Pelvic organ prolapse (POP) is a common condition in women, particularly affecting those who have had multiple vaginal deliveries, advanced age, or connective tissue weakness. Among the most severe forms of POP are Grade 4 cystocele and hysterocele, characterized by complete descent of the bladder and uterus into or beyond the vaginal introitus. These conditions significantly affect quality of life, leading to urinary incontinence, recurrent urinary tract infections, sexual dysfunction, and social discomfort.

Laparoscopic promontofixation, also known as laparoscopic sacrohysteropexy or sacrocolpopexy (depending on whether the uterus is preserved), has emerged as an advanced surgical technique to restore normal pelvic anatomy with high success rates, minimal invasiveness, and durable results.

Understanding Grade 4 Cystocele and Hysterocele

Cystocele: The herniation of the bladder into the anterior vaginal wall. Grade 4 indicates complete prolapse, with the bladder extending beyond the vaginal introitus.

Hysterocele: The descent of the uterus into the vagina; when associated with cystocele, it represents severe multi-compartment prolapse.

Conservative management, including pelvic floor exercises and pessary use, may be ineffective in severe cases. Surgical correction becomes necessary to restore anatomy, improve function, and prevent recurrence.

Laparoscopic Promontofixation: An Overview

Laparoscopic promontofixation involves attaching the prolapsed organ to the sacral promontory using a synthetic mesh. The technique provides durable support for the vaginal apex, bladder, and uterus (if preserved), restoring normal pelvic floor anatomy.

The laparoscopic approach offers several advantages:

Minimal Invasiveness – smaller incisions reduce postoperative pain and scarring.

Better Visualization – laparoscopy allows precise dissection and mesh placement.

Lower Recurrence – durable fixation to the sacral promontory reduces long-term prolapse recurrence.

Faster Recovery – patients return to normal activity sooner than after open surgery.

Surgical Technique
Patient Preparation and Positioning

The patient is placed in lithotomy position under general anesthesia.

A Trendelenburg tilt is applied to allow bowel loops to fall away from the pelvic area, providing optimal exposure.

Port Placement

Typically, three to four laparoscopic ports are placed:

A 10 mm umbilical port for the laparoscope.

Two 5 mm working ports in the lower abdomen for instruments.

Optional additional port for retraction or suturing.

Exposure and Dissection

The peritoneum over the sacral promontory is opened to expose the anterior longitudinal ligament.

The vesicovaginal and rectovaginal spaces are carefully dissected to mobilize the bladder and vagina.

Adhesions are lysed as needed.

Mesh Preparation and Placement

A synthetic, non-absorbable mesh is shaped according to the patient’s anatomy.

One end of the mesh is attached to the anterior vaginal wall to support the bladder (cystocele repair).

The mesh is extended to support the uterus or vaginal apex, depending on hysterocele repair.

Fixation to the Sacral Promontory

The proximal end of the mesh is secured to the anterior longitudinal ligament of the sacral promontory using non-absorbable sutures or tacks.

Care is taken to avoid injury to adjacent vessels, ureters, and nerves.

Peritoneal Closure

The peritoneum is closed over the mesh to prevent bowel adhesion and ensure smooth integration.

Hemostasis is confirmed, and ports are removed.

Advantages of Laparoscopic Promontofixation

Anatomical Restoration – Provides durable support for multiple compartments of the pelvic floor.

Preservation of Sexual Function – Maintaining vaginal length and uterine preservation enhances sexual function.

Reduced Postoperative Pain – Laparoscopic approach is less traumatic than open repair.

Shorter Hospital Stay – Most patients are discharged within 1–2 days.

Low Recurrence Rates – Fixation to the sacral promontory provides long-term stability.

Minimized Mesh Complications – Retroperitoneal placement reduces exposure to the vaginal mucosa.

Challenges and Considerations

Technical Expertise Required – Surgeons must be skilled in advanced laparoscopy, pelvic anatomy, and suturing.

Risk of Injury – Potential for injury to bladder, ureters, iliac vessels, or sacral nerves.

Mesh Complications – Rare instances of erosion, infection, or pain.

Patient Selection – Obese patients or those with previous extensive pelvic surgery may require careful planning.

Clinical Outcomes

Studies and expert experience show that laparoscopic promontofixation achieves:

High anatomical success rates (>90% at 2–5 years).

Significant improvement in urinary and pelvic symptoms.

Excellent patient satisfaction regarding cosmesis and functional outcomes.

Low recurrence of both cystocele and hysterocele compared to native tissue repair alone.

Conclusion

Laparoscopic promontofixation represents a gold-standard approach for severe pelvic organ prolapse, including Grade 4 cystocele and hysterocele. By restoring pelvic anatomy, supporting the bladder and uterus, and using minimally invasive techniques, it provides long-lasting functional and anatomical outcomes.

With appropriate patient selection, meticulous surgical technique, and advanced laparoscopic expertise, this procedure improves quality of life, preserves sexual function, and minimizes postoperative morbidity. HD visualization and careful dissection further enhance safety, making laparoscopic promontofixation a preferred approach in modern urogynecology.