Management of unintentional cystotomy during abdominal sacrocolpopexy presents a challenge to even the most experienced pelvic surgeon. The decision-making pathway that guides the surgeon through this intraoperative setback is based on preoperative patient counseling, the location and size of the cystotomy, and the availability of fascia and/or available tissue as an interposition layer or as an alternative to mesh.

A comprehensive preoperative discussion with the patient to review all the common approaches to apical prolapse repair is the cornerstone of management of intraoperative complications. It is paramount that the surgeon have a clear understanding of the patient’s preferences. Some patients are adamant about avoiding a second surgery (and choosing sacrocolpopexy), while others desire a vaginal approach with a shorter convalescence even if it may require a repeat operation in the future. Patients must be counseled on the possibility of deviating from their most preferred surgical plan if there is a bladder injury or other intraoperative event.

It is often feasible to complete the mesh sacrocolpopexy as planned after cystotomy closure. Most small bladder injuries can be safely closed primarily and allow sacrocolpopexy with mesh to be resumed. The cystotomy should closed in 2 layers using absorbable sutures such as 2-zero polyglactin, followed by tissue interposition utilizing either peritoneum or omentum. Sometimes there is abundant perivesical fat that can be harvested to cover a large cystotomy. The possibility of complications, such as mesh erosion into the bladder and vesicovaginal fistulas, must be considered when repairing a cystotomy at the time of sacrocolpopexy. Placing mesh near the site of cystotomy can potentially increase the risk of such complications.

We must always consider a conservative, alternative approach and avoid mesh insertion when there is a large cystotomy or attenuated tissue planes. If the cystotomy is located at the bladder base near the site of mesh attachment, it is best to either abort the planned mesh sacrocolpopexy or consider alternative repair. If the patient has preoperatively consented to alternative approaches, the case can be converted to transvaginal repair or an open sacrocolpopexy using autologous fascia, usually harvested from anterior fascia at the time of laparotomy incision. If the anterior fascia is attenuated, one can also harvest fascia lata from iliotibial band. Cadaveric fascia or other biologic graft material (such as cadaveric dermis) can provide a nice alternative that allows for completion of the operation robotically. Other hybrid alternatives, although not well studied in the literature, can also be considered, for example placement of biologic graft as the anterior leaflet of the Y (the portion of the Y mesh in contact with the bladder) with mesh as the remainder of the Y supporting the posterior vaginal wall and sacrum. Another option is placing the Y mesh as planned, but utilizing an additional layer of biologic graft between the anterior mesh and the bladder. Lastly, robotic uterosacral suspension is a successful apical suspension that avoids mesh usage.

When patients elect to have pelvic organ prolapse repair, the stakes are high to achieve the best outcome with the least invasive approach. Bladder injury during vaginal vault dissection can sometimes be unavoidable, and one should have a clear algorithm for management that includes careful preoperative guidance and a skill set for alternative repair.