Surgical Management of Recurrent Prolapse After Failed Vaginal Mesh

INTRODUCTION: Vaginal mesh was popular in the 2000s and early 2010s before it was removed from the market in April 2019. Vaginal mesh has risks, including mesh exposure/erosion, pelvic pain, dyspareunia, and infection. Nowadays, its use has been limited to rare cases, if at all. After failed vaginal mesh surgery, Sacrocolpopexy can be considered as it has lower rates of complications, failure, and recurrence of pelvic organ prolapse and is considered the gold standard for apical pelvic organ prolapse. OBJECTIVE: Our objective is to present the management of a patient with recurrent stage 3 pelvic organ prolapse, urinary and fecal incontinence, following prior vaginal mesh augmented repair. Our goal is to share how we managed this patient and to discuss potential avenues for management of such cases. METHODS: A 65-year-old G6P5 with a pertinent past medical history of T2DM (A1C 7.4%), HLD, and HTN presented for evaluation of pelvic organ prolapse, urinary and fecal incontinence. She had previous urogynecologic surgeries at an outside facility with anterior repair with Prolift and posterior repair with Prosima in 2010. She was initially feeling asymptomatic but then felt the return of vaginal bulge sensation. She had a past surgical history significant for abdominal surgeries including abdominoplasty, open cholecystectomy, TAH with prior Pfannenstiel incision. On the pelvic exam, she had evidence of recurrent pelvic organ prolapse and no mesh exposure on bimanual or digital rectal exam. Initial POP-Q exam showed stage 2 anterior, posterior, and apical wall prolapse. Initially, the treatment recommended was pelvic floor physical therapy. The patient returned following 2 months of PFPT with mild improvement in symptoms. On updated POP-Q exam, it was noted that she had rapidly worsening prolapse from stage 2 to stage 3. RESULTS: Given the severity of her symptoms, the patient opted to proceed with robotic-assisted sacrocolpopexy with polyproline type 1 mesh, right salpingectomy, and cystoscopy for the treatment of stage 3 pelvic organ prolapse. Pathology of the fallopian tubes came back normal. She presented for her post-op visit and pain was well controlled with no symptoms of stress urinary incontinence, vaginal bulge, or urinary retention. The patient was satisfied with the resolution of symptoms. CONCLUSIONS: Our video footage depicts previous failed vaginal mesh for the treatment of apical wall prolapse. After failed vaginal mesh surgery, sacrocolpopexy can be considered as a surgical approach for recurrent pelvic organ prolapse. It can provide more fine motor control to the dissection of densely adhered vaginal mesh and allow for better tensioning of the vaginal vault. Sacrocolpopexy has lower rates of complications, failure, and recurrence and is considered the gold standard for apical pelvic organ prolapse.