Genitourinary prolapse, commonly referred to as pelvic organ prolapse (POP), is a condition where the pelvic organs such as the uterus, bladder, or rectum descend from their normal anatomical position into or beyond the vaginal canal. It results from weakness or damage to the pelvic floor muscles, ligaments, and connective tissues, often caused by childbirth trauma, aging, menopause, obesity, or chronic increased intra-abdominal pressure. Women with genitourinary prolapse may present with pelvic pressure, urinary dysfunction, sexual difficulties, or visible bulging from the vagina.

Traditionally managed by vaginal or open abdominal approaches, prolapse surgery has been revolutionized by minimally invasive techniques. Laparoscopic surgery, particularly laparoscopic sacrocolpopexy and sacrohysteropexy, has emerged as the gold standard for durable, effective, and minimally invasive management of genitourinary prolapse.

Pathophysiology and Classification

Pelvic organ prolapse occurs due to weakening of support structures:

Anterior compartment: Involves cystocele (bladder prolapse).

Apical compartment: Uterine prolapse or vaginal vault prolapse (post-hysterectomy).

Posterior compartment: Involves rectocele or enterocele.

The severity of prolapse is graded by the Pelvic Organ Prolapse Quantification (POP-Q) system, ranging from Stage I (mild descent) to Stage IV (complete eversion of the vagina).

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Laparoscopic repair is particularly indicated in:

Symptomatic Stage II–IV prolapse affecting quality of life.

Younger women desiring uterine preservation.

Cases where vaginal repair has failed.

Women seeking minimal invasiveness with long-term durability.

Advantages of Laparoscopy

Magnified pelvic visualization and precise dissection.

Anatomical restoration with mesh placement mimicking natural ligament support.

Lower recurrence rates compared to vaginal approaches.

Shorter hospital stay and faster recovery.

Reduced intraoperative bleeding and postoperative pain.

Superior functional outcomes in terms of urinary and sexual function.

Laparoscopic Surgical Options
Laparoscopic Sacrocolpopexy

Considered the gold standard for post-hysterectomy vaginal vault prolapse.

Involves attaching the vaginal vault to the sacral promontory using a synthetic mesh, restoring vaginal axis and depth.

Steps:

Patient is placed in the Trendelenburg position.

Four-port laparoscopic entry is established.

Peritoneum over the sacral promontory is incised, and the anterior longitudinal ligament is exposed.

Vaginal vault or cuff is dissected free anteriorly and posteriorly.

A Y-shaped polypropylene mesh is sutured to the anterior and posterior vaginal walls.

The opposite end of the mesh is fixed to the sacral promontory with non-absorbable sutures.

Peritoneum is closed over the mesh to prevent bowel contact.

Laparoscopic Sacrohysteropexy

Preferred for uterine prolapse in women who wish to retain the uterus.

Mesh is used to suspend the uterus to the sacral promontory, preserving reproductive and hormonal functions.

Steps:

Similar to sacrocolpopexy, except mesh is anchored to the posterior cervix or uterine isthmus rather than the vaginal cuff.

Laparoscopic Paravaginal Repair

Addresses anterior compartment defects (cystocele).

Involves reattaching the detached pubocervical fascia to the arcus tendineus fascia pelvis (ATFP).

Laparoscopic Rectopexy

Performed for rectocele or concomitant rectal prolapse.

Rectum is mobilized and fixed to the sacrum, often combined with mesh reinforcement.

Postoperative Care

Foley catheter drainage for 24 hours.

Early ambulation and resumption of diet.

Analgesics and antibiotics as per protocol.

Avoidance of heavy lifting and straining for at least 6–8 weeks.

Pelvic floor physiotherapy recommended to enhance long-term outcomes.

Complications

Although safe and effective, laparoscopic prolapse surgery carries potential risks:

Intraoperative bleeding, particularly from presacral veins.

Mesh-related complications such as erosion, infection, or dyspareunia.

Injury to bladder, ureters, or rectum during dissection.

Recurrence of prolapse if repair is incomplete.

Rare risk of sacral osteomyelitis when mesh fixation involves deep sutures.

Outcomes and Prognosis

Numerous studies and meta-analyses have confirmed that laparoscopic sacrocolpopexy and sacrohysteropexy yield high long-term success rates exceeding 85–90%. Patient-reported outcomes demonstrate significant improvement in urinary continence, bowel symptoms, and sexual function. Mesh erosion rates are lower with laparoscopic techniques compared to vaginal mesh procedures, particularly when meticulous surgical technique and peritoneal closure are performed.

Recurrence rates remain minimal if mesh is securely fixed and concomitant pelvic floor defects are corrected during the procedure. The majority of women report high satisfaction, improved quality of life, and rapid return to normal activities.

Conclusion

Laparoscopic management of genitourinary prolapse represents a significant advancement in urogynecology, combining the durability of open abdominal procedures with the advantages of minimally invasive surgery. Techniques such as sacrocolpopexy and sacrohysteropexy provide excellent anatomical and functional outcomes with low recurrence rates. By addressing multi-compartmental defects and ensuring secure fixation, laparoscopy restores normal pelvic anatomy, improves quality of life, and preserves fertility when desired.

As surgical expertise and technology continue to advance, laparoscopic repair is becoming the standard of care for genitourinary prolapse, offering women a safe, effective, and lasting solution with minimal morbidity.