Management of recurrent vaginal prolapse is a clinical challenge. The anterior vaginal wall is the commonest site of prolapse recurrence after reconstructive pelvic surgery (reference 1). Classically, the use of vaginal mesh has been suggested as an option in the management of recurrent prolapse. Vaginal mesh use, however, was associated with significant risk of mesh complications (reference 2), without adding much benefit in terms of outcomes (reference 3). Alternative options for surgical management of recurrent anterior vaginal wall prolapse include the use of native tissue reconstruction versus abdominal mesh insertion. Increasingly, patients are reluctant to undergo mesh surgery even if the abdominal approach was used, and native tissue options are being explored. We evaluate laparoscopic paravaginal repair as a native tissue option for management of recurrent anterior vaginal wall prolapse. In this abstract, we present the two year outcomes of laparoscopic paravaginal repair for recurrent anterior vaginal wall prolapse, and demonstrate the surgical technique we follow for this approach.

52 women with recurrent anterior vaginal wall that underwent previous hysterectomy and at least one anterior repair were prospectively evaluated. All women filled the Prolapse Quality of Life Questionnaire (P-QOL), and were examined using the POP-Q system pre operatively and post operatively. In this abstract we present the two year outcomes. Post operatively, patients also filled the Patient Global Impression of Improvement Questionnaire (PGII). All patients signed an informed consent, and after routine laparoscopic entry, the retropubic space is opened and the bladder separated from the anterior abdominal wall and the pubic bone. A fourth port is then inserted in the suprapubic space. The bladder is then dissected medially with two fingers in the vagina, and the prolapsed para vaginal tissues are identified. The most cranial part of the prolapse is then attached in a tension free manner to the Cooper's ligaments, with two more sutures taken caudally. The process is repeated on the other side and the retropubis space is then closed. Cystoscopy is then performed to check bladder and ureter integrity.

Surgery was completed successfully in all subjects. There was one case of cystotomy during bladder dissection, that was repaired and the procedure continued as planned. Surgical time ranged from 45-70 minutes with no major peri operative complications. All cases were discharged home next day. at two years. At two years, 49 women reported feeling "much better' or "very much better" on PGII. Anatomically, point Ba was < -1 in all cases at two years. There was significant improvement of voiding and overactive bladder symptoms postoperatively.

To our knowledge, this is the first study that evaluates laparoscopic paravaginal repair outcomes for recurrent anterior vaginal wall prolapse. The strengths of this study include the two year outcomes, use of validated objective and subjective measures for prolapse assessment and the prospective study design. This study shows that laparoscopic paravaginal repair is an effective treatment option in patients with recurrent anterior vaginal wall prolapse and should be offered as a native tissue minimally invasive option for patients with this condition.

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Continence 12S (2024) 101522
DOI: 10.1016/j.cont.2024.101522