In April 2019, the FDA banned the use of vaginal mesh for prolapse repair. In October 2019, the AEU issued a consensus document on the use of mesh in prolapse surgery, recommending that this procedure be classified as a complex surgery to be performed only by accredited surgeons. In this video, we review the laparoscopic approaches available for prolapse treatment and discuss the most relevant technical aspects.

We present three laparoscopic treatment options for pelvic organ prolapse:

Laparoscopic colposacropexy: Mesh fixation to the anterior and posterior vaginal walls, uterosacral ligaments, and levator ani muscles to achieve comprehensive pelvic floor repair, securing it to the sacrum with subsequent culdoplasty.

Colposacropexy in hysterectomized patients: Mesh fixation to the anterior and posterior vaginal walls without reaching the levator ani muscles, securing it to the sacrum.

Pectopexy: Fixation of the vaginal vault to the pectineal ligaments.

Laparoscopic colposacropexy is indicated for symptomatic prolapse. If the prolapse is predominantly anterior or sacral access is not feasible, pectopexy is an alternative. This procedure involves fixing a macroporous polypropylene monofilament mesh, which can be manually shaped by the surgeon into a Y or lance form or purchased preformed in a Y shape, often with an anti-adhesive film coating to prevent bowel adhesions. In pectopexy, a PVDF (polyvinylidene fluoride) mesh in a tape-like shape is used.

Key findings and considerations include:

Avoidance of prophylactic incontinence treatment: Even in patients with mild preexisting incontinence, prophylactic treatment is not recommended to prevent overtreatment.

Uterus preservation: If the uterus is not pathologic, preserving it is associated with better sexual function, increased vaginal length, lower erosion rates, shorter operative time, reduced bleeding, and lower costs.

Identification of key anatomical landmarks: Awareness of critical structures such as the middle sacral artery, the ureter crossing over the iliac artery, and the relationship between the ureter and the uterine artery within the broad ligament is essential.

Extent of dissection: Whether to dissect up to the levator ani muscles in all patients remains a debated issue.

Mesh fixation options: The mesh can be secured using titanium staples or non-absorbable sutures, based on the surgeon’s preference.

Potential drawbacks of pectopexy: One criticism of this technique is the excessive verticalization of the vagina.

Laparoscopic colposacropexy is a safe and reproducible technique for the treatment of symptomatic prolapse and is currently considered the gold standard. When sacral access is not feasible, pectopexy serves as an excellent alternative.