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Open Sacrohysteropexy for Pelvic Organ Prolapse in a Congenital Bladder Exstrophy Patient
Patrick Curtin, MD, Yu Zheng, MD, Hailey Silverii, MD, Jenna Winebaum, MD, Shumyle Alam, MD, Lindsey Cox, MD.
Medical University of South Carolina, Charleston, SC, USA.

Abstract
Background
Pelvic organ prolapse is uncommon in pediatric patients, but can occur in patients with congenital urologic disorders such as classic bladder exstrophy (CBE). Following interventions including vaginoplasty or introitoplasty these patients may experience prolapse as an unintended consequence. Due to the paucity of pelvic floor musculature in classic bladder exstrophy prolapse repair can be challenging.
Methods
We present the case of a 15-year-old female with a history of (CBE). She had previously undergone two failed attempts at bladder exstrophy closure, ultimately undergoing cystectomy and creation of Mainz II pouch. Following a clitoroplasty and vaginoplasty she complained of bothersome pelvic pressure and bulging and was noted to have stage 2-3 apical prolapse. MRI of the pelvis showed descent of the uterus 4cm below the pubococcygeus line and the Mainz II pouch to be anterior and superior to the uterine fundus. She wished to proceed with reconstructive repair of her prolapse with preservation of fertility. The aim of this video was to describe open sacrohysteropexy in a pediatric patient with bladder exstrophy. Results The patient was positioned supine with slight frog leg with the vagina prepped into the field. A 10Fr foley catheter was placed into the rectum. A low midline incision was made and upon entering the abdomen, the Mainz II pouch was identified and confirmed with palpation of the foley catheter. The pouch was mobilized circumferentially and lifted superiorly allowing for identification of the right ureter and uterus. The sacral promontory was exposed, the overlying peritoneum was incised, and a space cleared for preplacement of two 2-0 gore tex sutures. The peritoneum was then dissected from the vagina as distally as possible until a 4cm area was identified along the posterior vagina and uterus for mesh placement. The anterior arm of a Vertessa light Y mesh was truncated due to the patient's desire for future fertility. Two 3-0 PDS sutures were placed on the proximal portion of the vagina to fix the distal extent of the posterior limb of the mesh to the vagina. Additional interrupted 3-0 PDS sutures were used to anchor the mesh to the posterior uterus. The distance required for reduction of the prolapse was measured and the goretex sutures were passed through the sacral limb of the mesh and tied down to complete the hysteropexy. The posterior peritoneum was then closed with running 2-0 vicryl suture.
Conclusion
Bladder exstrophy is rare, but these patients are at risk for pelvic organ prolapse due to absence of the anterior portion of the levator ani muscles, flattening of the normal conical shape of the pelvis, and anterior displacement of a shortened and stenotic vagina. Due to the paucity of pelvic floor musculature, transvaginal attempts at repair are generally unsuccessful. Transabdominal suspension is therefore a feasible and safe option. Given the complexity of this reconstruction we recommend incorporation of a multidisciplinary approach to pediatric prolapse given the knowledge of pediatric urologists regarding congenital anomalies and FPMRS Urologist's expertise with reconstructive techniques for prolapse.


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