Forty percent of women develop a degree of pelvic organ prolapse (POP) during their lifetime, and the life risk of requiring surgical repair is 11%. The current standard intervention for vault prolapse is a mesh colposacropexy or hysteropexy.  However, patients and surgeons are increasingly hesitant of the use of mesh given recent UK and FDA warnings and litigation. The use of autologous rectus fascia sheath (RFS), is increasingly being preferred in patients with stress urinary incontinence, the success rates for RFS seem to be broadly similar to those using polypropylene mesh. As such, it seems sensible to offer patients autologous RFS sacrocolpopexy and sacrohysteropexy as a mesh free alternative for uterine and vault prolapse. We report the use of RFS as a free graft for recurrent POP in a series of patients with complex pelvic floor dysfunction.

All patients had (multiple) previous gynaecological or urological surgeries, and had recurrent symptomatic POP. Patients were offered autologous RFS sacrocolpopexy or sacrohysteropexy instead of mesh. Procedures were performed through Pfannensteil access to harvest a strip of RFS 10-18 cm by 2.5 cm in length. Sacrocolpopexy and sacrohysteropexy were performed in similar fashion to their mesh alternatives. For sacrocolpopexy the RFS was reconstructed in Y configuration and secured to anterior vault and posterior wall with PDS sutures. For sacrohysteropexy the RFS was wrapped around the cervix through windows in the broad ligament. The apex of the sling was attached to the sacral promontory. In sacrocolpopexy, the sling was left tension-free, whilst sacrohysteropexy was tensioned to elevate the uterus out of the pelvis. The exposed length of RFS was extra-peritonealised where possible.

Seven patients, with mean age of 52 (33 – 64) years underwent autologous RFS POP repair (sacrocolpopexy n=4, and sacrohysteropexy n=3). Indications and re-intervention are shown on Table 1. All women had POP-Q stage 3 or more. The mean inpatient stay was 5.1 days (range 3 – 10), and mean follow-up is 16 (range 2 – 33) months. All patients have had improved POP-Q (C) stage ≤ 1 and symptomatic resolution of symptoms at last follow-up. One patient required extended antibiotic cover for a post-operative chest infection. There were no other complications reported.

Autologous fascia use as a POP graft has been reported in six series. In only two of these series was a free RFS graft employed, and only in our series was the technique of Y-shaped sacrocolpopexy and sacrohysteropexy described. In all these series, the outcomes seem equivalent to those of mesh repairs and significantly better than Pelvicol xenograft, although the follow-up is relatively short.

This is the first report of patients with recurrent, apical POP being managed with autologous RFS sacrocolpopexy and sacrohysteropexy, and only the third report of a free RFS graft being utilized with success. These three series demonstrate proof of concept for abdominal repair for POP, with safe and promising early functional results. The technique offers a mesh free approach, which could be considered for patients who are at potentially higher risk of synthetic mesh extrusion. Further study is required to identify patient suitability, durability of treatment and benefit over the standard treatment of polypropylene mesh repair.