Abstract
Video Objective The objective of this video is to demonstrate a non-mesh sacrospinous ligament (SSL) suspension for massive vaginal vault prolapse with ascites in a patient with stage IV metastatic colon cancer. Polyether-ether-ketone (PEEK) anchors and porcine bladder extracellular matrix for fixation and bio-scaffolding are utilized. The patient desired to undergo definitive surgical treatment of her symptomatic prolapse for the purposes of “personal dignity”. The patient also desired to maintain sexual options. Fixation utilizing PEEK anchors provides a vaginal repair that requires less dissection than traditional approaches to the SSL since anchoring is performed via palpation rather than tissue visualization. This is of great importance in patients with massive vault prolapse because of the obliteration of the operative field. The extracellular matrix provides bio-scaffolding which promotes constructive remodeling of the tissue rather than encapsulation of synthetic mesh. Risks and benefits were discussed at length including the direct spread of disease if the peritoneal cavity were entered. Synthetic polypropelene mesh continues to show diminishing acceptance with patients and continues to be a source of mass tort litigation. Internationally several jurisdictions have restricted the accessibility or banned the use of transvaginal mesh. Setting St. Agnes Hospital, Baltimore, Maryland Interventions The patient underwent transvaginal SSL suspension, anterior and posterior colporrhaphy, vaginal enterocele repair and perineoplasty utilizing PEEK anchors and porcine urinary bladder extracellular matrix. There were no intra-operative or post-operative complications. The follow up has been 8 months. The patient is currently sexually active. Conclusion Sacrospinous ligament suspension for the correction of massive vaginal vault prolapse utilizing PEEK anchors and porcine urinary bladder extracellular matrix is a reasonable alternative to transvaginal synthetic mesh repairs. Advantages to this vaginal approach include: 1) Avoidance of laparoscopic risks in a patient with massive ascites, 2) Avoidance of chronic pain, erosion and extrusion associated with synthetic mesh.
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