In 2008, the large number of reported adverse events with transvaginal placement of mesh to correct pelvic organ prolapse (POP) prompted the FDA to issue a public health notification outlining the potential serious consequences of such placement. The objective of this video was to describe our no mesh technique and steps of robotic assisted laparoscopic apical suspension (RALAS) in the treatment of patients with symptomatic apical vaginal prolapse.

Evaluation of our robotic no mesh surgical technique is described. Informed consent was obtained and discussed with the patient. 70-year-old Caucasian woman, gravida 3, para 2 had symptomatic POP apical/anterior stage III. Upon pelvic ultrasound evaluation, the uterus was small and adnexa appeared normal bilaterally. She failed pessaries and is sexually active. The most relevant complaints were vaginal bulging and pressure. She denied any urinary incontinence. During the surgery we used 1) 3-0, V-Loc™ (Covidien) and we reinforced these absorbable sutures with 2) 2-0, GORE-TEX® Suture (Gore Medical).  The da Vinci Si Surgical System was used with 4 arms and 5 trocars configuration, docking on the left side of the patient.

On the right/left apical support, we used V-Loc and Gore-Tex. These provided the initial 2 points suspension on the uterosacral ligaments (USL). We like to attach the left USL to the right USL. We then developed the space between the bladder and vagina and reinforced the pubocervical fascia with V-loc suture plications. The following 2 anterior apical support sutures are taken from the vagina to the transversalis fascia on the anterior abdominal wall.  We hid these sutures behind the peritoneum covering the bladder. The tension of these anterior sutures were maintained with Hem-o-lock (TeleFlex) and LAPRA-TY (Ethicon). Now using the spiral technique, we secured the suture through the posterior and anterior abdominal muscle fascia going initially from inside to outside and then back inside using a Carter-Thomason laparoscopic port closure system. This may provide a better long-term support for the anterior apical compartment.

In our opinion, RALAS-4 may represent an alternative to robotic or laparoscopic sacrocolpopexy. This new approach simulates the natural 4 point support given by USL and cardinal ligaments, with the additional benefit of no mesh and no dissection on the sacral promontory. With this technique, we are chasing the pelvic floor trifecta: no mesh, no complications, and good long-term anatomic support.