Uterine prolapse is a common pelvic floor disorder in elderly women, characterized by the descent of the uterus into or through the vaginal canal. It often results in pelvic pressure, urinary incontinence, sexual dysfunction, and reduced quality of life. While conservative management, such as pelvic floor exercises or pessaries, may provide temporary relief, surgical intervention is often required in advanced cases.

Laparoscopic hysterectomy combined with sacrocolpopexy has emerged as a gold-standard surgical option. This minimally invasive approach not only removes the prolapsed uterus but also provides durable suspension of the vaginal apex using mesh anchored to the sacral promontory, restoring normal pelvic anatomy.

Indications

Laparoscopic hysterectomy with sacrocolpopexy is indicated in elderly women with:

Symptomatic uterine prolapse, grade II or higher.

Recurrent prolapse after conservative or previous surgical management.

Associated stress urinary incontinence requiring concomitant repair.

Patients fit for general anesthesia and laparoscopic surgery.

Preoperative evaluation is crucial, including assessment of comorbidities common in elderly patients, such as hypertension, diabetes, or cardiovascular disease.

Preoperative Assessment

Clinical Examination:

Pelvic exam to determine prolapse stage using the Pelvic Organ Prolapse Quantification (POP-Q) system.

Assessment of vaginal, bladder, and rectal support.

Imaging:

Pelvic ultrasound to evaluate uterine size and adnexal pathology.

MRI in selected cases for complex pelvic floor defects.

Laboratory Work:

Routine hematology, coagulation profile, and metabolic panel.

Patient Counseling:

Discuss risks of surgery including bleeding, infection, organ injury, mesh complications, and postoperative sexual dysfunction.

Explain benefits: symptom relief, improved pelvic support, and enhanced quality of life.

Anesthesia and Patient Positioning

General anesthesia with endotracheal intubation.

Dorsal lithotomy position with arms tucked.

Trendelenburg tilt (15–30 degrees) allows bowel to move away from the pelvis for optimal visualization.

A Foley catheter is inserted to decompress the bladder during dissection.

Port Placement

Standard four-port laparoscopic setup:

Umbilical port (10–12 mm): Camera port.

Two lateral ports (5 mm): Working ports for dissection and suturing.

Suprapubic port (5 mm): Optional, for uterine manipulation or retraction.

Port placement is adjusted according to uterine size, pelvic anatomy, and presence of adhesions.

Surgical Steps
Diagnostic Laparoscopy

Survey of abdominal and pelvic organs to identify adhesions or pathology.

Adhesiolysis performed if necessary to create space for safe dissection.

Laparoscopic Hysterectomy

Round ligaments are coagulated and transected.

Broad ligaments are opened, ureters identified and protected.

Fallopian tubes and ovaries are either preserved or removed depending on patient’s age and pathology.

Uterine arteries are ligated at their origin for hemostasis.

Colpotomy is performed around the cervix for uterine removal.

Sacrocolpopexy

A synthetic mesh, often titanium-coated or polypropylene, is prepared for vaginal apex suspension.

Mesh is anchored to the anterior and posterior vaginal wall using non-absorbable sutures.

The proximal end of the mesh is attached to the sacral promontory, avoiding major vessels and nerves.

Mesh is retroperitonealized to prevent bowel adhesion and ensure long-term durability.

Vaginal Cuff Closure

Vaginal cuff is closed laparoscopically using absorbable sutures.

Ensures hemostasis and prevents mesh exposure.

Postoperative Care

Early ambulation and resumption of oral intake.

Pain managed primarily with NSAIDs; opioids only if needed.

Foley catheter typically removed within 24 hours.

Discharge usually within 48–72 hours depending on patient recovery.

Avoid heavy lifting, sexual activity, or straining for 6–8 weeks.

Follow-up for monitoring of mesh integration, urinary function, and prolapse recurrence.

Advantages

Minimally invasive: Reduced postoperative pain, small incisions, and faster recovery.

Durable pelvic support: Mesh suspension restores vaginal axis and prevents recurrence.

Improved quality of life: Relief of pelvic pressure, urinary incontinence, and sexual dysfunction.

Reduced complications: Lower blood loss and fewer wound infections compared to open abdominal sacrocolpopexy.

Comprehensive repair: Concomitant management of cystocele, rectocele, or enterocele possible.

Complications

Intraoperative: Bleeding, bladder, bowel, or ureteral injury.

Postoperative: Mesh erosion, infection, urinary retention, and recurrence.

Risk reduction: Careful dissection, proper mesh placement, and patient selection.

Conclusion

Laparoscopic hysterectomy with sacrocolpopexy is a safe, effective, and minimally invasive solution for elderly women with uterine prolapse. It combines the benefits of uterine removal with durable pelvic floor reconstruction, providing long-term symptom relief and improved quality of life.

With careful preoperative evaluation, meticulous surgical technique, and attention to postoperative care, this approach has become the preferred option