Robotic-Assisted Trachelectomy and Mesh Excision

INTRODUCTION: Sacrocolpopexy is the most durable procedure for apical pelvic organ prolapse that preserves the patient's sexual function. The most common reasons for mesh excision are mesh exposure and pain. Mesh and cervical infection following a sacrocolpopexy is a rare complication that usually requires mesh excision, and most trainees are unlikely to encounter it. OBJECTIVE: Our aim is to provide an instructional video on the surgical management of a patient with chronic cervicitis and mesh infection following a remote minimally invasive sacrocolpopexy. METHODS: Our patient is a 56-year-old woman with a history of a laparoscopic supracervical hysterectomy, bilateral salpingectomy, sacrocolpopexy, and mid-urethral sling 7 years prior to presenting with worsening vaginal discharge, pelvic pain, and lower back pain. Her medical history is notable for preexisting fibromyalgia, and her surgical history is notable for a prior vaginal mesh excision of a vaginal mesh exposure of the sacrocolpopexy mesh in the posterior vaginal wall 2 years prior to this current presentation. She received several courses of oral antibiotics for cervicitis by her local primary gynecologist. On exam, she had severe cervical tenderness and purulent discharge for the cervical os. There was no visible mesh exposure in the vagina, but mesh was palpable within the internal cervical os. Patient had notable lower back and sacral pain on exam; however, a lumbar spine and abdomino-pelvic MRI was negative for osteomyelitis or intra-abdominal infection. The patient underwent a robotic-assisted trachelectomy and complete mesh excision. We obtained written consent for the patient to use her video for educational and research purposes. The video was recorded on the robotic surgical system. The surgery was originally about 3 hours in length, and we used computer video editing software to trim the video and add helpful graphics and voiceovers. RESULTS: The surgery was completed without complications. All the sacral mesh and most of the mesh on the anterior and posterior vagina were successfully removed. Final pathology confirmed chronic cervical inflammation. At the 6-week postoperative follow-up, although she had some continued pelvic and back pain, her symptoms were greatly improved compared to her preoperative state. Prolapse recurred in the isolated distal posterior compartment. Patient was pleased with the surgical outcome. CONCLUSIONS: Following conservative management with antibiotic administration and pelvic floor physical therapy, mesh removal and trachelectomy should be considered in the treatment of chronic cervicitis following a sacrocolpopexy. Although imaging studies such as MRIs may assist in the treatment planning, a negative MRI should not preclude surgery as an option. Our video demonstrates a safe and effective technique for trachelectomy and mesh removal in the management of chronic cervical and mesh infection following sacrocolpopexy.