Pelvic organ prolapse affects 40-50%(1) of parous women who present with symptoms consistent with incontinence, voiding dysfunction, dyspareunia and vaginal bulge. Of those women, around 12-15% (2) will need surgery due to failure of conservative treatment. Laparoscopic or robotic sacrocolpopexy is considered the gold standard in advanced prolapse repair. Mesh complications occur infrequently, but infections, failure of prolapse repair and mesh erosions require mesh removal. The rate of mesh-related complications after sacrocolpopexy have been reported between 0% and 13% (2), depending on mesh material, length of follow-up and surgeon’s technique and experience. Common symptoms derived from mesh complications include chronic pelvic pain, dyspareunia and urinary and defecatory dysfunction. Presently, there is no consensus regarding treatment of these symptons. This work aims to describe the technique of laparoscopic mesh excision after sacrocolpopexy to help surgeons facing mesh complications.

We present the case of a 47-year-old patient with a history of laparoscopic sacrocolpopexy three years prior. She presented with chronic pelvic pain, urinary and defecatory dysfunction, and dyspareunia. Preoperative magnetic resonance imaging (MRI) demonstrated a moderate rectocele and cystocele, and significant posterior vaginal wall thickening. After a thorough history ,physical examination and urodynamics were performed, and imaging studies were conducted, the decision was made to proceed with surgical mesh removal .

The patient is positioned in lithotomy with slight Trendelenburg. 5 ports are placed: one 11mm supraumbilical; another 11mm in the right pararectal line laterally to the umbilicus; and further 3 ports of 5mm, one on the left pararectal line and two medial to the left and right anterior superior iliac spines. The procedure begins with cystoscopy, and bilateral ureteral stent placement. Subsequently we proceeded laparoscopically with extensive surgical excision of mesh. Laparoscopy demonstrated dense adhesions from the mesh  in the posterior vaginal wall to the rectum. We managed to removed almost the whole mesh from the posterior vaginal wall. We sutured the posterior vaginal wall and we explored the anterior vaginal wall , where the mesh was correctly positioned, therefore we left it in place.Postoperatively, the patient reports significantly reduced pain but persistent defecatory dysfunction.

Despite being challenging and non-standardized, laparoscopic mesh removal after sacrocolpopexy is a feasible and safe procedure when performed by experienced surgeons. This technique is feasible and is aimed at improving patients’ complaints and symptoms, when conservative treatment has failed.

Collins S, Lewicky-Gaupp C. Pelvic Organ Prolapse. Gastroenterol Clin North Am. 2022 Mar;51(1):177-193.
Sung VW, Jeppson P, Madsen A. Nonoperative Management of Pelvic Organ Prolapse. Obstet Gynecol. 2023 Apr 1;141(4):724-736.