doi:10.1111/jog.15146 J. Obstet. Gynaecol. Res. Vol. 48, No.

3: 850–856, March 2022

Uterine preserving technique in the treatment of pelvic

organ prolapse: Laparoscopic pectopexy

Süleyman Salman1 , Serkan Kumbasar1 and Ali S. Yeniocak2

1
Department of Obstetrics and Gynecology, Gazi Osman Paşa Taksim Research and Education Hospital, Istanbul, Turkey
2
Department of Obstetrics and Gynecology, Başakşehir Çam ve Sakura Research and Education Hospital, Istanbul, Turkey

Abstract
Objective: Apical prolapse constitutes an important part of pelvic organ prolapse. In this study, our aim
was to investigate the effectiveness of laparoscopic pectopexy that we made by preserving the uterus in the
surgical treatment of apical prolapse.
Methods: A total of 36 patients with apical prolapse who wanted to preserve their uterus underwent laparo-
scopic rectopexy. Apical prolapse and sexual function of the patients were evaluated preoperatively and
12 months after surgery using the Pelvic Organ Prolapse Quantification (POP-Q) scale and Pelvic Organ Pro-
lapse/Urinary Incontinence Sexual Questionnaire (PISQ-12) sexual questionnaire form. Preoperative medical
records and postoperative clinical results were recorded.
Results: There were no intraoperative or postoperative complications in the patients who underwent laparo-
scopic pectopexy. The average duration of surgery was 48.7  9.8 min. Two patients had a recurrence of api-
cal prolapse. In the Aa, Ba, C, and D points in the POP-Q staging, significant changes were observed.
Postoperative PISQ-12 scores improved significantly (p < 0.05).
Conclusion: Uterine-preserving laparoscopic pectopexy is a safe, feasible, and effective method for treating
pelvic organ prolapse. It also improved the PISQ-12 and POP-Q scores in POP patients. Laparoscopic
pectopexy may increase a surgeon’s technical perspective for pelvic organ prolapse surgery.
Key words: apical prolapse, laparoscopic pectopexy, uterine preserving surgery.

Introduction and vaginally assisted laparoscopic uterine

Pelvic organ prolapse (POP), which is an important
problem, negatively affects the lives of many women.1
It has been reported that the rate of apical prolapse in
POP is between 5% and 15%.2 Apical prolapse cases
can be treated with abdominal or transvaginal
approaches. Although open abdominal surgery, lapa-
roscopic surgery, and robotic surgery techniques are
available as surgical treatment approaches, laparo-
scopic surgical methods are widely used.3 Nowadays,
sacropexy, pectopexy, laparoscopic ligament suspen-
sion, laparoscopic uterosacral ligament suspension,
sacrocolpopexy methods are used for the surgical
treatment of apical prolapse.4,5 Sacrocolpopexy has
been described as the suspension of the prolapsed
organ to the sacrum with mesh.6 The mesh is fixed to
the anterior longitudinal ligament at the level of the
sacral 2 and sacral 3 vertebrae. It is necessary to dis-
sect close to important anatomical structures such as
the hypogastric nerve, left common iliac vein, right
common iliac artery, and median sacral vessels in the
surgical procedure to fix the mesh to the anterior lon-
gitudinal ligament.7 Although sacropexy is a very
effective method, it can cause stress urinary

Received: April 29 2021.

Accepted: December 27 2021.
Correspondence: Suleyman Salman, Department of Obstetrics and Gynecology, Gazi Osman Paşa Taksim Research and Education
Hospital, Istanbul, Turkey.
Email: sleymansalman@gmail.com

850 © 2022 Japan Society of Obstetrics and Gynecology.


incontinence and defecation problems.8 De novo defe-
cation problems have been reported in 17%–34% of
the cases who underwent sacropexy.9 The laparo-
scopic pectopexy described by Banerjee and Noe can
be considered as an easier method, especially in
patients who are obese and in cases where dis-
section of the presacral area is difficult.10 The
iliopectineal ligament (Cooper ligament) used in
pectopexy is a strong ligament. The part of the
iliopectineal ligament at the level of the second sacral
vertebra (S2) is the most appropriate place to fix the
mesh. The most suitable position for the physiological
vaginal axis is provided by fixing the mesh here.11 In
pectopexy, where apical support is provided by
suspending to the iliopectineal ligament with a mesh,
the possibility of organ damage is less, and the vagi-
nal axis provided is close to natural. In this study, we
aimed to investigate the effects of lateral pectopexy,
which is a uterus preserving surgery, on prolapse and
sexual function in a group of patients with uterine
apical prolapse who did not want their uterus
removed.
Materials and Methods
A total of 36 patients were included in this observa-
tional prospective study. Our study was carried out
between March 2019 and March 2021 in the depart-
ment of Gynecology and Obstetrics in Gaziosmanpasa
Training and Research Hospital, Istanbul, Turkey.
Patients who had apical prolapse and did not want a
hysterectomy were included in the study. Laparo-
scopic pectopexy was performed in all patients, and
the uteruses of all patients were preserved. All opera-
tions were performed by the same surgeon. After the
surgical method was explained in detail to all
patients, the surgical procedure was performed after
obtaining their informed written consents. Ethical
approval of the study was obtained from the
Gaziosmanpasa Training and Research Hospital ethics
committee (date: 13/03/2019 number: 35).
Prolapse evaluations of patients with apical pro-
lapse during gynecological examination were made
according to the Pelvic Organ Prolapse quantification
system (POP-Q). Patients with pelvic organ prolapse
stage 2 and higher according to POP-Q were included
in the study. Patients with pelvic mass, morbid obe-
sity, and patients with previous prolapse surgery
were excluded from the study. Surgical notes and
videos of the patients were recorded.
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Laparoscopic pectopexy
The patients were evaluated preoperatively and at
the 12th month postoperatively. Physical examination
was performed in the lithotomy position and with a
Valsalva maneuver. Prolapse findings were evaluated
according to POP-Q.12 Transobturator tape (TOT) pro-
cedure was performed simultaneously on patients
with stress urinary incontinence. Pelvic Organ Pro-
lapse/Urinary Incontinence Sexual Function Ques-
tionnaire (PISQ-12) was used to evaluate sexual
function preoperatively and at the 12th month after
surgery.13 PISQ-12 is a five-point Likert-type scale
consisting of 12 questions, each item scored between
0 and 4, evaluating sexual function in patients with
lower urinary tract complaints. A high PISQ-12 score
is associated with good sexual function. In our study,
the validated Turkish form of PISQ-12 was used.14
Surgical procedure
All operations were performed under general anesthe-
sia and in the lithotomy position. Since laparoscopy
was to be performed, the patient was positioned so
that both arms were next to the patient. Rubin’s can-
nula was inserted into the cervix. After the abdomen
was inflated with carbon dioxide up to a pressure of
15 mmHg, the abdomen was entered with a 10 mm
trocar. Since the surgeon worked on the left side of
the patient, entry into the abdomen was 2 cm medial
to the left crista iliaca anterior superior with a 5 mm
trocar, from the left paraumbilical area with a 5 mm
trocar, and 2 cm medial to the right crista iliaca ante-
rior superior with a 5 mm trocar. The patient was
placed in the Trendelenburg position. The duration of
surgery was measured as the time between the first
skin incision and the last skin suture.
Laparoscopic pectopexy technique was performed
as described by Banerjee and Noe.15 Peritoneal inci-
sion was made from the right round ligament toward
the pelvic side wall using bipolar scissors and bipolar
cautery. The right external iliac vein was visualized
with blunt and sharp dissection and the right
iliopectineal ligament was exposed. The same proce-
dure was done for the left side. Peritoneal incision
was made beginning over the cervix toward both
sides and the places where the mesh was to be fixed
were prepared. A 2  15 cm long mesh (Covidien,
France) was extended into the intra-abdominal cavity.
The ends of the mesh were fixed on both sides to the
iliopectineal ligaments intracorporeally with a non-
absorbable suture. The mesh was fixed to the anterior
surface of the cervix with a nonabsorbable suture in
the tension-free position. It was closed with an
851
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Salman et al.

absorbable suture covering the peritoneal mesh

(Figure 1). Pectopexy procedure has shown schemati-
cally (Figure 2).

Statistical analysis
Patients’ baseline characteristics were reported as
mean  SD, and percentages for continuous and cate-
gorical variables, respectively. Student t test was used
for paired data to compare preoperative and postop-
erative data, using the SPSS program version 20.0
(Statistical Package for Social Science, SPSS, Chicago,
Illinois, USA). Statistically significant differences were
considered when the p-value was less than 0.5
FIGURE 2 Schematic view of pectopexy procedure

Results
A total of 36 patients underwent surgery. The average
age of the patients was 58.72  3.61 years, the mean
body mass index (BMI) of the patients was
28.63  4.52 kg/m2, and the mean parity of the patients
was 3.2  0.8. Twelve patients had a previous cesarean
section, and seven had tubal ligation. The average
duration of surgery was 48.7  9.8 min, the mean blood
loss was 112  30.7 mL, and the mean hospital stay
was 1.8  0.7 days. All patients were operated on lap-
aroscopically, and all patients were discharged within
48 h. After the patients were discharged, they were

FIGURE 1 Intraoperative stages. (a) Dissection of the bladder peritoneum, exposing the right and left iliopectineal liga-
ments. (b) Fixation of the mesh to the cervix and iliopectineal ligaments. (c) Closure of the peritoneum over the mesh.
(d) Complete closure of the mesh with peritone

852 © 2022 Japan Society of Obstetrics and Gynecology.

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Laparoscopic pectopexy

TABLE 1 Patient characteristics and previous pelvic PISQ-12 scores were evaluated preoperatively and
surgery histories in the laparoscopic surgery group postoperatively at 12 months. PISQ-12 scoring signifi-
Variable Statistic cantly improved after surgery (Table 4, Figure 3).
Age 58.72  3.61
Gravidy 4.4  0.5
Parity 3.2  0.8 Discussion
Operation time (mean) 48.7  9.8
BMI (kg/m2) 28.63  4.52
Estimated blood loss 112  30.7
The most accepted method of surgical treatment of
Hospital stay (days) 1.8  0.7 apical prolapse is sacral colpopexy, providing good
History of pelvic surgery anatomical results and effective long-term treat-
Cesarean section 12 ment.16 However, when performing laparoscopic
Tubal ligation 7 sacropexy, the dissection is worked close to the sig-
Additional procedures
moid colon, right ureter, hypogastric nerves, and pre-
Anterior colporraphy 13
Posterior colporraphy 6 sacral veins, which are important anatomical
Transobturator tape 6 structures. Complications related to these important
Bilateral salphingoopherectomy 10 structures can lead to poor consequences.17 Laparo-
Abbreviation: BMI, body mass index. scopic sacropexy is a technically difficult surgical
method. The main reason for this difficulty is surgical
checked on the 10th postoperative day and then at dissection of the anterior surface of the sacrum. In
3-month intervals. TOT was performed in 6 patients, sacropexy, fixation of the mesh to the anterior longitu-
posterior colporrhaphy in 6 patients, and anterior col- dinal ligament may cause mesh erosion and, conse-
porrhaphy in 13 patients with stress incontinence. Sal- quently, ileus and osteomyelitis.18 Laparoscopic
pingophorectomy was performed simultaneously in pectopexy has emerged as an alternative to sacropexy
10 patients (Table 1). in the surgical treatment of apical prolapse. Laparo-
De novo stress incontinence did not develop in any scopic pectopexy provides anatomical results similar
patients. In the operation, bleeding occurred in the to sacropexy, as well as shorter operation times and
corona mortis during dissection in one patient, and lower complication rates. Laparoscopic pectopexy is
this bleeding was stopped with bipolar cautery. There easier to learn and apply than sacropexy.15
was no decrease in hematocrit in this patient. Recur- The mesh is fixed to the iliopectineal ligament. Thus,
rence of apical prolapse was observed in two patients it was predicted that complications would be lower in
(5%). All complications are shown in Table 2. this method.19 It has been reported that intraoperative
The patients’ landmarks for POP-Q were evaluated hemorrhage may occur in laparoscopic pectopexy.20
preoperatively and postoperatively at the 12th month. However, we did not encounter any intraoperative
In the anterior vaginal wall, the Aa point improved hemorrhages that would cause a decrease in hemato-
from 2.0  0.5 to 2  0.4, and the Ba point from crit in our study. De novo constipation is also seen
2.2  1.2 to 2.5  0.2 (p < 0.001). The Ap point on after sacropexy.21 The reason for this is thought to be
the posterior vaginal wall increased from 1.4  0.6 to the fixation of the mesh to the right side of the sacral
2.2  0.4, and the Bp point increased from 1.8  1.6 longitudinal ligament and the reduction of the pelvic
to 2.6  0.3 (p < 0.001). The C point score increased space. In addition, damage to autonomic nerve fibers
from 2.4  0.5 to 6.4  0.6 and significantly may also contribute to this problem. De novo constipa-
improved. Before and after surgery, total vaginal tion was not observed in our study.
length increased from 7.1  0.4 to 7.2  0.6, but this Bladder, ureter, and bowel injuries are major com-
change was not significant (Table 3). plications in laparoscopic sacropexy.19 In our study,
there were no complications related to these struc-
TABLE 2 Complications related to surgery groups
tures. POP treatment refers to clinical improvement
N (%) and less than stage-2 prolapse according to POP-Q
Ureteral kinging (n) 0 (%0.0) staging. It has been reported that the anatomical suc-
Mesh erosion (n) 0 (%0.0) cess rate for sacropexy is 83.3%. Noe et al. reported a
Bladder injury 0 (%0.0) 2.3% relapse of apical prolapse after pectopexy.11 In
_
Intraoperative hemorrhage 1 (%2.7)
our study, apical prolapse relapsed after 1 year in two
Relapse rate 2 (%5)
patients (5%). Bilier et al. reported that they

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Salman et al.

TABLE 3 Pre- and postoperative (12-month follow-up) pelvic organ prolapse quantification (POP-Q)
POP-Q variables Preoperative assessment mean  SD Postoperative assessment mean  SD p-Value
Aa 2.0  0.5 2  0.4 <0.001
Ba 2.2  1.2 2.5  0.2 <0.001
Ap 1.4  0.6 2.2  0.4 <0.001
Bp 1.8  1.6 2.6  0.3 <0.001
C 2.4  0.5 6.4  0.6 <0.001
D 1.4  0.8 6.6  0.7 <0.001
TVL 7.1  0.4 7.2 0.6 NS
Note: NS represent p > 0.05.
Abbreviation: TVL, total vaginal length.

TABLE 4 Pre and posttreatment (12-month follow-up) results of Pelvic Organ Prolapse/Urinary Incontinence Sexual
Questionnaire (PISQ-12)
Pretreatment Posttreatment Differentiation (post-/pretreatment)
Outcome mean  SD mean  SD mean  SD pa-Value
Behavioral motive 6.3  3.6 10.9  0.6 4.5  7.6 <0.001
factor
Physical factor 6.5  2.6 17.8  2.8 11.3  0.2 <0.001
Partner-related 6.4  2.8 9.6  4.8 3.2  2.0 <0.001
factor
Total score 19.4  6.2 38.8  7.4 19.4  1.2 <0.001
Note: Data are expressed as mean  SD. and Paired t-test on differences.
a

45.00 novo stress urinary incontinence rate has been reported

40.00 to be around 5% in laparoscopic pectopexy.11 However,
35.00
30.00
de novo stress urinary incontinence was not observed in
25.00 Pretreatment our study.
20.00 Posttreatment(12- An important advantage of laparoscopic pectopexy
15.00 month follow-up) has been reported as its protection against de novo
10.00
5.00 anterior and lateral defect cystocele.11 In our study, de
0.00 novo cystocele and de novo stress urinary incontinence
were not observed. We think that pectopexy is protec-
tive against anterior defects. In our study, the patients
did not have any problems with defecation, and no sig-
nificant organ damage was observed. In the 1-year
FIGURE 3 Subscales mean scores and total PISQ-12 in follow-up of the patients, there was a significant
pretreatment and posttreatment (12 month follow-up)
patients improvement in the POP-Q status. In laparoscopic
pectopexy operation, the cervix or vaginal apex is
suspended forward and up; it can be thought that this
performed two anterior colporrhaphy and three pos- situation will cause de novo rectocele. Due to the posi-
terior colporrhaphy simultaneously with pectopexy.20 tion of the mesh in pectopexy, it has been reported that
In our study, anterior colporrhaphy was performed in there is no risk of intestinal obstruction, and the rates of
13 patients, posterior colporrhaphy in 6 patients, and serious complications are low.24 De novo rectocele did
TOT in 6 patients. not develop in any of our patients. We think that the
Mesh erosion related to the synthetic mesh has not protection of the uterus of the patients may contribute
been reported in laparoscopic pectopexy.22 In our to this. Increasing the quality of sexual life after POP
study, no mesh-related erosion was observed after a surgery is an important issue. Especially in young
1-year follow-up. The de novo stress urinary inconti- patients, it has been reported that, besides anatomical
nence rate has been reported to be between 15.9% and success, protection of the uterus is important in improv-
37.6% in patients who underwent sacropexy.23 The de ing sexual function.25 In our study, we found that

854 © 2022 Japan Society of Obstetrics and Gynecology.


patients’ sexual function improved according to the
PISQ-12 scoring result in their 1-year follow-up. The
patients were in a better condition than before the sur-
gery in terms of sexual function. In studies investigat-
ing the effects of POP repair on female sexual function,
it is stated that uterine-preserving surgery results in
more positive results in women in terms of desire,
arousal, and orgasm, and increases body image, self-
confidence, and attractiveness.26 We think that the
preservation of the uterus of all the patients we studied
contributed to their sexual improvement.
Not having a hysterectomy also prevents complica-
tions related to hysterectomy.
The short duration of operation in POP surgery is espe-
cially important in elderly patients. It was reported that
the average duration of operation was 46.21  18.47 min
when pectopexy was performed alone.24 In our study,
the duration of operation was approximately
48.7  9.8 min, which is a short time. Uterus-preserving
POP surgery has been researched and applied since the
1990s. Advantages of preserving the uterus were mainte-
nance of pelvic anatomy, reduction of intraoperative
blood loss, shortening of duration of operation and hos-
pital stay, reduction of mesh erosion rate, and increased
self-confidence and sexuality of the patient.27
In a recent report on women who underwent lapa-
roscopic pectopexy for POP and got pregnant after
laparoscopic pectopexy, four women delivered via
cesarean section28; Bagli and Tahaoglu reported that
they did not see relapse in apical prolapse or other
compartments 3, 6, and 12 months after delivery28;
thus uterine preserving pectopexy could be a safe
alternative method for POP in symptomatic woman
of reproductive age who wish to preserve fertility.28
In conclusion, laparoscopic pectopexy is a useful
method in apical prolapse surgery with low complica-
tion rates and short duration of operation. Laparo-
scopic pectopexy should be recommended in the
surgical treatment of apical prolapse.
Conflict of interest
The authors declare no conflict of interest.
Data availability statement
The data that support the findings of this study are
available from the corresponding author upon reason-
able request. 10
© 2022 Japan Society of Obstetrics and Gynecology.
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Laparoscopic pectopexy
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