Pelvic organ prolapse (POP) is a common problem affecting many women with a lifetime risk of undergoing surgery close to 10 %.​  In case of apical prolapse, abdominal sacral hysteropexy (ASP) is considered the gold-standard but dissection of the promontory may cause life-threatening complication. Lateral suspension with mesh was developed in 1967 and offers an alternative without the risk of promotory dissection. The risk of POP reoperation for recurrence is estimated between 6 and 10 % and associated with preexisting weakness of the pelvic floor. Surgery in case of recurrence is often challenging. This video illustrates one possible option in case of apical recurrence after hysteropexy by lateral suspension with a mesh

A fifty-year-old female gravida 3, para 1, with history of POP reconstructive surgery by robotic-assisted lateral suspension with mesh three years ago,  presented with recurrence of uterine prolapse. At clinical examination, there was a uterine prolapse overpassing the hymen of 3 cm due to pericervical fascial defect with an enlarged and elongated cervix. Ultrasonography showed a slightly enlarged uterus with two myomas of 4 and 2 centimeters respectively. We decided to perform a robotically-assisted laparoscopic hysterectomy and bilateral salpingectomy with high utero-sacral ligament suspension

We used the Da Vinci XI system (Intuitive Surgical®) with an 8 mm port for a 0° optic and two 8 mm lateral ports with one additional 10 mm paraumbilical trocar for the assistant. A Hohl uterine manipulator was used to expose the uterus. The intra-abdominal status showed a desinsertion between the uterine isthmus and the mesh. We performed a standard hysterectomy with bilateral salpingectomy preserving the attachment of the mesh to the vesico-vaginal fascia, to limit the risk of recurrence in the anterior compartment. After closing the vaginal vault with 4 x points of Vicryl 0 we proceeded to the vaginal vault suspension to the middle portion of the utero-sacral ligaments by two points of Vicryl 0  under visual control of the ureters on both sides. To reduce the risk of mesh exposure at vaginal vault, we lowered the epiploon and fixated it on the vaginal dome.

Our video illustrates the feasibility of laparoscopic high uterosacral ligament suspension of the vaginal vault after previous hysteropexy by lateral suspension with mesh. There are a multitude of different surgical techniques to treat pelvic organ prolapse, with vaginal, abdominal or laparoscopic approach, preserving or removing the uterus, using native tissue or a mesh. Therefore, every surgeon should master different techniques in order to choose the best suited one in each situation. In case of uterine pathology with enlarge or elongated cervix, laparoscopic high uterosacral vaginal vault suspension with or without robotic assistance may be an interesting alternative treatment to the traditional vaginal route, limiting the risk of ureteral injury. In case of recurrence after previous mesh surgery it allows the surgeon to better apprehend the prosthesis to limit the risk of recurrence and potential erosion