Surgical Approach to Robotic-Assisted Sacrocolpopexy Anterior Arm Revision

INTRODUCTION: Sacrocolpopexy is a gold standard surgery for pelvic organ prolapse (POP) given its long-term success, ranging from 78–100%, and lower recurrence rate compared to native tissue repair. Recurrence is reported in 1.5% to 11% of cases, with 4% undergoing reoperation. When reoperation is performed, only 1.7% of cases undergo mesh revision. Recurrence most commonly affects the anterior compartment and may be due to mesh detachment from the vagina or sacrum, mesh stretching, inadequate dissection of the vagina, or previously unaddressed lateral defect. Risk factors for recurrence include larger (≥4 cm) genital hiatus and need for concomitant anterior colporrhaphy at time of index sacrocolpopexy. Additionally, the use of ultra-lightweight mesh has been noted to have a shorter time to recurrence versus lightweight mesh. Given the overall low rate of recurrence and sacrocolpopexy mesh revision, few studies exist to discuss the technique of this challenging yet effective surgery. OBJECTIVE: The objective of this study is to demonstrate the surgical approach used to revise single-compartment mesh detachment after sacrocolpopexy. METHODS: The patient presented 6 years after sacrocolpopexy with complaints of vaginal bulge after a fall. Isolated stage 2 anterior POP was noted with preservation of posterior and apical support. She desired surgical treatment and underwent robotic-assisted sacrocolpopexy anterior arm revision. She consented to video recording. A vaginal sizer was placed based on the patient’s total vaginal length. The peritoneum overlying the vaginal cuff was incised, and the vesicovaginal space was dissected, confirming anterior arm mesh detachment. The bladder was filled retrograde to safely delineate structures. The long arm of the preexisting mesh was found to be securely attached to the sacrum, and its attachment point to the vaginal cuff was identified. Polypropylene mesh was secured to the anterior vagina using a series of 8 interrupted braided polyester sutures, with care taken to avoid kinking or folding of the mesh. The vaginal manipulator was briefly removed to allow for digital exam, which confirmed the absence of suture in the vagina. The cephalad end of the new anterior arm was anchored to the long arm of the preexisting mesh using interrupted braided polyester sutures. The point of attachment suspended the vagina to approximately two-thirds of its total length. Excess mesh was trimmed, and the peritoneum was closed to cover the mesh using running absorbable barbed suture. Cystoscopy confirmed the absence of bladder injury or suture. RESULTS: The patient’s surgical course was complicated by postoperative ileus that resolved with conservative measures. She otherwise recovered well with no recurrence of prolapse at the 6-week follow-up. CONCLUSIONS: This compartmentalized approach to mesh revision avoids unnecessary sacral dissection, leading to shorter operative times and reduced patient complications. Utilization of preexisting mesh precludes the need for an additional vaginal suspension. This approach is versatile and can also be used to correct posterior arm detachment. In conclusion, robotic sacrocolpopexy mesh revision is a safe, effective, and efficient option for the surgical treatment of recurrent prolapse due to single-compartment mesh failure.