The transvaginal mesh (TVM) technique provides excellent repair of pelvic organ prolapse (POP). In Japan, commercially available kits with pretailored mesh are not available. Therefore, POP repairs with the use of polypropylene mesh self-tailored by the surgeon have been undertaken according to the TVM procedure.1–4 We repaired a vault prolapse associated with bladder herniation (Fig. 1a) using self-tailored mesh in a case of pelvic trauma involving symphysis pubis diastasis (Fig. 1b) in a patient aged 38 years. This patient had a hysterectomy for myoma uteri at the age of 46 years. Her vault prolapse occurred at the age of 53 years, and since then she has been left untreated for 17 years.
We modified several steps of the usual TVM procedure because of the bladder herniation through the diastased symphysis pubis. Two incisions were carried out on the anterior and posterior vaginal wall. The dissection of the anterior vaginal wall was continued between the bladder and the pelvic side wall in a blunt or sharp way laterally until the tendinous arch of the pelvic fascia between the pubic symphysis and the ischial spine was identified. Between two vaginal incisions, a submucosal tunnel of 4 cm in length was created. To restore the bladder herniation through the diastased symphysis pubis, an inverted U-shaped skin incision was made in the pubic area. The bladder hernia was dissected away from the surrounding tissues. The obturator foramen was exposed at the lateral edge of the inverted U-shaped incision. The transobturator “outside in” passage of the eyed needle at the anteromedial edge of the obturator foramen was tried, but was unsuccessful because of the diastased symphsis pubis. Therefore, the passage of the eyed needle at 5 mm medial from the pubic descending limb was made into the paravesical region (Fig. 2). Next, the passage of the eyed needle at the posteromedial edge of the obturator foramen was made forwards to 1 cm in front of the ischial spine. These needles carried the threads to secure the anterior arms of the anterior part of the mesh placed at the vesicovaginal dissection space.
A cutaneous incision was made at 3 cm laterally and 3 cm down from the anus, and the passage of the eyed needle was made through the sacrosciatic ligaments towards the ischial spine. These needles carried the threads to secure the posterior arm of the posterior part of the mesh, which was passed into the pararectal space through the sacrosciatic ligaments. The mesh with six arms, which consisted of three parts, were placed in the anterior, intermediate and posterior parts of the vaginal wall. The vaginal incisions were closed, and the inverted U-shaped skin incision was closed over the second patch mesh (4 × 5 cm) to reinforce the bladder hernia.
The vault prolapse was anatomically corrected by the self-tailored mesh and the bladder hernia was remarkably decreased in size by the second patch mesh. The advantage of self-tailored mesh provides wider indication for POP repair surgery. The indication for self-tailored mesh surgery includes vaginal prolapse where transobturator passage is unable to be used, and previous pelvic surgery by the abdominal approach and previous colporrhaphy by the vaginal approach.