Pelvic Organ Prolapse (POP) is a common health condition in women, especially in the elderly. Although it is not a life-threatening condition, it impacts on quality of life. The surgical approaches using synthetic meshes grew in popularity once they show good long term results and more accessible applications. However, mesh-related events increased with its widespread usage,  including mesh exposure, pain, and dyspareunia. Looking for an alternative technique to avoid mesh usage, we proposed to use the autologous rectus fascia (ARF) in a similar way that it has been successfully used in urinary stress incontinence surgeries. With the ARF, it is possible to support the vaginal apex successfully. This video aims to demonstrate the technique of sacrospinous hysteropexy using autologous rectus fascia for apical POP treatment.

A 63-year-old woman with POP  stage IV had obstructive lower urinary tract symptoms without urinary incontinence. She described the necessity to reduce the prolapse as the only way to void. No topic estrogen was prescribed before the surgery, neither oral hormone replacement therapy. Through a Pfannenstiel incision, it was possible to harvest a rectus fascia sling with approximately 90 x 10 millimeters. Our goal was to harvest an aponeurosis size quite similar to a synthetic apical sling available in the market. The anterior vaginal wall was hydrodissected and incised longitudinally from the level of the bladder neck to the cervix. It is essential to maintain the vaginal wall thickness during the dissection, and carefully sort out the connective tissue between the bladder and the vagina. The bladder base is then released from the anterior aspect of the cervix in order to create a site to pericervical ring repair and to fix the ARF. Blunt dissection was extended downwards through the lateral aspect of the levator ani fascia until the identification of the ischial spine and sacrospinous ligaments bilaterally. The pubocervical fascia rupture was identified and sutured to the anterior aspect of the cervix using 2.0 polypropylene interrupted stitches. Therefore, the anterior prolapse was corrected, and the next step aimed at the apical correction. A 2.0 polypropylene thread mounted on a specially designed tissue anchor system (TAS) was fixed into the sacrospinous ligament about 2 cm away from the ischial spine for further rectus fascia anchoring. The same step was repeated on the opposite side. We sutured the middle section of the rectus fascia to the anterior aspect of uterine cervix fascia with interrupted polypropylene 2.0 stitches. Later, both sides of rectus fascia were fixed to the two polypropylene threads previously attached to sacrospinous ligaments. After the sutures were tied, the autologous fascia took the cervix upwards and corrected the apical prolapse. Finally, the vaginal wall was closed with absorbable interrupted sutures. A vaginal pack was kept overnight as well as the Foley catheter. Both were removed at the first postoperative day when the patient was discharged from the hospital.

The patient resumed her usual activities after one week. She was advised not to do hard physical activities, neither sexual intercourse for two months. This patient underwent a monthly follow-up with appointments to evaluate complaints of urinary incontinence, dysfunctional voiding, pelvic pain, and dyspareunia. After six months of follow-up, she was still satisfied without recurrence, neither local complications.

This video demonstrates stepwise the feasibility of transvaginal correction of high stage apical pelvic organ prolapse without using synthetic mesh. This technique can be used for advanced stage POP patients, especially for those who want to keep her uterus and vaginal length. It is also an alternative to avoid even laparoscopic or robotic mesh implants techniques.

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