Excision of Pelvic Mesh in the Setting of Discitis After Sacrocervicopexy

INTRODUCTION: Minimally invasive sacrocolpopexy is an effective reconstructive surgery for pelvic organ prolapse. Lumbosacral osteomyelitis and discitis are rare but serious complications and are often delayed diagnoses. OBJECTIVE: The aim of this video is to demonstrate stepwise technique in excision of pelvic mesh and discuss the management of patients with discitis after sacrocervicopexy with mesh. METHODS: A 63-year-old female underwent robotic-assisted laparoscopic supracervical hysterectomy, sacrocervicopexy with mesh, and midurethral sling. Two months later, she reported progressively worsening low back pain. Four months postoperatively, pain was persistent despite outpatient treatment with steroids. MRI spine was consistent with discitis, and she had an elevated erythrocyte sedimentation rate and c-reactive protein. IV antibiotics were initiated, and bone biopsy was performed. Neurosurgery consultants concluded that osteomyelitis was unlikely, but they would be available when the patient underwent surgical excision of the sacrocervicopexy mesh. This video was created to provide a stepwise demonstration, with English narration, of surgical excision of sacrocervicopexy mesh and discuss management and treatment of discitis. Measures were taken to protect the patient’s privacy and confidentiality throughout the video creation process. The patient gave written consent for filming the surgery. The target audience for this educational video includes minimally invasive surgeons who perform mesh colpopexy. RESULTS: In the operating room, an exam under anesthesia showed no vaginal mesh, suture erosion, or granulation tissue with a normal-appearing cervix. Cystoscopy was normal and a right ureteral catheter was placed before Foley placement. Five robotic ports were placed across the abdomen at the level of the umbilicus. Lysis of adhesions freed the mesh and bladder from omentum and rectosigmoid. The medial edge of the peritoneum overlying the long arm of the mesh was incised. Blunt and sharp dissection released pelvic sidewall retroperitoneal fat and perirectal fat from the mesh. Dissection to mobilize the mesh arm was performed superomedially until attachment at sacral promontory and multiple sutures were visible. The long arm of the mesh was transected inferiorly, separating it from the attachment to the cervical stump without disrupting the peritoneal closure overlying the stump. The mesh and 0.5 cm of surrounding circumferential indurated presacral fat were fully dissected from the anterior longitudinal ligament and a 4.5-cm segment removed from the surgical field. Another 3-cm mesh segment was excised and removed from the cervicovaginal junction. The patient was discharged on postoperative day 3 with a plan for 6 weeks total of IV antibiotic therapy. CONCLUSIONS: This video demonstrates a novel surgical technique of sacrocervicopexy mesh excision for discitis. Lumbosacral discitis is a rare but critical complication of sacrocolpopexy, often associated with concomitant total hysterectomy, vaginal mesh, or suture exposure. Patients typically present with low back pain. Diagnosis is supported by MRI and elevated inflammatory markers such as erythrocyte sedimentation rate and c-reactive protein. Bone biopsy, if possible, prior to initiating IV antibiotics aids in targeted therapy. Treatment consists of extended IV antibiotics and/or surgical excision of mesh. Additionally, consultation with neurosurgery and colorectal surgery prior to surgical excision is highly recommended.