A 61-year-old woman presented with progressive pelvic floor dysfunction, including fecal incontinence, mixed urinary incontinence, and symptomatic pelvic organ prolapse. She had a history of perineal pressure, incomplete bowel evacuation, and bothersome vaginal bulge. Initial evaluation by her primary care physician revealed a stage II midline cystocele, rectocele, urethral hypermobility, and suspected rectal prolapse. Pelvic examination confirmed anterior and posterior vaginal wall laxity with associated perineal descent [4] .

The patient was taken to the operating room and placed in a lithotomy position. Following administration of local anesthesia with 0.25% Marcaine and epinephrine, the anterior vaginal wall was incised vertically to expose the endopelvic fascia. The paravesical space was carefully dissected, and the cystocele was repaired by plicating the fascia with interrupted 2-0 Vicryl sutures. Hemostasis was maintained throughout.

Subsequently, the posterior vaginal wall was addressed. Local anesthesia and hydrodissection facilitated tissue separation. Excess vaginal tissue was excised, and the rectovaginal fascia was dissected and plicated with 2-0 Vicryl sutures. The dermal biological graft was then placed over the fascia, and it was intentionally selected to be used due to its thickness. The sacrospinous ligament was fixed to the perineal body to support the vaginal apex. Intraoperatively, a large grade 3 rectal prolapse was identified. Bilateral Prolene sutures were placed into the perirectal tissue to elevate and reduce the prolapse. The posterior vaginal wall was closed using running locking sutures. Attention was then directed to the mid-urethra. After local anesthesia, a suburethral incision was made, and a mid-urethral sling was placed bilaterally via a transobturator approach. Sling tension was adjusted appropriately, and cystoscopy confirmed ureteral patency and absence of injury. The incision was closed with interrupted sutures.

The patient tolerated the procedure well. Vaginal packing was placed, surgical counts were confirmed correct, and she was transferred to the recovery room in stable condition. Follow-up was scheduled for two weeks postoperatively.

Intraoperative evaluation confirmed a grade 3 rectal prolapse, according to the Oxford Rectal Prolapse Grading System. The Oxford Rectal Prolapse Grading system provides a way to clinically explain the severity of a prolapse, with grade 3 indicating a prolapse that is of full thickness extending beyond the anal verge, which assists in the decisions regarding management. The patient’s postoperative course was monitored closely over a three-month period. On the day of surgery, she tolerated the procedure well without intraoperative complications. At her two-week follow-up, she reported some vaginal bleeding and discharge. By the six-week visit, the bleeding had resolved, though she continued to experience mild pain; importantly, she denied any recurrence of stool incontinence. On examination at 2 weeks, 6 weeks, and 3 months, there was no evidence of stool in the vaginal vault or fistula tract, and no complications were noted. At her three-month follow-up, the patient reported a marked improvement in symptoms, had resumed walking and normal daily activities, and overall demonstrated a favorable recovery following the combined vaginal rectopexy and pelvic floor repair.

Pelvic organ prolapse is defined as the descent of pelvic organs that herniate into the vagina, often due to damaged ligaments or muscle weakness. Posterior wall prolapse includes different pathologies such as external rectal prolapse, internal rectal intussusception, enteroceles, sigmoidoceles, or posterior enteroceles [5] [6] . In cases of rectal prolapse, surgical options include vaginal rectopexy, posterior suture rectopexy, posterior mesh rectopexy, resection rectopexy, and perineal approaches [7] . Our team introduced a transvaginal sacrospinous suture rectopexy. The sacrospinous ligament has been a cornerstone landmark for vaginal vault suspension for decades. By avoiding entry into the peritoneal cavity, this minimally invasive technique may broaden treatment options and make surgery feasible for patients who might otherwise be poor candidates [8] .

Ventral or vaginal rectopexy can be performed using native tissue, synthetic mesh, or biologic grafts, as utilized in this case. With rising safety concerns related to syn-thetic mesh, particularly erosion associated with pore size in pelvic floor repairs [9] , some surgeons have turned to biologic alternatives. A 15-year retrospective cohort study [4] supports the use of biologic mesh, stating that minimally invasive repairs using biologic grafts offer favorable short- and long-term recurrence rates and fewer complications compared to synthetic mesh. However, this study was limited, as it was based on a single surgeon’s experience, which limits generalizability.

In a case series comparing the use of synthetic mesh and biological mesh in laparoscopic ventral rectopexies, recurrence rates and morbidity outcomes were comparable in the two groups. However, in terms of functional outcomes, this study found that de novo symptoms were less reported in the group that utilized the biological mesh [10] . A systematic review of laparoscopic ventral mesh rectopexies found that the mesh-related erosion after the procedure was more frequent after utilizing synthetic mesh, compared to biologics [11] . Because existing cost analyses are both limited and outdated, meaningful comparisons between biologic grafts and synthetic mesh could not be made, and the overall economic implications remain unclear. Future studies are needed to clarify the economic impact of these interventions. Along with the overall scarcity of published data on biologic graft use in vaginal rectopexy, this highlights the need for future studies to address cost-effectiveness and long-term outcomes. This present case contributes additional insight into its feasibility and favorable short-term outcomes.