In the following video, we present management of recurrent posterior prolapse, perineal descent, and defecatory dysfunction in a patient with a prior sacrocopalpexy via a combined repeat sacrocopalperineopexy and modified anterior rectopexy approach. These are our disclosures. The perineal body serves as an integral support to the pelvic floor, working as a fulcrum that tends to remain stable even in stage 4 prolapse. However, when the integrity of the perineal body is lost, patients suffer from perineal descent, where the leading edge of the prolapse is actually the perineal body. This is a 42-year-old paraphore with stage 2 prolapse by POPQ, complicated by perineal descent, internal rectal prolapse, and defecatory dysfunction. In 2008, she had a prior robotic-assisted laparoscopic supracervical hysterectomy and sacrocopalpexy with mesh extended down to the perineum. We assumed that the apex was well-supported, therefore we would primarily be working posteriorly. Our plan was to cut the mesh just proximal to the cervix to allow access to the posterior compartment. However, upon inspection, it was obvious that the proximal arm had been somehow severed just distal to the promontory and therefore could no longer be relied on to provide apical support. The two segments are shown here. The decision was made to leave the portion of the mesh attached at the sacrum intact and dissect out the entire proximal arm of the original mesh. To do so, care was taken to open the right paracolic gutter while hugging the mesh and essentially cutting the patient away from the mesh itself, thus leaving the entire proximal arm intact. The robotic tenaculum was used to create traction as originally planned to operate in the posterior compartment. The rectivaginal space was entered in the usual fashion for a robotic sacrocopalpexy. The original sacrocopalpexy mesh was laying flat against the posterior wall and seemed to have excellent tissue ingrowth and mesh integrity, therefore it was left intact. Care was taken to create a hemostatic plane in between the rectum and the posterior vaginal wall with the mesh attached. The dissection was carried on further from the end of the old mesh to the perineal body. The bedside assistant is shown here manipulating the perineal body to verify we are at that level. It can be seen that the perineum had descended five centimeters beyond the edge of the mesh material at some point post-operatively. Wide mobilization of the rectum was carried out by disconnecting the rectum from the surrounding adventitial tissue with care taken to avoid the levator anti-muscles. This tissue will ultimately be used to perform a plication in hopes of restoring the rectum to its normal caliber. So here we see the width of the distended rectum. The same adventitial tissue is placated with braided delayed absorbable suture with great care taken to avoid placement of the sutures within the rectum or levator muscles. A series of these sutures are placed to fold the stretched out rectal tissue inwards in hopes that ultimate healing will result in a rectum of normal caliber. Excellent hemostasis is maintained throughout and with each suture placement care is taken to avoid the rectum. So a second layer of similar application sutures is placed to provide one extra layer of material between the mesh and the rectum. With this second layer care is taken to avoid the levators as well. So the plication of the adventitial tissue is now complete. Three permanent sutures were placed through and into the perineal body. They were tested to verify strength. The new mesh was attached to these perineal body sutures and then fastened to the posterior vaginal wall as would be done with any sacrocopalpexy. This mesh being so lightweight we determined it would be safe to apply a double ply of mesh material into the posterior space. Therefore the new mesh was fastened to the posterior vaginal wall and old mesh along the length of the rectovaginal space. The new mesh was also fastened at the apex. So vaginal palpation revealed that traction on the proximal arm of the mesh resulted in excellent support of the anterior vaginal wall. Therefore the anterior arm of the new mesh was not needed and was cut away. The new proximal arm was sutured to the old proximal arm in hopes of enhancing support and strength. The rectal plication was fastened to the posterior aspect of the new mesh in hopes that they would heal as one unit and no longer act independently of one another. So multiple attachments were made between the rectal plication and the posterior arm of the mesh with care taken to avoid injury to the rectum. So now the rectal plication is completely attached to the posterior arm of the mesh. The attachment of the original mesh to the sacrum was left intact and a new aspect of the anterior longitudinal ligament was exposed. Two separate permanent sutures were used for sacral attachment of the mesh complex. A running stitch and monofilament delayed absorbable suture was used to cover the mesh completely. At this point the mesh is completely covered and the robotic portion of the surgery is complete. The patient was discharged home on post-op day one with no complications. An office visit three weeks later showed positive objective and subjective outcomes with normalization of bowel habits. Here we have a video of her examination on that day with coughing. You can see that the apex anterior wall, posterior wall, and perineal body are all very well supported. Key elements of the procedure are as follows. Wide mobilization of the rectum, robust posterior plication, no levator plication, permanent sutures connecting the Y-mesh to the perineum, and attachment of the posterior plication to the posterior aspect of the mesh. Thank you for viewing our video.

recurrent posterior prolapse

perineal descent

defecatory dysfunction

sacrocolpopexy

perineal body