This video describes robotic-assisted surgical treatment of dyspareunia from prior sacrocopopexy. It will show how mesh can be removed via robotic-assisted laparoscopy, how cadaveric fasciolata can be utilized in place of polypropylene mesh, and ultimately will show one surgical option for patients who develop dyspareunia and or pelvic pain after sacrocopopexy. This is a 58-year-old nullogravida patient who originally presented to our service with symptomatic pelvic organ prolapse, including uterine prolapse, cystoseal, and rectoseal. She was taken to the operating room in November of 2010 and received a total abdominal hysterectomy with abdominal sacrocopopexy, abdominal enteroseal repair, and posterior repair, utilizing a polypropylene mesh material. Her immediate postoperative course was uncomplicated, but six months following her surgery, the patient developed pain during intercourse. Evaluations showed no mesh erosion, but bimanual examination revealed significant anterior vaginal wall tenderness, right side greater than the left. A CAT scan was ordered to evaluate for pathology. The study was negative, so she was sent to a pelvic floor physical therapist for continuing conservative management. Despite these efforts, her dyspareunia persisted. The patient was then taken to the operating room for diagnostic laparoscopy, mesh culture, and chemo-denervation. The cultures returned negative, and the diagnostic laparoscopy showed no significant adhesive disease, infection, or any other visible pathology within the pelvis. This video clip shows the post-surgical field as seen during the diagnostic laparoscopy. There appears to be no significant adhesive disease and no signs of infection. Ultimately, we decided to remove the synthetic polypropylene mesh placed during the previous sacrocopopexy and replace it with cadaveric fascia lata. The peritoneum overlying the vaginal cuff is incised to gain access to the polypropylene mesh overlying the vagina. Once the mesh material has been reached, the bladder can now be dissected off of the mesh. Once the bladder has been dissected off of the mesh, a corner of the anterior leaf of the mesh is grasped and elevated to aid in removal of the material from the vagina. The material is removed with both blunt and sharp dissection. During the dissection, the mesh material is removed in such a way as to leave as much vaginal tissue behind as possible and to avoid colpotomies. Now that the mesh has been dissected off of the bladder and the anterior vaginal wall, attention is turned to the posterior vaginal wall. In a similar fashion, the posterior leaf of the mesh material is dissected off of the vagina. The vaginal portion of the mesh is cut from the sacral portion and is removed. Rather than remove the mesh from the sacrum, we decided to leave the sacral portion of the mesh and use this as the attachment point for the anterior and posterior leaf of the fascia lata. The cadaveric fascia lata is introduced into the abdomen and oriented for suturing on the posterior vagina. The posterior leaf of the fascia lata has been sutured to the posterior vagina and is now attached to the remaining sacral portion of the polypropylene mesh. Appropriate vaginal tension is obtained by using an EEA scissor placed vaginally. Next the anterior leaf of the fascia lata is sutured to the anterior vaginal wall and in a similar fashion is attached to the sacral mesh. Finally, the peritoneum is closed using monocryl in a purse string fashion. Postoperatively, the patient did very well and was discharged home on postoperative day 2. Follow-up evaluation showed good healing with good support, and by post-op month 3 she reported resolution of her dyspareunia. Recent follow-up on post-op month 8 showed good support with continued reports of pain-free intercourse. This case illustrates one possible method for surgical management of dyspareunia after sacrocopopexy.

surgical procedure

dyspareunia

polypropylene mesh

cadaveric fascia lata

pelvic pain