Laparoscopic sacropexy (SP) is the gold standard technique for the  correction of apical prolapse of pelvic organs  [1]. However, other easier laparoscopic techniques such as  pectopexy  (PP)  [2] and laparoscopic lateral suspension of Dubuisson (LLS)  [3] have become popular.

The aim of this study was  to evaluate the baseline characteristics as well as the surgical results of a cohort of patients operated  for pelvic organ prolapse through laparoscopic surgery using these 3 surgical techniques.

This is a single-center prospective study of patients undergoing laparoscopic repair of apical prolapse. The 3 techniques that we currently offer in our service have been compared: -Group -Group A: Sacropexy (SP), Group B: Dubuisson laparoscopic lateral suspension (LLS) and group C: Pectopexy (PP).
The inclusion criteria were patients with primary or recurrent symptomatic prolapse in stage > II according to the POP-Q.  We excluded women with cervical elongation (defined as POP-Q Point C minus Point D ≥4). It was  possible to perform hysteropexy, cervicopexy or colpopexy in all groups. The exclusion criteria for hysteropexy (in these cases we perform supracervical hysterectomy) were contraindications for uterine preservation: uterine pathology, risk of ovarian/tubal cancer (BRCA 1 and 2), or endometrium, treatment with tamoxifen, and inability to follow a gynecologic cancer prevention program. 

 Other exclusion criteria were: history of abdominal prolapse reconstructive surgery, history of prolapse reconstructive surgery with vaginal mesh, Stage I according to the POP-Q classification, asymptomatic prolapse, medical contraindication for general anesthesia and patient preference for treatment vaginal surgery.

The primary outcome was treatment failure, which is defined as the existence of any of the following 3 elements:
(1) new treatment for prolapse (pessary placement or surgery)
(2) anatomical outcomes, defined as  recurrence of apical prolapse (stages II-IV) and any non-static POP-Q measurement greater than 0
 (3) symptoms, measured using the validated PFDI-20 questionnaires (specifically the question: "Do you notice a sensation of lump in your genitals?", including the subanalysis of the questionnaires (POPDI-6, CRAD-8 and UDI-6) and PISQ-12.

The secondary objectives were to assess if there were differences in surgical times, complications, adverse events, individual anatomical measurements in the POP-Q examination, the presence, severity and impact of symptoms or discomfort derived from prolapse, urinary, intestinal and of pain, measured by validated scales: the PFDI-20 and PISQ-12

We have operated a total of 180 cases: 115 SP, 33 LLS and 32 PP. There were no significant differences in the mean age of the patients in the 3 groups or in vaginal deliveries. There were differences in BMI, the mean was 27.51 (±4.45) Kg/m2 for the PP, and 25.67 (±3.69) Kg/m2 for the SP group (p=0.025). Another difference was the percentage of previous hysterectomies, the main was 28.1% for PP, 21.7% for SP and 5.7% for LLS (P=0.049). There were also differences in the apical stage, being more advanced in SP compared to the other 2 techniques (56.6% stages III in SP, vs 38.2 and 29% in LLS and PP respectively, p=0.001). However, the decrease in the anterior compartment was greater (stage III) although it was not significant (in the LLS (70.6%) and in  PP (63.3%) than  in SP (26.9%). There were only differences  at previous point D or C (Douglas or  Vaginal dome) of the POP-Q :  2.55 (±2.76) for the SP, 0.650 (±2.22) for LLS and 1.13 (±2.58) for PP ( p=0.003). There were also differences in the perineal body (pb): it was 2.82(±0.76) for SP, 2.98(±1.76) for LLS and 3.23(±0.82) for PP (P=0.021). We also did not find differences in the ultrasound data (genital hiatus area) between the three groups. There were no differences in the symptoms assessed by the POPDI-6, CRAD-8 and UDI-6 scales previos to surgery. Only patients who were not included for SP reported a higher percentage of constipation (9.6 for SP, 14.3 for LLS and 28.1% for PP) (Table 1).
Regarding surgical results, the highest rate of supracervical hysterectomies were performed in the SP group (78.3%) and the lowest in the LLS (5,7%)(P=0.000). The surgical time was significantly longer in the SP [214.44 (±65.38) vs LLS 108.79 (±34.93) and PP 163.83 (±49.80) minutes p=0.000], although the surgical time used in subtotal hysterectomy in the 3 groups was not statistically different. We also did not find significant differences in the rate of intraoperative complications (Table 2).
  Regarding post-surgical results, there were no significant differences in the rate of reintervention or pessary use due to recurrence. Nor in the non-static measures of the POP-Q greater than 0. We only found significant differences in the recurrence of stage III posterior prolapse, being greater in PP than in SP (3.1% vs 0.9%, p=0.019). Regarding the individual points of the POPQ, the only significant difference found was the total vaginal length (TVL), being greater for SP [8.81 (±1.37); 7.93(±1.15) in LLS and 7.74cm (±1.18) in PP, P=0.000].  We did not  find differences in the post-surgical symptoms assessed by the question "do you notice a lump in your genitals?" included in the PFDI-20 questionnaire or in the responses to the POPDI-6, CRAD-8, UDI-6 and PISQ-12 scales (Table 2).

Although there are some differences in the baseline characteristics of the patients prior to surgery, such as a higher BMI for the SP group and anatomical differences since the highest rate of apical stages III and IV are also in the SP, it is interesting to consider the other 2 alternative techniques because there are no significant differences in the failure rate (measured by the apical recurrence rate, reintervention rate or use of pessaries and symptoms). Regarding the POPQ measures, we only found differences in the higher TVL in the SP. However, the much shorter surgical time in alternative techniques is notable (in LLS less than half time compared with time used for SP) with no differences in intraoperative complications.

More studies are needed, especially randomized, multicenter clinical trials to compare the effectiveness between these alternative techniques (LLS and PP) with respect to the gold standard (SP).

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