When the dissection is complete, I have two cannulas in place on each side, each holding a retrieval device. To attach the mesh, I first place a delayed absorbable suture into the vesicovaginal space through the apex of the vagina, and attach the apical portion of the mesh onto the suture.
I then place each posterolateral, or deep, arm of the mesh by passing about 1 cm of the end of the arm through the loop of the retrieval device, and then pulling the loop back through the cannula. During these maneuvers, we must be sure that no tissue becomes caught in the mesh or the retrieval device loop. The superficial arms of the mesh are then similarly placed.
At this point, I remove the Foley catheter, inject about 300 cc of sterile water into the bladder, and use a 70-degree cystoscope to look through the urethra and into the bladder to confirm the absence of any mesh, perforation, or other injury to the bladder. I also check the functioning of the ureters, and check for any pathology in the bladder. I then empty the bladder and reinsert the Foley catheter before proceeding to finish the mesh placement.
The key to successful mesh placement—and a reduced risk of mesh erosion—lies in placing the mesh loosely in the vesico-vaginal space.
I try to ensure loose placement by lifting up the mesh as I'm removing the cannula so that I can feel the back of the pubic bone. During cannula removal, you can also ensure that the edge of the mesh is at least one finger's breadth away from the pelvic side wall.
Loose placement of the mesh is necessary because the mesh-scar tissue complex that forms will shrink by about 25%–30%. If the mesh is too tight, the risk of erosion and exposure of that mesh to the anterior vaginal wall will rise significantly. It may even appear (if you look into the vagina at the end of the procedure) as if the patient still has a first- or second-degree cystocele. This is fine. Your goal is to have an anterior vaginal wall that is well supported but not straight and tight.
I close the incisions using a running, interlocking Vicryl stitch. I also use vaginal packing for 24 hours, and I send the patient home after the packing and Foley catheter are removed.
The vaginal packing is another key feature of this procedure, as it helps to prevent hematoma formation, which can lead to mesh erosion. It also facilitates the adherence of the mesh to the back of the vaginal epithelium. From my experience, 24 hours is all that is needed.
Most of my patients have reported pain levels of about 3 out of 10, and some are fine with an NSAID. Some are given ketorolac (Toradol) for several days, and others who have more severe pain may be given a conventional narcotic. Patients are seen in the office 2 weeks later and are counseled to call earlier in the case of a high fever, increased vaginal bleeding other than spotting, or significant pain.
Some physicians send patients home with instructions to use vaginal dilators on a daily basis in order to keep the mesh as pliable as possible as it integrates into the scar tissue that forms, but we don't have any studies on the effects of such a recommendation.
Posterior Prolapse Repair
If you are looking at the posterior vaginal wall, the lower third of the vagina overlies the perineal body, and the upper two-thirds overlie the rectum. A full-thickness incision is made either vertically in the middle third of the posterior vaginal wall or transversely through the vaginal epithelium at the junction of the middle-third and lower-third of the vagina.
Using curved Mayo scissors or my finger, I mobilize the rectum away from the vaginal epithelium. I then slide my finger laterally until I feel the iliococcygeus muscle, at which point I gently dissect down until I feel the ischial spine. Any filmy tissue on the sacrospinous ligament should be wiped away medially from the ischial spine at this point.
I also mobilize the rectum away from the underside of the posterior vaginal wall to allow access to the apex of the vagina. Just as with the anterior surgery, all of this dissection should involve minimal blood loss (no more than 50 cc).
The 5-mm incisions for passage of the cannula-equipped guides are made through the skin of the buttocks at 3 cm lateral and 3 cm posterior to the anus. I like to have the patient's back parallel to the floor and to lower the table accordingly so the cannula-equipped guide can be pushed straight in and the tip advanced toward the underside of the sacrospinous ligament.