gms | German Medical Science

Introduction: Pelvic organ prolapse (POP) is a common condition among women, negatively affecting their quality of life. Apical prolapse is often the coexisting pathology with a prevalence of up to 40%. Sacrocolpopexy (SCP) is considered the gold standard for treating apical prolapse. Despite high success rates, 4% of women require repeat prolapse surgery after SCP and approximately 1% of women for an apical prolapse. As an alternative, apical fixation to the sacrospinous ligament offers also high success rates. In contrast to many studies defining the success rate of SCP, only a few studies have aimed specifically to identify the surgical management of SCP failure regarding a revision laparoscopy.

Methods: This case report describes sacrospinous ligament fixation of the cervix following SCP failure. A 60-year-old non-sexually active postmenopausal woman was referred to our center with bulging symptoms and urinary frequency after a laparoscopic supracervical hysterectomy and sacrocolpopexy with concomitant colposuspension by POP and stress urinary incontinence 6 years ago. Clinical examination revealed a 3rd grade prolapse of the cervix and the bladder according to POP-Q (Aa +3/ Ba +6/ C +6) (Figure 1a [Fig. 1]). According to ultrasound, the mesh was likely detached from the sacrum. The vaginal symptoms score and QOL score were 42 and 10 (ICIQ-VS). Initially, we offered conservative treatment with a cube pessary in response to the patient's request for minimal treatment. The patient was referred after 3 weeks due to unsatisfactory treatment with the cube pessary. We recommended sacrospinous fixation of the cervix as the least invasive surgery after discussing all treatment options. An anterior colporrhaphy was first performed to correct the cystocele followed by a posterior colpotomy below the cervix. A sacrospinous ligament fixation of the cervix with two non-absorbable sutures was performed to achieve an apical fixation (Figure 1b [Fig. 1]).

Results: The first follow-up occurred 7 weeks after surgery. The clinical examination showed proper apical fixation and a fixed anterior vaginal wall according to POP-Q (Aa -3/ Ba -3/ C -8) (Figure 1c/d [Fig. 1]). The vaginal symptoms score and QOL score improved significantly (10 and 3) (ICIQ-VS). The second follow-up occurred 5 months after surgery. The clinical examination showed proper apical fixation and a mild prolapse of the anterior vaginal wall according to POP-Q (Aa -2/ Ba -2/ C -8) (Figure 1e [Fig. 1]). The vaginal symptoms score and QOL score were 8 and 0 (ICIQ-VS).

Conclusion: Pelvic floor reconstruction should provide effective support with minimal perioperative morbidity. Sacrospinous ligament fixation of the cervix is a feasible and effective method for treating apical prolapse following SCP failure. The safety and time effectiveness of vaginal surgery must be considered in the treatment of POP recurrence following laparoscopic surgery.