Spondylodiscitis secondary to colposacropexy is an extremely rare entity. Infection and mesh rejection are the main causes. Removal of the mesh is essential for patient's recovery. This could be a very challenging surgical procedure.

72-year-old woman with a history of an abdominal hysterectomy because of myomatous uterus at the age of 45. Anterior vaginal mesh placement for symptomatic cystocele at the age of 55. No other medical history of interest. 

She consulted for symptomatic grade III prolapse (Badden Walker) of the vaginal vault / stage 2 prolapse (POP-Q). No urinary or fecal incontinence. No other pelvic floor symptoms.

A laparoscopic colposacropexy is performed using SERATEX® E9 (Serag-Wiessner) mesh for fixation of pelvic structures to the sacrum. This mesh is made of polypropylene, polyglycolic acid-caprolactone dyed (PGACL). Is a monofilament and partially absorbable, the PGACL portion is absorbed within 90-120 days. Ethibond-Excel 0 (Ethicon) suture is used to fix the mesh to the structures. Is a braided and non-absorbable surgical suture composed of polyethylene. We use a 6-point technique, two points to fix the mesh to both elevator ani muscle, two points to fix the mesh to the vaginal vault, one point to fix the mesh to the anterior vaginal wall and one point to fix the mesh to the sacrum. Procedure was done under prophylactic intravenous antibiotic (cefazolin 2 grams). The immediate postoperative course was normal, and the patient was discharged in good general condition after 24 hours. 

One month after surgery the patient presented with lumbar pain and general malaise. She was admitted due to persistence of severe low back pain, poorly controlled with first level analgesia. She received intravenous antibiotics (Cloxacillin 500miligrams each eight hours) with associated second level intravenous analgesia but continued to have a torpid evolution. Magnetic resonance imaging (MRI) was performed showing alteration of the signal of the bone marrow of the vertebral body of L5 and of the upper vertebral plate of S1. Mild collapse of the body of L5. Soft tissue material surrounding L5-S1 with small prevertebral laminar collection. The findings are related to spondylodiscitis (image 1). 

After a multidisciplinary meeting, it was proposed to remove the mesh.

 An exploratory laparoscopy is performed. When removing mesh at the level of the insertion in the sacrum, capsulation of the mesh, granulation tissue and serous material was seen probably related to a mesh rejection. Non purulent material was seen. Mesh was found to be unanchored from the distal part, all suggestive of mesh rejection.  Mesh was completely removed with no complications (image2).

Culture of the mesh showed “Bacillus Cereus” sensible to linezolid, but the microbiologist notes that it could be a contaminant. Patient received six-week prophylactic intravenous antibiotics with cloxacillin 500miligrams each 8 hours and linezolid 600mg each 12 hours, blood test parameters started to normalized and back pain disappeared. She was discharged completing one more month of oral antibiotics with cloxacillin 500mg each 6 hours just in case an infection was the cause of the mesh rejection. 

We cannot be sure if the Bacillus Cereus is a possible contaminant of the sample and it is a rejection of the mesh with no added infection or if it is truly a mesh rejection secondary to infection. This is probably a mesh rejection without superimposed infection, based on the patient's evolution and the findings at surgery.

Spondylodiscitis secondary to colposacropexy should be suspected when the patient starts with moderate lumbar pain and is not correctly controlled with first level analgesia. Mesh rejection should be considered when patient does not improve after antibiotics. Complete removal of the mesh is needed in order to ensure patient's recovery.

1.	Da-Cheng Qu et al,. 2019. Management of lumbar spondylodiscitis developing after laparoscopic sacrohysteropexy with a mesh: A case report and review of the literature. Medicine (Baltimore). Dec;98(49):e18252.
2.	Di Marco et al,. 2004. Robotic- assisted laparoscopic sacrocolpopexy for treatment of vaginal vault prolapse. Urology 63:373–376.
3.	Hart et al,. 2004. Abdominal sacral colpopexy mesh erosion resulting in a sinus tract formation and sacral abscess. Obstet Gynecol 103:1037–1040.