Laparoscopic Surgery for Pelvic Organ Prolapse

Laparoscopic Surgery for Pelvic Organ Prolapse

Pelvic organ prolapse happens when the uterus, vaginal vault or the walls of the vagina drop down because their support has weakened. Many women are treated without surgery. When an operation is needed for prolapse at the top of the vagina, keyhole sacrocolpopexy, which lifts the vagina with a mesh fixed to the sacral bone, is one of the main options. This article explains when it is considered, what the evidence shows and what the risks are, including those of mesh.

What pelvic organ prolapse is

Prolapse is a descent of pelvic organs into or out of the vagina. Women notice a lump or bulge, a dragging sensation, or bladder, bowel and sexual symptoms. Prolapse can involve the front wall (bladder), the back wall (rectum) or the apex, meaning the uterus or, after hysterectomy, the top of the vagina (vault). Laparoscopic mesh surgery is mainly used for apical prolapse, and NICE advises repair without mesh for the front and back walls.

Surgery is not the first step

NICE guideline NG123 advises that surgery be offered to women whose symptoms have not improved with non-surgical treatment, or who decline it. For stage 1 or 2 prolapse with symptoms, NICE suggests considering a supervised programme of pelvic floor muscle training for at least 16 weeks as a first option. Pessaries are another non-surgical option.

What the guidelines say

Source	Document	Relevant position
NICE	Urinary incontinence and pelvic organ prolapse in women, NG123	For vault prolapse, offer a choice of vaginal sacrospinous fixation with sutures or sacrocolpopexy (abdominal or laparoscopic) with mesh. For anterior and posterior prolapse, offer repair without mesh. Use a decision aid, explain the uncertainty about long-term adverse effects for all procedures, and if mesh is used, record the procedure in the national registry and give the woman written details of the implant. Offer a review 6 months after surgery.
NICE	Sacrocolpopexy using mesh for vaginal vault prolapse	May be used with standard governance, consent and audit arrangements. Safety concerns are serious but well recognised, and efficacy evidence is adequate. Patients should understand the risk of recurrence and of serious complications such as mesh erosion into the vagina. Selection and treatment should be by clinicians who specialise in prolapse and incontinence, with specific, up-to-date training who perform the procedure regularly.
NICE	Uterine suspension using mesh, including sacrohysteropexy	May be used with standard arrangements. Patients should be entered on a registry such as the British Society of Urogynaecology database, selected by a multidisciplinary team, and device problems reported to the MHRA Yellow Card Scheme. Pregnancy after the procedure is not recommended.
Cochrane	Surgery for apical vaginal prolapse (2023)	59 randomised trials with 6,705 women. Sacral colpopexy gave lower rates of prolapse awareness, recurrent prolapse on examination, repeat prolapse surgery and stress incontinence than several vaginal procedures. Transvaginal mesh showed no advantage over native tissue repair. Evidence certainty ranged from very low to moderate.
BSUG	Sacrocolpopexy patient information leaflet (2022)	Gives plain-language outcome and complication figures for women. It is a patient leaflet, not a clinical guideline.

I could not open the NICE page for sacrocolpopexy with hysterectomy for uterine prolapse, so that procedure is not described. The RCOG/BSUG consent advice for sacrocolpopexy was not found either.

Laparoscopic sacrocolpopexy: how it works

A strip of synthetic mesh is attached to the top of the vagina and fixed to the sacral bone, which lifts the vault back into place. It can be done by open surgery, through a bikini-line incision, or by laparoscopy, through three or four small cuts, according to the BSUG leaflet. The BSUG leaflet notes it may also correct bladder or bowel prolapse to some extent.

1. Before. The type and stage of prolapse, symptoms and your wishes are discussed. You are told the type of mesh, whether it is permanent, and the risks. A urodynamic test may be done to predict urinary leakage after surgery.
2. Operation. Under general anaesthesia, the surgeon places the camera and instruments, frees the top of the vagina, attaches the mesh to it and secures the other end to the sacral bone. The mesh is then covered over with peritoneum.
3. After. Hospital stay is typically short, and a review with a vaginal examination is advised at 6 months, with a check for mesh exposure when mesh is used (NICE NG123).

The steps above describe the general approach; the exact method differs between surgeons.

Laparoscopic compared with open and vaginal surgery

• Laparoscopic compared with open sacrocolpopexy: The BSUG leaflet states there is no difference in success between the two, and laparoscopic surgery may cause less blood loss, fewer wound infections and a shorter hospital stay. The Cochrane review likewise found no differences in the main outcomes between routes, with shorter admission for the laparoscopic compared with the open approach, and a shorter operating time than robotic surgery.
• Sacrocolpopexy compared with vaginal surgery: in 7 trials with 613 women, awareness of prolapse was estimated at 8% after sacral colpopexy against 18% after vaginal procedures (risk ratio 2.31). Repeat prolapse surgery was estimated at 6% against 14% (risk ratio 2.33), with moderate certainty for both. Stress urinary incontinence was also more likely after vaginal procedures.
• Hysteropexy (keeping the uterus): Cochrane found little or no difference between vaginal hysterectomy and sacral hysteropexy on awareness, repeat surgery or prolapse on examination.

The balance is not one-sided. Vaginal sacrospinous fixation avoids mesh and an abdominal operation, and NICE lists it as an equal choice for vault prolapse. The better outcomes of sacrocolpopexy must be weighed against the extra risks of an abdominal operation and permanent mesh.

Risks

The BSUG leaflet quotes these figures for sacrocolpopexy.

• Mesh erosion into the vagina in about 2 to 3 in 100, which may need further surgery. Mesh infection is uncommon. Infection of the sacral bone (osteomyelitis) is serious but rare.
• Bladder injury in about 1 in 200 and bowel injury in about 1 in 1,000.
• Wound or urine infection in about 5 to 13 in 100.
• Recurrence of the same prolapse in about 1 in 10, and about 3 in 10 eventually needing treatment for another prolapse. About 85 in 100 had no prolapse symptoms at 2 years, and no longer-term figures are available.
• Stress incontinence in about 1 in 10, and problems emptying the bladder.
• Conversion to open surgery, bleeding, blood clots and, rarely, being unable to do the operation.

NICE notes that uncertainty about long-term effects applies to all prolapse operations, and mesh problems can be reported through the MHRA Yellow Card Scheme. Contact your surgical team or seek urgent care for fever, heavy bleeding, severe pain, trouble passing urine, or unusual discharge after the operation. This is general advice.

Why mesh is discussed so carefully

Mesh used in the vagina through the vaginal route has been restricted in the UK: NICE removed vaginal mesh for anterior or posterior prolapse from its guideline, and states it should be used only in research. Cochrane found no advantage of transvaginal mesh over native tissue repair, with a mesh exposure rate of 17.5% in 7 trials. Abdominal mesh sacrocolpopexy is treated separately, and NICE accepts it with safeguards: specialist surgeons, multidisciplinary team input, registry entry and clear written information. You should be told what type of mesh is used and whether it is permanent.

Frequently asked questions

Do I need surgery for every prolapse?

No. Mild prolapse often improves with pelvic floor training, and pessaries are an option. Surgery is offered when other treatment has not helped or has been declined.

Is the keyhole route better than open surgery?

The success rate appears similar. The BSUG leaflet says keyhole surgery may give less blood loss, fewer wound infections and a shorter hospital stay. The best route depends on you and your surgeon's experience.

Will the prolapse come back?

It can. The BSUG leaflet estimates that the same prolapse returns in about 1 in 10, and about 3 in 10 eventually need treatment for another prolapse.

Can I avoid mesh?

Yes. For vault prolapse NICE offers vaginal sacrospinous fixation with sutures as an alternative, and for front and back wall prolapse it recommends repair without mesh. Ask your surgeon about the trade-offs.

Sources

This article is educational and does not replace individual medical advice. Details were taken from the pages below; some points rely on summaries, so confirm exact recommendations against the originals before clinical use.

• NICE NG123: Urinary incontinence and pelvic organ prolapse in women
• NICE: Sacrocolpopexy using mesh to repair vaginal vault prolapse
• NICE: Uterine suspension using mesh, including sacrohysteropexy, to repair uterine prolapse
• Cochrane: Surgery for women with apical vaginal prolapse (CD012376)
• BSUG: Sacrocolpopexy patient information leaflet