retzius dissection was utilized to perform a Birch-Coppo suspension. Sutures were placed at either side of the mid-urethra and bladder neck and attached to Cooper's ligament for urethral support. This observational case series included 7 patients who had 3-month follow-up data. Post-operatively, no patients had anterior or apical descent beyond the hymen. 100% of patients had apical support at stage 0 to 1. Anterior vaginal compartment ranged from stage 0 to 2 with no paravaginal defects or prolapse beyond the hymen. Patient perception of improvement also ranked high with all patients reporting feeling much to very much better. Pelvic floor distress inventory significantly improved in all categories from pre- to 3-months post-operative. In conclusion, addressing paravaginal defects at the time of sacrocopalpexy may improve success rates of pelvic organ prolapse repair. We look forward to sharing long-term data to compare success rates to sacrocopalpexy alone.

robotic-assisted paravaginal repair

space of Retzius dissection

anterior vaginal compartment

sacrocopalpexy

paravaginal defect