bladder exstrophy is a congenital urinary tract , pelvis , and pelvic floor anomaly which is thought to be due to a premature rupture of the cloacal membrane during fetal development . in females , this disorder is characterized by an open bladder , abdominal wall defect , separation of the pubic bones , bifid clitoris and an abnormal pelvic diaphragm musculature . the vagina is shortened and placed anteriorly . the cervix enters the anterior vaginal wall more caudally and is therefore positioned closer to the often narrow introitus . due to the altered anatomy pessary treatment may be first choice treatment , but it is not always possible because of the short vagina and lack of support from the pelvic floor . we present two cases with surgical treatment of severe uterine prolapse in young women with bladder exstrophy . patient a , a 14-year - old female with congenital bladder exstrophy was referred to our department because of pelvic organ prolapse . she had a history of multiple surgeries , including bladder closure , bladder neck reconstruction , ileovesicostomy ( monti catheterizable stoma ) , introitoplasty and abdominal wall reconstruction . she had a shortened vagina of 56  cm and no additional anterior or posterior compartment prolapse . an incision was made 3  cm lateral and inferior from the anus on both sides , through which the trocars were inserted . the trocars were fixed through the sacrospinal ligaments at 23  cm from the ischial spines . the posterior mesh was modified in such a way that the central portion , usually covering the rectocele , was removed and a broad loop with a 2-cm central part was left ( fig .  1 ) . this modified mesh was implied and fixed with three polypropylene 2 - 0 sutures through the posterior side of the cervix . with gentle traction on the modified mesh , the cervix six weeks following surgery , the patient was free of prolapse symptoms . at physical examination , the grey portion of the prolift posterior has been used in this study a modified prolift procedure was used . the grey portion of the prolift posterior has been used in this study patient b was a 22-year - old nulliparous female with symptoms of uterine prolapse and dyspareunia . she had previously undergone multiple operations due to bladder exstrophy , which included vaginoplasty and mitrofanoff urinary stoma . physical examination showed a prolapse of the cervix till 3  cm beyond the hymenal remnants with no additional anterior or posterior compartment prolapse . the length of the vagina was 5  cm ( pop - q aa 3 , ba 3 , c 3 ; hg 4 , pb 3 , tvl 5 ; ap 3 , bp 3 , d 1 ) . the same procedure as described above was performed . during surgery , the cervix was elevated till 1  cm above the hymenal remnants . sixteen months following surgery , dyspareunia was still present , but the patient was free of prolapse symptoms . the cervix was located at the hymenal remnants ( pop - q aa 3 , ba 3 , c 0 ; hg 4 , pb 3 , tvl 45 ; ap 3 , bp 3 , d 4 ) . pelvic organ prolapse can be a difficult and bothersome problem in women with bladder exstrophy . mathews et al . have described a prevalence of 18% with a mean age at onset of 16  years . different surgical techniques have been proposed for the correction of uterine prolapse in these women [ 25 ] . moreover , removing the uterus without providing support to the vaginal vault will not solve the problem . fixation of the uterus to the anterior abdominal wall is a possibility . especially in women with bladder augmentation muir et al . have presented a case of recurrent pelvic organ prolapse successfully managed with a sacral colpopexy . boemers et al . have described the rotundum psoas hitch procedure in females with bladder exstrophy . the round ligaments have been detached from the inner inguinal ring and fixed to the psoas muscle on both sides , thereby fixing the uterus in a more cranial and dorsal position . the authors conclude that this method was an effective prevention or correction of procidentia in patients with bladder exstrophy and should be combined with other abdominal surgeries . we preferred a vaginal approach for surgical management of prolapse in these patients with bladder exstrophy , to avoid further abdominal operations and adhesions . recently , palma et al . have performed a vaginal sacrospinous hysteropexy using a mesh in a patient who desired uterine preservation for future pregnancies . our procedure was minimally invasive with a low risk of morbidity , such as adhesion formation and organic lesions due to altered anatomy . mesh - related problems such as erosion , pain and dyspareunia , however , may be difficult to manage and need to be considered . although the short - term functional results were acceptable in these two cases , the anatomical results with the cervix at the level of the introitus were less optimal than aimed for . we have not considered this beforehand , but it might have been an option to use vaginal dilators preoperatively to increase vaginal length . from literature , we know that the use of synthetic mesh placed through an abdominal approach provides solid and durable support to the uterus . unfortunately , no data is available yet on long - term follow - up of vaginal meshes , which would be especially informative in these young women . furthermore , data on mesh material in relation to pregnancy and delivery are absent as well . primary caesarean section in a multidisciplinary session in order to preserve the previous reconstructions may be recommended in these women . in conclusion , this report is on a vaginal surgical technique with use of mesh material in two women with bladder exstrophy and uterine prolapse . the modified prolift procedure is a minimally invasive technique with low risk of morbidity , which preserves fertility . the vaginal approach in these women with a history of multiple abdominal operations may be safer and therefore preferable . the functional and anatomical results were acceptable , but longer - term results are required to evaluate this technique .
the incidence of pelvic organ prolapse is 18% in women with bladder exstrophy . 
 a vaginal technique to correct the prolapse may be preferable in these women with multiple abdominal operations in their histories . 
 we have performed a modified prolift procedure for the repair of severe uterine prolapse in two young women . a review of the literature is presented .