A Collaborative Approach to Multicompartment Pelvic Organ Prolapse

Abstract

Multicompartment pelvic organ prolapse is common yet frequently underreported and unrecognized. Although not life-threatening, the impact on quality of life and daily functioning can be significant. Multidisciplinary evaluation and treatment with specialists in colorectal and female pelvic medicine and reconstructive surgery (FPMRS) help to identify patients who will benefit from surgical treatment of vaginal and rectal prolapse. Both abdominal and perineal combined procedures can be offered to patients with a single operation and concurrent recovery period without increasing complications.

Historically, pelvic care has been compartmentalized, with gynecologists focusing on abnormalities of the uterus and vagina, colorectal surgeons focusing on disorders of the bowel, and urologists focusing on bladder symptoms. ¹ The lack of recognition of the interrelated nature of the pelvic organs, muscles, and nerves has perpetuated fragmented care and often-incomplete assessment of pelvic floor dysfunction. With growing awareness of the pathophysiology of pelvic floor disorders, gynecologists and urologists united to create female pelvic medicine and reconstructive surgery (FPMRS) specialty training for pelvic organ prolapse, management of urinary symptoms, and reconstruction for conditions like fistulae and urethral diverticula. ² Similarly, there is a movement toward subspecialty training involving collaboration with colorectal surgeons to address bowel dysfunction and posterior compartment prolapse. Over the past two decades, there has been a slow and steady trend toward team-based care of complex health issues, including pelvic floor dysfunction, with an emphasis on identification and surgical treatment of multicompartment pelvic organ prolapse.

The significance of pelvic floor disorders cannot be overstated with childbirth being one of the key drivers in pelvic floor anatomic deficits. Over 23% of women in the United States have a symptomatic pelvic floor disorder and this number increases to 50% by age 80 years. ³ Approximately 11% of women will undergo a procedure for vaginal prolapse in their lifetime. ⁴

In patients presenting with rectal prolapse, the presence of urinary incontinence and pelvic organ prolapse (POP) is between 21 and 34%. ^{5 6} In a study of 508 women undergoing ventral rectopexy, 53% of patients reported feelings of pelvic organ bulging and 46% noted preexisting urinary incontinence. ⁷ Combined surgical procedures with rectopexy and colpopexy are more commonly performed as women report concurrent symptoms. Data from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) between 2005 and 2014 showed that, among 3,600 women undergoing a rectopexy, 206 (5.7%) underwent a combined procedure with a sacrocolpopexy. ⁸ The proportion of combined surgeries increased with time (up to 7.7% in 2014) and morbidity was similar between rectopexy only and combined procedure groups (14.8 vs. 13.6%, p  = 0.65).

Rectal and vaginal prolapse can both be treated with an array of surgical procedures. Repair of concurrent prolapse may be abdominal (robotic, laparoscopic, or open) or perineal. Surgical approach is determined by surgeon preference and experience, patient's goals, medical comorbidities, frailty, and presence and type of prior prolapse repairs. ⁹ A perineal approach is recommended for frail patients with perineal proctectomy and colpocleisis. ^{10 11} In younger and healthier patients, a laparoscopic or robotic abdominal approach is preferred often with mesh or graft for the ventral rectopexy and sacrocolpopexy. ¹²

A systematic approach to addressing prolapse starts with identifying bladder, prolapse, and bowel symptoms and then referring to appropriate specialists. Learning to work with colleagues for a unified approach can take some finesse and flexibility. In the following sections, we hope to share with you some of our experience with a collaborative multicompartment approach.

Pelvic Floor History

A thorough pelvic floor history should include bladder and bowel symptoms, incontinence, feelings of prolapse, difficulty emptying bladder or bowel, pain, and sexual function. Standardized tools such as the Pelvic Floor Distress Inventory (PFDI-20) and Pelvic Floor Impact Questionnaire (PFIQ-7) can be used to assess symptom severity and impact on quality of life. ¹³

Comorbidities and risk factors for pelvic floor dysfunction should be identified and reviewed with all patients with prolapse. Underlying conditions, such as diabetes, connective tissue, and immunological disorders, and neuromuscular conditions, should be optimized by a medical specialist. Healthy lifestyle and modifiable behaviors, such as dietary choices, exercise, smoking, alcohol consumption, and chronic straining, need to be independently addressed prior to considering surgical intervention.

For patients with pain syndromes with or without narcotic dependence, we recommend evaluation of emotional state and coping strategies, weaning off narcotics if possible, and mindfulness or cognitive behavioral therapy. A history of sexual assault is important to identify prior to exam to minimize additional medical trauma associated with vaginal and rectal manipulation. Some patients may require an exam under anesthesia for a thorough evaluation. For elderly or poorly functioning patients, an evaluation for frailty can be helpful to identify surgical risk and areas for geriatric optimization.

Female Pelvic Medicine-Focused History and Examination

A focused history for pelvic floor disorders should include urinary daytime and nighttime symptoms, history of infections, sensation of incomplete bladder emptying, hematuria, vaginal pain, and vaginal bulge/pressure. The history should also include any prior surgeries, obstetric history, such as operative deliveries (forceps/vacuum) and perineal lacerations involving the anal sphincter, and any genitourinary disorders, such as renal stones or chronic kidney disease. Abnormal vaginal bleeding or discharge should be addressed as these could be a result of poor vaginal tissue quality (atrophy) or uterine pathologies, such as endometrial hyperplasia or cancer. Vaginal exam is performed in the supine or standing position. A pelvic organ prolapse quantification (POP-Q) examination is performed to determine the extent of anterior, apical, or posterior vaginal prolapse with the Valsalva. ¹⁴ Vaginal prolapse is staged from 1 to 4, with stage 1 being minimal prolapse and stage 4 being complete eversion of the uterovaginal tissue. Urinary leakage with cough or the Valsalva is also determined. The uterus and adnexa are palpated for any masses, and a Kegel squeeze is elicited to determine pelvic floor muscle strength.

Colorectal-Focused History and Examination

A focused bowel history should include bowel consistency and frequency, use of laxative or bowel stoppers, and digital or positional maneuvers required to defecate. The presence of mucus discharge, fecal soiling or leakage, and urgency or passive incontinence may suggest internal or occult external rectal prolapse, sphincter dysfunction, or dyssynergic defecation. Rectal examination can be performed squatting, standing, on the commode, or in the prone or lateral positions. Patients are encouraged to bring in a picture of the prolapse in situations where it can be painful or difficult to elicit during examination. Visual inspection of the anus is reported as closed, open, or patulous, and visible contractions of the sphincter with squeeze and movement of the pelvic floor with the Valsalva are documented. Response to soft or sharp stimuli provides rudimentary information about neurological status. The patient is asked to perform a strong pushing Valsalva's maneuver to assess for rectal mucosa or full-thickness rectal prolapse. Anoscopy visualizes the hemorrhoid complex and can help to identify internal or full-thickness rectal prolapse.

Pelvic Floor Testing

Additional pelvic floor testing is performed on a case-by-case basis. Defecography helps to identify multicompartment or occult prolapse, enterocele, sigmoidocele, and perineoceles. Unrecognized anatomic findings can lead to treatment failures. Anorectal manometry helps to determine anorectal sphincter pressures, sensation, and coordination. Motility testing may be recommended in patients with severe constipation to identify slow transit in addition to rectal dysfunction that can occur as a consequence of prolapse.

Urodynamic testing is a combination of procedures to determine bladder and urethral function and can be performed with reduction of vaginal prolapse using vaginal swabs or pessaries. Of women with vaginal prolapse, 40% suffer from stress urinary incontinence (urinary leakage with activity, lifting, or coughing/sneezing) and 37% have overactive bladder. ¹⁵ In addition, roughly 25% of women who undergo abdominal sacrocolpopexy for vaginal prolapse report bothersome stress urinary incontinence after surgery. ¹⁶ Correction of anterior and apical vaginal prolapse may “unkink” the urethra and bladder neck, unmasking stress urinary incontinence. Preoperative urodynamic testing may help to identify patients at higher risk for de novo postoperative stress urinary incontinence who can be offered prophylactic anti-incontinence procedures at the time of prolapse repair.

Benefits to a Multidisciplinary Evaluation and Surgery

In our multidisciplinary pelvic health clinic, we have the unique ability to screen and schedule appropriate patients with urinary, prolapse, and defecatory dysfunction for a combined consultation and evaluation. We use a standardized intake form. Each specialist has the opportunity to interview the patient and, with the patient's permission, a single examination is performed. At the end of the appointment, we create a coordinated plan, which may include pelvic floor exercises, medical treatments or referrals, additional pelvic floor testing, and surgery, if appropriate. Administrative support is the most important component to facilitating a multidisciplinary clinic. Most facilities do not have the ability to coordinate multiple specialists in one location. In those practice models, detailed questioning about vaginal and rectal prolapse can guide a referral to the appropriate specialist.

A guiding principle for all prolapse surgery is attention to and focus on what bothers the patient. This facilitates setting patient goals and expectations. Patients are discussed as part of a multidisciplinary pelvic floor conference where imaging, anorectal testing, and urodynamic testing are reviewed. All patients under consideration for abdominal mesh are discussed. The ultimate benefit is a comprehensive patient-centered approach and single-coordinated surgery.

Surgical Decision Making

For women with both vaginal and rectal prolapse, the surgical options include both abdominal and perineal repairs. The decision making regarding surgical approach can be complex and national guidelines are lacking. In general, an abdominal approach is considered more durable for rectal prolapse repairs via open, laparoscopic, or robotic techniques. For abdominal procedures suture rectopexy, ventral mesh rectopexy and sigmoid resection with suture rectopexy are all potential options and can be performed with sacrocolpopexy with or without hysterectomy or incontinence procedures.

Our preference for a healthy, posthysterectomy woman with rectal prolapse and anterior or apical vaginal prolapse who is willing to consider mesh, is a ventral rectopexy and sacrocolpopexy ( Fig. 1 ). For a woman who would like to avoid mesh, we offer a suture rectopexy and vaginal suspension procedure (uterosacral ligament suspension or sacrospinous ligament fixation) with anterior and posterior colporrhaphy.

Fig. 1.

Ventral rectopexy and sacrocolpopexy: mesh is sutured to the anterior rectum and anterior vagina and both mesh are fixed to a single point along the anterior longitudinal ligament. (Reprinted with permission, Cleveland Clinic Center for Medical Art & Photography © 2010–2019. All Rights Reserved).

For a woman with uterus in place, her options include concomitant total hysterectomy, supracervical hysterectomy, or hysteropexy (suspension surgery without removal of the uterus). Traditionally, a total hysterectomy was performed with a vaginal apex suspension; however, many FPMRS surgeons offer vaginal suspension without hysterectomy due to a growing preference among women to avoid hysterectomy, as well as data showing similar success rates between procedures with and without hysterectomy. Women may have concerns about sexual function and a desire to retain reproductive organs. Vaginal mesh exposure after sacrocolpopexy ranges from 3 to 6%, with higher rates of exposure in women who are smokers or underwent concurrent hysterectomy. ¹⁷ To avoid a higher rate of mesh exposure in total hysterectomy patients, many surgeons will perform a supracervical hysterectomy in a patient with a history of normal Pap smears. If a hysteropexy is performed with mesh, the mesh is applied to the anterior vagina and cervix with two arms traveling posteriorly through the broad ligaments to the sacrum. If a hysterectomy is required in the future for abnormal bleeding or suspicions of cancer, an FPMRS surgeon should be present to assist with dissection around the mesh and possible resuspension.

Frail patients and those with multiple comorbidities are usually offered perineal procedures to avoid longer operative times and the risks associate with abdominal surgery. Perineal approach for rectal prolapse can be combined with a vaginal suspension surgery or obliterative vaginal surgery, such as a colpectomy in prior hysterectomy patients or colpocleisis in women with a uterus in place. In these procedures, the vaginal epithelium is removed and the vaginal canal is closed with draining channels if the uterus is left in place.

Coordination of Care in the Operating Room

For surgeons, the coordination of operative schedules can be a challenge. Administrative support and block scheduling for combined procedures is the best way to promote multidisciplinary care. Rotating the cases in different specialty rooms is more equitable to the participating surgeons. Involving the fellows and residents from different specialties promotes a collaborative environment. Preoperative planning includes both surgeons understanding patient goals and setting realistic expectations. After induction of anesthesia, the patient is reexamined by all surgeons and the surgical plan and order of procedures is confirmed. Additional surgical attending support is a real benefit in complex cases.

Outcomes of Combined Repairs

Few studies report outcomes and complications in women undergoing surgery for combined rectal and vaginal prolapse. In 2018, a study utilizing NSQIP data identified 206 women who underwent a rectopexy with sacrocolpopexy from 2005 to 2014 and compared these cases to 3,394 women who underwent rectopexy alone. ⁸ Overall morbidity was not significantly different between the groups (14.8% rectopexy only vs. 13.6% combined surgery, p  = 0.65). A later NSQIP study of vaginal and rectal prolapse surgeries from 2013 to 2016 found 123 concurrent laparoscopic sacrocolpopexy and rectopexy cases. ¹⁸ Complication rates between colpopexy, rectopexy, and concurrent procedures were not significantly different (6.2, 7.6, and 8.9%; p  = 0.058).

Of the few studies reporting outcomes in combined rectal and vaginal prolapse surgery, nearly all are retrospective case series ( Table 1 ). These studies primarily describe results in abdominal repairs, with a mix of open and laparoscopic approaches. Follow-up ranged from 6 months to 5 years. The largest study included 110 patients who underwent abdominal mesh rectopexy and sacrocolpopexy with no rectal prolapse recurrence during a median follow-up of 29 months. ¹⁹ Nearly all studies reported rectal and vaginal prolapse recurrence and complications, with overall low rectal prolapse recurrence (0–13.5%), vaginal prolapse recurrence (0–10%), and reoperations for any reason (0–5.4%). Four studies reported that one to two patients required excision or rubber banding for mucosal rectal prolapse and one study reported seven patients required treatment for hemorrhoids. ^{19 20 21 22} During the follow-up period, two studies reported vaginal prolapse surgery for recurrence in two to three patients, and two studies reported surgery for stress urinary incontinence for two to four patients. ^{20 23} Intraoperative complications, such as conversion to open surgery, presacral bleeding, or bladder/ureteral injuries, were rare with no reported transfusions across studies. In a study of 59 patients undergoing laparoscopic or robotic ventral rectopexy with sacrocolpopexy/hysteropexy, five (8.5%) required readmission for sepsis, ileus, small bowel obstruction, pulmonary embolism, and pelvic abscess. Other infrequent complications across all studies included one postoperative discitis requiring surgery, two vaginal mesh exposures/erosions, and one mortality. Patient-reported outcomes varied among the studies, with few including validated symptom and distress questionnaires. In one study of 51 patients who underwent robotic ventral mesh rectopexy and sacrocolpopexy, postoperative PFDI scores significantly improved in all subscales (pelvic, urinary, and colorectal/anal distress). ²²

Table 1. Outcomes and complications of combined rectal and vaginal prolapse surgery.

Study	N	Country	Rectal prolapse surgery	Vaginal prolapse surgery	Median follow-up time (mo)	Recurrence	Retreatment or reoperation	Complications
Ayav et al 24	8	France	Abdominal mesh rectopexy with sigmoid resection	Sacrohysteropexy with mesh	17	Full-thickness rectal prolapse: 0% Vaginal prolapse: 0%	Sigmoid resection to improve postoperative constipation: 1 (12.5%)	Mortality: 0
Collopy and Barham 20	89	Australia	Abdominal mesh rectopexy	Pelvic cul-de-sac closure with mesh suspension of vaginal apex	60	Full-thickness rectal prolapse: 0% Vaginal apex: 0% Distal vaginal walls: 10%	Mucosal prolapse surgery: 2 (2%) Colporrhaphy: 3 (3%) Bladder neck surgery: 4 (4.5%)	Incisional hernia: 5 (5.6%) Infection: 0 Mortality: 0 Ureteral injury: 0
Jallad et al 25	59	United States	Laparoscopic or robotic ventral rectopexy (mesh or biologic graft)	Laparoscopic or robotic sacrocolpopexy or sacrohysteropexy with mesh	17	Rectal prolapse: 8 (13.5%) Vaginal prolapse: 5 (8.5%)	None reported	Bladder injury: 1 (1.7%) Conversion: 1 (1.7%) Postoperative discitis requiring surgery: 1 (1.7%) Readmission: 5 (8.5%) Sepsis: 1 (1.7%) Vaginal mesh exposure: 1 (1.7%) Wound infection: 4 (6.8%)
Kiyasu et al 26	7	Japan	Laparoscopic ventral rectopexy with mesh	Laparoscopic sacrocolpopexy	13	Full-thickness rectal prolapse: 0% Vaginal prolapse: 0%	None reported	Postoperative complications: 0
Lim et al 23	29	United Kingdom	Abdominal mesh rectopexy	Sacrocolpopexy	26	Full-thickness rectal prolapse: 0% Vaginal prolapse: 2 (6.9%)	Vaginal prolapse surgery: 2 (6.9%)	Vaginal mesh erosion requiring surgery: 1 (3.4%)
Popp and Augustin 27	32	Germany	Abdominal mesh rectopexy	Sacrocolpopexy	Not reported	Vaginal prolapse: 1 (3.1%)	Not reported	Femoral palsy: 1 Hematomas: 3 Mortality: 1 (suicide within 1 month)
Riansuwan et al 28	23	United States	Open or laparoscopic rectopexy (resection, suture, or mesh)	Vaginal suspension, colporrhaphy, or sacrocolpopexy	4.1 years	Full-thickness rectal prolapse: 2 (8.7%) Vaginal prolapse: not reported	Not reported	30-day reoperation: 1 (4.3%)
Sagar et al 29	10	United Kingdom	Laparoscopic mesh rectopexy	Laparoscopic sacrocolpopexy, posterior colporrhaphy	6	Not reported Improved pelvic floor distress inventory scores	Not reported	Infections: 0
Slawik et al 21	74	United Kingdom	Laparoscopic ventral rectopexy with mesh	Laparoscopic sacrocolpopexy	54	Full-thickness rectal prolapse: 0%	Tension-free vaginal tape for stress urinary incontinence: 2 (2.7%) Rectal mucosectomy or excision of hypertrophied rectal mucosal prolapse: 4 (5.4%)	Rectal ulcers: 5 (6.3%) Sepsis: 0
Van Zanten 32	53	Netherlands	Robotic ventral rectopexy with mesh	Robotic sacrocolpopexy	12–48	Full-thickness Rectal Prolapse: 0% Internal rectal prolapse: 15% Apical vaginal prolapse: 4%	Hemorrhoid treatments: 7 Repeat rectopexy: 1 Delmormes procedure: 1 Tension-free vaginal tape: 5	Asymptomatic vaginal mesh exposure: 1 New obstructed defecation: 5
Van Iersel et al 30	51 (cohort)	Netherlands	Robotic ventral rectopexy with mesh	Robotic sacrocolpopexy	12	Full-thickness rectal prolapse: 0% Vaginal prolapse: 2 (3.9%)	Hemorrhoid treatments (staple hemorrhoidectomy or rubber banding): 7 (13.7%) Tension-free vaginal tape for stress urinary incontinence: 3 (5.9%)	Conversion: 1 Fecal obstruction: 1 Mesh complication requiring surgery: 1 Mortality: 0 Vaginotomy: 1
Wallace 33	63	United States	Perineal approach (Delorme or Altemeier) Abdominal approach (open, laparoscopic or robotic suture or mesh rectopexy)	Vaginal or abdominal colpopexy, colpocleisis, anterior repair, and/or posterior repair	Average 325 days	Not available	Recurrent rectal prolapse requiring surgery: 14% Recurrent vaginal prolapse requiring surgery: 4.8%	<30-day complications: 19% (highest in laparotomy group) Sacral osteomyelitis: 1
Watadani et al 19	110	United States	Abdominal mesh rectopexy	Sacrocolpopexy	29	Full-thickness rectal prolapse: 0%	Rubber banding for rectal mucosal prolapse: 1 (0.9%)	Incisional hernia: 3 (2.7%) Mortality: 0 Presacral bleeding: 2 (1.8%) Pulmonary embolism: 2 (1.8%) Ureteral injury: 2 (1.8%) Wound infection: 8 (7.3%)
Yang et al 31	69	South Korea	Laparoscopic ventral rectopexy (lateral suspension, mesh)	Laparoscopic sacrocolpopexy (apex only)	3	Full-thickness rectal prolapse: 1 (1.4%)	Rubber banding for rectal mucosal prolapse: 2 (2.9%)	Conversion: 0 Mesh complication: 0

Coordination of Ventral Rectopexy and Sacrocolpopexy

The patient is placed on a gel pad, a bean pad, or thick foam to avoid sliding while in steep Trendelenburg's position during surgery. Following anesthesia induction, she is positioned in the dorsal lithotomy position in Allen or Yellofins (Allen Medical Systems, Acton, MA) stirrups. Arms are tucked and the chest is secured. Padding is used around all pressure points to avoid nerve or joint injury.

Anal and vaginal examination under anesthesia is performed with both surgeons present to evaluate the extent of prolapse and confirm surgical plan. The lead point of the rectal prolapse, which is the most proximal aspect of the rectal intussusception, is determined since fixation of the mesh to the rectal prolapse lead point is imperative to avoid rectal prolapse recurrence. Anterior, apical, and posterior vaginal walls are examined to confirm repairs for vaginal prolapse. If stool is present in the rectal vault, irrigation with a large mushroom catheter hooked up to intravenous (IV) tubing and warm saline is used until the water is clear.

The abdomen, perineum, vagina, and rectum are prepped and the patient is draped. The XI robot (Intuitive, Sunnyvale, CA) port placement is just above the umbilicus with either a Veres's needle or cut down technique. Alternatively, in patients with suspected adhesions, the preferred entry point is the left upper quadrant (Palmer's point). An orogastric tube and Foley's catheter must be placed prior to trocar insertion.

The camera trocar is placed approximately one- to two-finger breadths above the umbilicus and CO ₂ pneumoperitoneum is established. Trocars are placed under direct vision 7- to 8-cm apart in a straight line. Care is taken to avoid the inferior and superficial epigastric vessels during trocar placement. All trocars are 8 mm with four robotic trocars and one 8-mm AirSeal (CONMED, Utica, NY) accessory port, which is placed along the right lateral location. Needles and mesh can be placed through the 8-mm accessory port.

The camera is placed in the umbilical port and targeting of the robot is performed for visualization of the pelvis. A cadiere or tip-up instrument is placed in arm 1 for retraction and a fenestrated bipolar is placed in arm 2. A monopolar scissors or hook is inserted in arm 4. After the rectal and vaginal dissections are complete the fenestrated grasper and scissors are exchanged for a needle driver in arm 2 and Mega Suture Cut in arm 4 ( Table 2 ).

Table 2. Operative steps: describes the operative steps for ventral rectopexy and sacrocolpopexy.

1. Clear the pelvis

2. Dissect presacral fat to visualize anterior longitudinal ligament of the sacrum

3. Create peritoneal flaps

4. Dissect the rectal vaginal septum

5. Dissect and excise the pouch of Douglas

6. Dissect bladder off of the vagina

7. Place and suture fixation of mesh to the rectum

8. Place and suture mesh to the vagina

9. Tension and fix both meshes proximally to the same location on the sacrum

10. Check for fixation of the prolapse and finger sweep into the vagina and rectum for suture

11. Close the peritoneum to cover the mesh

12. Cystoscopy

Step 1. Clearing the Pelvis

If the patient has a uterus, a uterine manipulator is inserted and an assistant located between the legs elevates the uterus up toward the pubic bone. The patient is placed in steep Trendelenburg's position and gravity helps to move the small bowel out of the pelvis into the upper quadrants. Redundant sigmoid is retracted out of the pelvis. The right ureter is usually visible coursing along the side wall. If the sigmoid colon obscures visualization, an Endoloop can be placed on an epiploicae to retract redundant sigmoid colon out of the pelvis.

Step 2. Dissecting the Anterior Longitudinal Ligament on the Sacrum

This step can be performed by either the colorectal or FPMRS surgeon. This will be the single fixation point for both vaginal and rectal mesh. The camera is positioned in a 30-degree down position to visualize the sacrum. Using robotic arm 1, the sigmoid colon mesentery is gently grasped and moved to the left. The fenestrated grasper in arm 2 is used to elevate the peritoneum midway between the right ureter and the rectal mesentery and the peritoneum is opened. With the scissor tips positioned perpendicular to the sacrum, dissection is taken directly down onto the anterior longitudinal ligament along the sacrum taking care to avoid the presacral veins or the left common iliac vein. There is a loss of tactile dexterity using robotic technology and the assistant can help to identify the sacrum by pushing on the sacrum with a laparoscopic instrument.

Step 3. Create Peritoneal Flaps

The opening in the peritoneum is extended caudal midway between the rectum and pelvic side wall. The peritoneum is elevated off to the rectal mesentery as flaps that will later be used to cover the mesh. The lateral rectal ligaments are left intact. Dissection is taken caudal to the uterosacral ligaments and in a J -shape between the rectum and vagina.

Step 4. Dissect Rectovaginal Dissection

The rectovaginal septum is dissected by retracting the pouch of Douglas up and out of the pelvis and scoring the peritoneum in the midline. The robotic camera is rotated to a 30-degree up position and sharp and blunt dissection is used to develop a plane down to the perineal body. The levator ani muscles can be visualized laterally. An assistant sits between the legs and places sizer into the vagina. The sizer is pushed up and toward the pubic bone to elevate the vagina.

Step 5. Dissect and Excise the Pouch of Douglas

The pouch of Douglas is excised off of the anterior rectum, so that the lead point of the prolapse is exposed. The excess pouch of Douglas is excised making sure to leave enough peritoneum to completely cover the mesh. If concurrent anterior repair or hysteropexy is being performed, the excess pouch of Douglas is left to facilitate covering of the mesh.

Step 6. Anterior Dissection

If the patient has a uterus, a total or supracervical hysterectomy is then performed. If the patient has had a prior hysterectomy, then a transverse incision of the peritoneum is made at the vaginal cuff. The bladder is then dissected off the anterior vagina until the bladder neck is reached for a distance of at least 5 cm. Backfilling the bladder may help to delineate the plane between the vagina and bladder if there is scarring in the area.

Step 7. Place and Suture Fixation of Mesh or Biological Graft to the Anterior Rectum

After dissection is complete, the fenestrated bipolar (arm 2) and scissors (arm 4) are exchanged for a needle driver on the left and a mega suture cut on the right. A polypropylene mesh or biological graft is cut in a hockey stick fashion approximately 5 cm × 5 cm tapered up to 2 cm. Taking seromuscular bites, the mesh is sutured to the anterior rectum using 2–0 polydioxanone (PDS) sutures. Approximately 12 sutures are placed. A sizer in the rectum helps to delineate the anatomy and moving the sizer to the left or right helps to ensure adequate coverage of mesh over the distal rectum.

Step 8. Suture Mesh to the Vagina

A light-weight polypropylene mesh is trimmed to the length and width of the anterior vagina. Biologic graft is typically not used for the sacrocolpopexy due to variable results in the literature. The mesh strip is then sutured to the anterior vagina with PDS or GoreTex sutures. A minimum of five sutures are placed with at least two of those sutures placed at the vaginal apex. A separate strip of mesh can be sutured to the posterior vagina at the discretion of both surgeons.

Step 9. Tension Both Meshes and Fix the Mesh Proximally to the Sacrum

The camera is repositioned to a 30-degree down angle. The mesentery is retracted laterally to expose the spot on the sacrum that was previously dissected. Since the prolapse is reduced and in anatomic position, the posterior rectal mesh should lay flat up to the sacrum. No additional tension is placed on the rectal mesh. The vaginal mesh is tensioned so that the anterior, apical, and posterior vaginal prolapse are reduced, elevated, and without significant stretching. Before attaching the mesh to the sacrum, the vaginal mesh is held against the sacrum and a vaginal exam is performed to ensure adequate prolapse reduction.

Once the vaginal mesh is tensioned, a suture is placed through the anterior mesh, posterior rectal mesh, the sacrum and then back through the mesh. The needle is placed, so that it skives the ligament to avoid suture placement that is too deep or within a disc space. The assistant places gently pressure on the mesh to keep it flat as the operator is tying so that the mesh lies flush with the anterior longitudinal ligament. At least two sutures are placed.

Step10. Examination of the Prolapse

Rectal and vaginal finger sweep is performed to assess that the lead point has been adequately incorporated on the repair and that there are no inadvertent sutures in the rectum or vagina. If sutures were visualized these would be removed.

Step 11. Closing the Peritoneum

The peritoneum is closed over the mesh. Care is taken to only suture the lateral edge of the peritoneum since the right lateral peritoneum can retract and aggressive bites may cause kinking or injury to the right ureter. Creating adequate flaps of peritoneum in the beginning of the case facilitates peritoneal closure.

Step 12. Cystoscopy

Cystoscopy is performed to evaluate for foreign body, injury, or suture in the bladder and to ensure the ureters, particularly the right ureter, are not kinked or occluded. Preoperative phenazopyridine or intraoperative intravenous indigo or methylene blue is recommended to assist in the evaluation of ureteral efflux.

Conclusion

Combined rectal and vaginal prolapse causes significant patient distress and requires a multidisciplinary management approach. Treating these patients while working in concert with other specialties is rewarding and educational. In the healthy patient, an abdominal approach with robotic ventral rectopexy and sacrocolpopexy is a safe and effective procedure. Consideration of patient factors and goals are necessary for successful surgical management and perioperative care.