Modifications in surgical procedure are necessary to accommodate abnormal anatomy. The objective of this video is to illustrate an example of a left-sided sacrocolopexy to accommodate a right-sided pelvic kidney. Renal ectopia, or an ectopic kidney, occurs when there is failure of the kidneys to ascend to the renal fossa at the level of the 10th thoracic vertebra. These ectopic kidneys may be lumbar, abdominal, or pelvic, the latter being the most common. Ectopia may be associated with fusion or rotation malformations, as well as Mullerian anomalies. The patient is a 63-year-old G5P3 who presented with recurrent vaginal vault prolapse one year after vaginal hysterectomy, utero-sacral vaginal vault suspension, and posterior repair. Physical exam revealed anterior and apical prolapse to the level of the hymen. Given the patient's need to perform daily manual labor and her recurrence within one year of initial surgery, she was offered prolapse repair with mesh augmentation. Risks and benefits of retreatment were discussed with her, and she consented to minimally invasive sacrocolopexy. The patient's past medical history was notable for a congenital right-sided pelvic kidney diagnosed many years prior to her surgery through imaging. Upon accessing the patient's peritoneal cavity through open laparoscopic technique, the right-sided pelvic kidney was noted to be overlying the right aspect of the sacrum. This blocked surgical access to the right side of the sacral promontory, necessitating a left-sided approach to the sacrocolopexy. Extensive adhesions were seen, including the rectosigmoid aberrantly adherent to the vagina and bilateral sidewalls. This obliterated cul-de-sac was likely secondary to scarring after her previous utero-sacral ligament suspension. These adhesions were taken down via extensive dissection. To aid in exposure during adhesiolysis and colpopexy, the redundant bladder was elevated using a temporary stay suture, lifted through the abdominal wall with the assistance of an endoclosure device. With the assistance of colorectal surgery, the sigmoid was mobilized off of the left pelvic sidewall. This was accomplished with a vessel sealer device using both blunt dissection as well as energy. Dissection of the left presacral space was completed as part of the sigmoid mobilization. Throughout this process, the left ureter was visualized. The dissection continued, mobilizing the rectosigmoid medial to the left utero-sacral ligament, almost to the level of the pelvic floor. Dissection of the rectum away from the vagina was also completed. Similar to the suture retraction of the bladder, the mobilized, redundant rectosigmoid was temporarily retracted cephalad and towards the right in order to aid in visualization for the mesh attachment. The anterior vaginal dissection was then performed with cold scissors. Using 2-O monofilament delayed absorbable suture, the anterior vaginal mesh was attached to the anterior vaginal wall. The excess mesh was trimmed. The posterior mesh was placed in the appropriate location and was attached in a similar fashion. An additional anterior abdominal port was placed for the use of the laparoscopic tacking device. After appropriate tensioning, the sacral arm of the mesh was tacked to the anterior longitudinal ligament with multiple tacks, approximately at the level of S2. The peritoneum was re-approximated over the mesh. Vaginal exam revealed excellent apical and anterior support. The temporary stay sutures were removed. The patient tolerated the procedure well. At 6 weeks after surgery, the patient had experienced no complications and exam showed excellent vaginal support. While in this patient, a pelvic kidney was known preoperatively. A pelvic kidney is a potential unexpected finding upon laparoscopic entry. The rate of ectopic kidney is estimated at 1 in 1,000. If a surgeon were to encounter a pelvic kidney during a planned minimally invasive sacrocolpopexy, she could proceed in a few different ways. First, she could proceed with rectosigmoid mobilization and complete a left-sided sacrocolpopexy as with this case. Second, she could continue with endoscopic approach and complete a laparoscopic or robotic assisted utero-sacral vaginal vault suspension. Third, she could abort the endoscopic approach and proceed with a vaginal prolapse repair, potentially with graft augmentation, depending on preoperative counseling with the patient. The latter two options would have been inappropriate for this patient, given her recurrence after recent native tissue repair and the preoperative discussion she had with her surgeon about vaginal mesh. In summary, sacrocolpopexy can be completed despite a right-sided pelvic kidney. This requires mobilization of the rectosigmoid and an increased awareness of presacral anatomy.

left-sided sacrocolpopexy surgery

right-sided pelvic kidney

vaginal vault prolapse

mesh augmentation

congenital right-sided pelvic kidney