Genitourinary prolapse, commonly referred to as pelvic organ prolapse (POP), is a condition in which the bladder, uterus, vaginal vault, or rectum descends into or beyond the vaginal canal due to weakness of the pelvic floor support system. It is a prevalent disorder, particularly among multiparous and postmenopausal women, affecting quality of life through symptoms of pelvic pressure, urinary dysfunction, defecatory issues, and sexual difficulties.

In his lecture, Dr. R. K. Mishra emphasizes how advances in laparoscopic techniques have transformed the management of genitourinary prolapse. Minimally invasive surgery has provided durable, anatomically sound solutions with reduced morbidity compared to traditional vaginal and open abdominal approaches.

Pathophysiology

Pelvic support structures include the uterosacral ligaments, cardinal ligaments, endopelvic fascia, and levator ani muscles. When these structures weaken or are damaged, pelvic organs lose their support and begin to prolapse.

Anterior compartment prolapse – cystocele.

Apical compartment prolapse – uterine prolapse or vaginal vault prolapse (after hysterectomy).

Posterior compartment prolapse – rectocele or enterocele.

According to Dr. Mishra, accurate identification of the compartment involved is critical before planning laparoscopic repair.

Indications for Surgery

Not all prolapses require surgical intervention. Indications for laparoscopic management include:

Symptomatic Stage II–IV prolapse interfering with daily activities.

Recurrent prolapse after vaginal surgery.

Uterine preservation requests in young women.

Associated urinary incontinence or obstructive symptoms.

Need for long-term durable anatomical correction.

Advantages of Laparoscopic Management

Dr. Mishra highlights several advantages of laparoscopy over vaginal and open abdominal approaches:

Enhanced visualization of pelvic anatomy due to magnification.

Precise dissection and mesh placement.

Durability with lower recurrence rates.

Faster recovery and shorter hospital stay.

Reduced morbidity such as blood loss and wound complications.

Cosmetic benefit with minimal scarring.

Laparoscopic Techniques
Laparoscopic Sacrocolpopexy

This is considered the gold standard for post-hysterectomy vaginal vault prolapse.

Steps described by Dr. Mishra:

Ports are placed—one 10 mm umbilical port and three 5 mm working ports.

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

The vaginal cuff is dissected free anteriorly and posteriorly.

A Y-shaped polypropylene mesh is fixed to the anterior and posterior vaginal walls using non-absorbable sutures.

The proximal end of the mesh is anchored securely to the sacral promontory.

The peritoneum is closed over the mesh to prevent bowel adhesions.

This restores vaginal axis, length, and function effectively.

Laparoscopic Sacrohysteropexy

For women with uterine prolapse wishing to preserve the uterus, this procedure suspends the cervix or uterine isthmus to the sacral promontory using mesh. It provides excellent anatomical correction while maintaining reproductive and hormonal functions.

Paravaginal Repair

For anterior compartment prolapse (cystocele), laparoscopic paravaginal repair reattaches the pubocervical fascia to the arcus tendineus fascia pelvis (ATFP).

Posterior Compartment Repair

Rectocele or enterocele can be addressed by reinforcing the rectovaginal fascia or performing laparoscopic rectopexy, often combined with anterior or apical repairs.

Intraoperative Considerations

Ureteric safety is paramount while dissecting near uterosacral ligaments.

Mesh fixation should be tension-free to prevent erosion and dyspareunia.

Peritonealization over the mesh reduces bowel complications.

In cases of stress urinary incontinence, a concomitant laparoscopic Burch colposuspension may be considered.

Postoperative Care

Foley catheter for 24 hours.

Early ambulation and resumption of diet.

Analgesia and prophylactic antibiotics.

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

Pelvic floor physiotherapy to enhance outcomes.

Complications

Dr. Mishra stresses the importance of recognizing and preventing complications:

Intraoperative bleeding from presacral veins.

Visceral injuries to bladder, ureter, or rectum.

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

Recurrence if repair is incomplete or improperly anchored.

Outcomes and Prognosis

Studies and clinical experience demonstrate high success rates with laparoscopic prolapse repair:

Symptom relief in urinary, sexual, and bowel functions.

Durable anatomical results with recurrence rates lower than 10%.

Low complication rates with meticulous surgical technique.

High patient satisfaction due to rapid recovery and improved quality of life.

Conclusion

In his lecture, Dr. R. K. Mishra emphasizes that laparoscopic management of genitourinary prolapse has redefined standards of care in urogynecology. Procedures like laparoscopic sacrocolpopexy and sacrohysteropexy combine anatomical restoration with minimal invasiveness, ensuring long-term durability, symptom relief, and preservation of sexual and reproductive function.

Laparoscopy provides the surgeon with unparalleled visualization and precision, and for patients, it offers faster recovery, fewer complications, and superior outcomes. With ongoing refinements in surgical techniques and mesh technology, laparoscopic management continues to evolve as the preferred approach for genitourinary prolapse worldwide.