Recurrent prolapse and mesh erosion are known complications that can arise in the setting of pelvic organ prolapse repair utilizing synthetic mesh.  Management of such outcomes can be technically demanding and require surgical innovation. The objective of this presentation is to outline a novel surgical technique for a robotic-assisted sacrocolpopexy utilizing a posterior rectus fascia graft.

A 68-year-old G3P3 female with three previous vaginal deliveries presented with pelvic organ prolapse and symptomatic vaginal mesh erosion. The patient had a previous vaginal hysterectomy and right salpingo-oophorectomy followed by a robotic-assisted sacrocolpopexy for symptomatic pelvic organ prolapse.  This was complicated by vaginal mesh erosion and she underwent a transvaginal mesh excision.  As a result, the patient presented for management of ongoing mesh erosion as well as symptomatic pelvic organ prolapse recurrence.  Given her previous surgical history as well as current state of mesh erosion, the patient was counseled on surgical management and elected to proceed with a robotic-assisted sacrocolpopexy utilizing a posterior rectus fascia graft.

Preoperative physical exam demonstrated pelvic organ prolapse recurrence and vaginal mesh erosion.  Intraoperatively, she was placed in the dorsal lithotomy position and was prepped and draped in the normal sterile fashion with administration of preprocedural antibiotics.  Four robotic ports were inserted in the standard robotic-assisted sacrocolpopexy fashion as well as a right-sided assistant port. The sacral limb of the previous mesh was identified and the overlying peritoneum was incised and dissected inferiorly towards the vagina utilizing a vaginal probe to guide the dissection.  A vaginotomy was created to excise  the eroded mesh in its entirety.  The previous mesh was then dissected off of the vagina both anteriorly and posteriorly and the vaginotomy was closed. The robot was redocked after rotating the boom with the utilization of two additional left sided ports to create the posterior rectus fascial graft harvest. Borders of the facial harvest included the linea alba medially, semilunar line laterally, and the inferior border was just immediately superior to the arcuate line.  The dissection was carried superiorly for a distance of approximately 20 cm to construct a “Y” autologous suspension graft.  The robot was then docked in the original position and the fascial harvest was secured to the vagina anteriorly and posteriorly with the superior limb secured to the sacral limb of the previous mesh.  Two months postoperatively, the patient had a well-supported vaginal apex with no evidence of foreign body extrusion and a well-healed vaginal cuff.

Robotic-assisted sacrocolpopexy using a posterior rectus fascia graft is feasible, particularly in the setting of previous surgical repair of pelvic organ prolapse.