Abstract
Background
Pelvic organ prolapse is a common gynecological disorder seen in Asian women, more in rural area. It is seen in both old age and young women. Presenting complaints includes something coming out of vagina, chronic pelvic pain, urinary and bowel symptoms. Sacrohysteropexy is the gold standard procedure for its management. Recently, laparoscopic pectopexy is described as a new alternative procedure, which is equally effective and associated with far lesser complications. Thus, this study is conducted to see the outcomes of laparoscopic pectopexy.
Method
This retrospective observational study is conducted in the department of obstetrics and gynecology, over the period of three years. Thirty-five patients, operated by laparoscopic pectopexy, were included in study. Twenty-five cases were young patient with prolapse, while 10 patients were of vault prolapse. Inclusion criteria were POP-Q stage ≥ II. All cases were done by same surgical team. Data were analyzed in terms of demographic profile. Video recording of surgery were checked to calculate operating time and estimated blood loss. All intraoperative and postoperative complications were recorded. Follow-up was done at 1 month and 6 months.
Results
Out of 35 cases, 10 were vault prolapse and 25 cases were uterine prolapse. No major intraoperative complications like visceral injury and major hemorrhage were found. Average operating time was 96 min. Average estimated blood loss was 50–100 ml. All patients were followed up at 1 month, 3 months and 6 months postoperatively. All patients were highly satisfied with surgery. None of the patients had de novo apical prolapse/recurrence of symptoms.
Conclusion
Laparoscopic pectopexy is a novel promising technique to manage prolapse with minimal intraoperative and postoperative complications. It is a safe and feasible alternative to sacropexy. So, it should be considered as a first-line surgery for management of apical prolapse.
Keywords: Laparoscopy, Prolapse, Pectopexy, Sacropexy
Introduction
Pelvic organ prolapse (POP) is a common gynecological condition seen in Asian women. It is defined as downward displacement of pelvic organ (uterus/cervix/vagina) through the vaginal wall [1]. It is very commonly seen in rural areas.
It is seen in mostly parous women (50%) of age 50 years [1]. This problem is faced by not only old-age perimenopausal women but also seen in young women of reproductive age group.
There are various risk factors found to be associated with pelvic organ prolapse which are as follows: multiparty, first pregnancy at young age, delivery at home by dais, prolonged labor, early return to home activities postpartum, prolonged sitting in squatting position and advancing age. These factors are very commonly seen in rural areas of Asian countries. Post hysterectomy, incidence of vault prolapse is 3.6 women/1000 women/year. This incidence further increases with increase in age [2].
Women with POP, present in OPD with various complaints such as something coming out of vagina, chronic pelvic pain, backache, dyspareunia, urinary and bowel symptoms. Urinary symptoms include altered bladder habits, urinary retention and incontinence, and irritative symptoms include increased frequency of micturition, burning during micturition and obstructed voiding. Bowel symptoms are like difficulty in passing stools, fecal urgency or incontinence [3]. These symptoms hamper daily life of women so it should be managed timely.
Various modalities have been described to combat this problem. Conservative management is done by lifestyle advice, pelvic floor muscle training and use of mechanical devices.
Various surgical approaches have been defined including hysterectomy, sling surgeries, sacrohysteropexy, pectopexy and sacrocolpopexy. Essential element of any surgical treatment is effective support of the specific prolapsed point.
These procedures can be done by open technique or by minimally invasive techniques.
Sacrohysteropexy/sacrocolpopexy are considered as the gold standard procedure of management of uterine/vault prolapse in which uterus/vault is anchored via mesh to the anterior longitudinal ligament over sacral promontory [4].
However, recently, in 2007, a new alternative procedure is being found, i.e., laparoscopic pectopexy which is found to be equally effective as sacrohysteropexy/ sacrocolpopexy with far lesser complications rate. Added advantage of laparoscopic pectopexy is significant reduction of recurrence rate [5].
Thus hereby we are going to describe a study conducted in rural area of Asia to see the outcomes of laparoscopic pectopexy surgery. Till now, no Indian study has been published with these many cases of laparoscopic pectopexy.
Methods
This is a retrospective observational study conducted in the department of obstetrics and gynecology, over the period of three years (July 2019 to January 2023).
Ethical permission the study was conducted after taking approval from institution ethical committee.
This study included 35 patients, operated by laparoscopic pectopexy technique. Twenty-five cases were young patient with prolapse, while 10 patients were of vault prolapse. These patients presented to gynecological OPD with various complaints, including prolapse, backache, dyspareunia and urinary symptoms. All patients were examined, and grading was done by POP-Q classification. Inclusion criteria were POP-Q stage ≥ II. Exclusion criteria were previous surgery for vaginal prolapse and severe PID. Blood investigations and ultrasound pelvis were done. After preanesthetic checkup and after taking informed consent, patients were taken for surgery (laparoscopic pectopexy).
All medical records were reviewed, and data were analyzed in terms of demographic profile (age, weight, BMI, parity and previous surgery). Video recording of surgery were checked to calculate operating time, estimated blood loss and any intraoperative complications. Immediate postoperative complications like fever, surgical site infections and blood transfusions were recorded. Patients were followed at 1 week, 3 months and 6 months for any recurrence symptoms, de novo prolapse, de novo urinary/ defecation problems.
All cases were done by same surgical team, after informed consent. All cases were done under general anesthesia in dorsal lithotomy position. Patient is again examined under anesthesia to look for degree of prolapse as shown in Fig. 1A. After painting with povidone-iodine, and draping the patient, uterine manipulator (Marwah’s) was inserted after Foley’s catheterization. Primary port of 10 mm was placed at umbilical site (via direct trocar technique). Pneumoperitoneum was created by using CO2 insufflators at 12 mm Hg. Two secondary ports of 5 mm each were placed on left lateral side (ipsilateral). Operating time was calculated from first skin incision to last skin suture.
Fig. 1.
Image showing preoperative image (A) and postoperative image (B) of women with second-degree uterovaginal prolapse who underwent laparoscopic pectopexy surgery
In cases of young prolapse, firstly, uterovesical fold of peritoneum is opened, and bladder was pushed down. Uterine isthmus area is prepared to place the mesh. Peritoneal layer was further opened along the left round ligament toward the pelvic side walls. Dissection is continued to expose iliopectineal ligament on left pelvic wall as shown in Fig. 2. A segment of around 3–4 cm of iliopectineal ligament is exposed for mesh fixation. Similar procedure is done on other side to expose right iliopectineal ligament. While in case of vault prolapse, peritoneum is opened at top of vault to push down the bladder anteriorly and bowel posteriorly. Vaginal cuff area is prepared to place the mesh.
Fig. 2.
Image showing dissection over lateral pelvic wall showing iliopectineal ligament during laparoscopic pectopexy group
Iliopectineal ligament is defined as extension of lacunar ligament which runs on pectineal line of pubic bone as shown in Fig. 3. It is stronger than sacrospinous ligament and arcus tendineus of pelvic fascia. Since, the ligament is attached on second sacral vertebrae, so anchoring the vaginal tissue on it, helps in maintaining the physiological axis.
Fig. 3.
Image showing clinical anatomy of iliopectineal ligament
Mesh used in all cases was polypropylene macroporous mesh of size 12-15 cm × 1–1.5 cm. It is cut into a broad strip as shown in Fig. 4. Mesh is introduced in the abdomen via 10 mm port. It is first anchored over anterior surface of uterus/top of vault via nonabsorbable braided polyethylene suture 2–0. 3–4 sutures were taken to secure the mesh. After straightening the mesh, anchoring is done at lateral part of iliopectineal ligament via tackers/ suture as shown in Fig. 5. At this time, uterus/vault is kept relaxed. After fixing the mesh, peritoneum is closed via Vicryl suture no 1. Round ligament was plicated in cases where long relaxed ligament was found. In 3 cases, bilateral uterosacral ligament plication was done. After finishing the procedure, ports were removed. Skin suture were applied with nonabsorbable suture 2–0. After completion of surgery, patient is examined vaginally to look for result as shown in Fig. 1B.
Fig. 4.
Image showing polypropylene macroporous mesh, cut into tongue shaped with size 12–15 cm × 1–1.5 cm
Fig. 5.
Image showing placement of mesh from uterus to right iliopectineal ligament
In few cases, uterosacral ligament plication was done. It was done specially in cases where ligaments were long and laxed. Peritoneum was opened. Suture was applied from one uterosacral ligament to other uterosacral ligament, in a figure of 8 patterns.
During postoperative period, catheter is removed with 24–48 h. Patients were discharged under satisfactory condition within 72 h. Follow-up was done at 1 week, 1 month, 3 months and 6 months.
Results
In the current study, a total of 35 cases of laparoscopic pectopexy were included. Out of these 35 cases, 10 cases were of vault prolapse and rest 25 cases were young patient with uterine prolapse. Most common symptoms of presentation were something coming of vagina, lower back pain and dyspareunia. Exclusion criteria were previous operations for correction for prolapse, pelvic inflammatory disease or suspected massive adhesions due to previous surgery.
Data of demographic profile including age, parity and BMI, of all patients were collected. Among women with uterine prolapse, women belonged to age-group of 20–55 years with average age of 23.35 years. Those who presented with vault prolapse were of age-group 40–65 years with average age of 52.44 years. Mostly women were of average built (BMI 20–25 kg/m2) however 11 women had high BMI of > 25 kg/m2. Overall average BMI was 25.66 kg/m2.
All patients were examined. Grading of prolapse was done by POP-Q classification. All cases were of ≥ grade 2 prolapse. After informed consent, patients were taken for surgery. All surgeries were done by same surgical team.
Surgery time was calculated from first skin incision to last skin suture. During initial cases, surgery time was little longer (mean operating time 120 min) in first ten cases. But with surgical expertise, mean operating time was reduced to 108 min in next ten cases. It was further reduced to average operating time of 96 min in last fifteen cases.
During surgery, various parameters were assessed. Intraoperative and postoperative results are summarized in Table 1.
Table 1.
showing the intraoperative and postoperative complications of the surgery
| Intraoperative complications | |
| Estimated blood loss: | < 100 ml |
| Time of surgery: | 90–120 min (average 96 min) |
| Conversion to laparotomy: | Nil |
| Injury to bladder/bowel/ureter: | NIL |
| Fixation done by | a) sutures: 12 cases |
| b) tackers: 23cases | |
| Duration of hospital stay: | 2–3 days |
| Postoperative complications | |
| Wound complications | NIL |
| Fever/blood transfusions | NIL |
| Recurrence/De novo cystocele/rectocele/defecation disorder/dyspareunia | NIL |
| Failure | 1 patient (young nulliparous prolapse, cervical elongation) |
| Delayed complication: Bilateral ureteral kinking | 1 case (B/L uterosacral ligament plication) |
No major intraoperative complications like visceral injury and major hemorrhage were occurred.
Blood loss was assessed during surgery, and average estimated blood loss was found to be 50–100 ml.
Mesh was anchored over iliopectineal ligament by either tackers or by nonabsorbable suture polyethylene suture 2–0.
Suturing was done in 12 cases, while in rest 23 cases, tacks were applied.
Cystocele was present in 6 patients with no stress urinary incontinence. Cystocele repair was done in only 2 cases. In rest of the 4 cases, it was managed by pectopexy surgery only. Rectocele repair was done in 5 patients.
Postoperatively, patients were comfortable and were discharged under satisfactory conditions within 72 h. No immediate postoperative complications like fever, wound sepsis and blood transfusions were seen in any of the case.
All patients were followed up at 1 week, 1 month, 3 months and 6 months postoperatively. All patients were highly satisfied with surgery. None of the patients were found to have de novo apical prolapse or de novo recurrence of anterior or lateral cystocele or de novo urinary or bowel complaints.
However, one patient presented after 1 month of surgery with second-degree prolapse. That was probably due to wrong selection of case. She was a case of cervical elongation, so patient was reoperated after 6 weeks. Manchester surgery was done, and patient is doing well now.
Another case presented at 1 month of surgery with complaint of pain abdomen. Ultrasonography was done, found to have bilateral hydroureteronephrosis. CECT urography revealed bilateral ureteral kinking. This was the case in which, bilateral uterosacral ligament plication was done. It was managed by bilateral ureteral stenting. Stents were removed after 8 weeks, and patient is doing well now.
Discussion
Apical prolapse can be managed by various open and laparoscopic surgeries. Laparoscopic surgery has been performed over 20 years.
Initially, laparoscopic sacrocolpopexy/sacrohysteropexy was done. It is considered as a gold standard surgery for management of apical prolapse [4]. In this surgery, uterus/ vault in anchored over anterior longitudinal ligament at level of sacral promontory. However, there are many problems related to this surgery. First is intraoperative risk of injury to bowel and ureter. Secondly, major risk of hemorrhage due to injury to presacral vessel is present. Since mesh is placed between sacrum and vagina, so it causes narrowing of pelvis. So, this causes risk of developing gastrointestinal complications like defecation disorders, subacute intestinal obstruction and paralytic ileus. Also, there is risk of injury to hypogastric nerves, which also leads to defecation difficulties. Another problem is the difficulty of carrying this surgery in obese patients due to difficulty of surgical field [6–9].
So, in 2007, Banerjee and Noe described a new technique for management of apical prolapse as laparoscopic pectopexy, in which mesh is anchored over the lateral part of iliopectineal ligament [10].
Clinical anatomy of the pectineal ligament [11] is shown in Fig. 3:
The pectineal ligament, also known as Cooper’s ligament, was first described by Sir Astley Cooper as the ligamentous extension lying over the iliopectineal line4. It lies between the anterior superior iliac spine and pubic tubercle. The posterolateral reflection of this ligament from the pubic tubercle forms the lacunar ligament. From the pectineal attachment of the lacunar ligament, the fibrous connective tissue called the pectineal ligament, which is a ligamentous extension, arises which lies laterally below the superior pubic ramus. The medial part of pectineal ligament close to the pubic tubercle is the thickest section, and it becomes thinner while extending laterally.
The pectineal ligament has close proximity to the external iliac vessels, which lie on its superolateral part. On the other hand, the pubic vein or arterial anastomosis between the inferior epigastric artery and obturator artery (corona mortis) is also adjacent to the pectineal ligament. At the inferolateral part of the pectineal ligament, the obturator nerve and obturator vessels are found. This obturator region consists of many vascular variations and anastomosis that the surgeon should be careful of during surgery.
Since this ligament is a strong ligament, even stronger than sacrospinous ligament or arcus tendon of pelvic fascia, so is hold the suture well. So, there is minimum risk of recurrence of prolapse. Rather, it provides protection against lateral defect due to lateral placement of mesh over lateral pelvic wall. This ligament is situated at second sacral vertebrae (S2), so it helps in maintaining the physiological axis of vagina.
In the pectopexy surgery, the mesh follows of pathway of uterus/vault, round ligament, broad ligament and lateral pelvic wall. Thus, there is no hindrance by bowel or ureter. No major vessel or nerve plexus is at risk of injury in this procedure. Since, it does not cause any narrowing of pelvis, so there is no association with de novo urinary or bowel complaint by this technique.
In 2015, a pilot study was published by Karl-Gunter Noe et al. [12] to compare outcomes of standard laparoscopic sacral cervicopexy with the new laparoscopic pectopexy. A total of 85 cases were included. Forty-four were operated by laparoscopic pectopexy and 41 cases by sacropexy. Eighty-one cases were examined at 12–37 months after surgery (mean time 20.67 months). A clear difference was found regarding occurrence of postoperative complications like de novo defecation disorders (0% in pectopexy, 19.5% in sacropexy) and de novo lateral defect cystocele (0% in pectopexy, 12.5% in sacropexy). Incidence of apical descensus relapse rate was lower in pectopexy group (2.3%) than sacropexy group (9.8%), however difference was statistically not significant. Hence, it was concluded that laparoscopic pectopexy is a novel method of management of vaginal prolapse which offers clear practical advantage over the laparoscopic sacropexy. The results are quite comparable with our study in which no case of de novo defecation disorder and lateral defects were found in laparoscopic pectopexy group.
In a study conducted by Alper Biler et al. in 2018 [13], laparoscopic pectopexy was found to be a promising endoscopic prolapse surgery and a good alternative technique to sacrocolpopexy. They conducted a retrospective cohort study to investigate differences in perioperative complications and short-term outcomes of patients who underwent abdominal sacrocolpopexy/ sacrohysteropexy, laparoscopic sacrocolpopexy/sacrohysteropexy and laparoscopic pectopexy. This study included 110 patients over a period of 6 years. A total of 68 abdominal sacrocolpopexy, 14 laparoscopic sacrocolpopexy and 28 laparoscopic pectopexy were analyzed. Baseline characteristics and intraoperative variables were similar. Complications were seen in 13.2% patients of group abdominal sacrocolpopexy, 7.1% of laparoscopic sacrocolpopexy and 3.6% of laparoscopic pectopexy group. However, mean operating time was significantly shorter in the laparoscopic pectopexy group (74.9 min) as compared to the other group. During the six-month follow period, no prolapse recurrence and mesh erosion/exposure were observed in any group. De novo stress urinary incontinence, urgency and defecation problems as well as perioperative complications were not found to be statistically significantly different between the groups. But the minimally invasive approach was found to be significantly associated with reduced procedural-related morbidity. The results are similar to the current study.
In 2017, Kale et al. [14] published a study to share their first experience with laparoscopic pectopexy at a single center to evaluate its feasibility. Seven patients underwent this surgery. Medical records and short-term clinical outcomes were analyzed. No major intraoperative and postoperative complications were found. No de novo prolapse, urgency/ defecation problems/ stress urinary incontinence/anterior and lateral defect cystocele /rectocele were found during postoperative follow-up period of 6 months.
An international multicenter study was published by Noe et al. in 2021 [15], in which a randomized trial was conducted, focusing on the combination of traditional native tissue repair with pectopexy or sacrocolpopexy. Eleven clinics and 13 surgeons in four European counties participated in the trial. In order to ensure a standardized approach and obtain comparable data, all surgeons were obliged to follow a standardized approach for pectopexy, focusing on the area of fixation and the use of a prefabricated mesh. The mesh was solely used for apical repair. All other clinically relevant defects were treated with native tissue repair. Colposuspension or TVT was used for the treatment of incontinence. Data were collected independently for 14 months on a secured server; 501 surgeries were registered and evaluated. Two hundred and sixty-four patients out of 479 (55.1%) returned for the physical examination and interview after 12–18 months. The mean duration of follow-up was 15 months. The overall success of apical repair was rated positively by 96.9%, and the satisfaction score was rated positively by 95.5%. A positive general recommendation was expressed by 95.1% of patients. Pelvic pressure was reduced in 95.2%, pain in 98.0% and urgency in 86.0% of patients. No major complications, mesh exposure or mesh complication occurred during the follow-up period. Thus, it was concluded that in clinical routine, pectopexy and concomitant surgery, mainly using native tissue approaches, resulted in high satisfaction rates and favorable clinical findings. The procedure may also be recommended for use by general urogynecological practitioners with experience in laparoscopy.
In 2021, another study of retrospective case series was published by Winget et al. [16] on laparoscopic pectopexy. It included 7 women who underwent laparoscopic pectopexy at one academic institution between October 2019 and December 2020. The patients had preoperative vaginal vault prolapse (pelvic organ prolapse quantification system [POP-Q], stage 2 and 3). Pectopexy was performed because of relative contraindications to sacrocolpopexy, including use of antiplatelet therapy, extensive adhesions and chronic back pain with lumbo-spinal fusion. No intraoperative complications were documented in this cohort. Average blood loss was 32.9 mL. All the patients were discharged home within 24 h. One patient experienced urinary retention that required release of the retropubic midurethral sling placed at the time of pectopexy. The most recent follow-up examination occurred at an average of 127 days after the procedure. All 7 patients had a resolution of their prolapse (POP-Q ≤ 1). This case series highlights the application of pectopexy for patients with extensive adhesions, use of antiplatelet therapy and lumbar or sacral spinal surgical history. The complication rates and operative results are comparable with sacrocolpopexy at intermediate-term follow-up in this small case series, indicating that pectopexy may be a promising alternative for patients with relative contraindications to sacrocolpopexy.
In the current study here, authors have conducted a study on 35 cases, which underwent laparoscopic pectopexy. No major complications occurred during or after surgery. No de novo prolapse/lateral defect prolapse/SUI cases were found postoperatively. However, we were not able to do follow-up at 12 months/longer time. Besides, there was no control group on our study to compare the results.
Conclusion
Sacrocolpopexy/sacrohysteropexy are a gold standard surgery for management of pelvic organ prolapse. However, now laparoscopic pectopexy has evolved, which offers many advantages over sacrocolpopexy, which are as follows:
During laparoscopic pectopexy, surgeon has a wide surgical field area in pelvis and the vital structures lie far away from this field. So, there is minimal risk of injury to bladder/bowel/ureter. Also, it is easier to de done in obese patients than sacropexy.
During laparoscopic pectopexy, minimal blood loss occurs during the surgery. While during sacrocolpopexy, there is major risk of hemorrhage from presacral vessels, which lies in the surgical field.
After laparoscopic pectopexy, there is minimum risk of developing de novo defecation/urinary problems. However, sacrocolpopexy leads to narrowing of pelvic outlet due to which patients develop de no stress urinary incontinence/urgency/defecation problems postoperatively.
In laparoscopic pectopexy, mesh is anchored over lateral part of iliopectineal ligament. This ligament is the second strongest ligament of the abdomen. So, there is minimum risk of recurrence of apical prolapse. Additionally, it provided protection against the lateral defect prolapse, since mesh is attached at its lateral part.
Height of lateral fixation of iliopectineal ligament corresponds to second sacral vertebrae (S2), so physiological axis of vagina is achieved in pectopexy surgery.
Mean operating time to do laparoscopy pectopexy is less, and it further decreases with increase in experience of surgeon and the surgical team. So, it has a faster learning curve especially for the young budding endoscopic surgeons.
Hence to conclude, our study has shown that laparoscopic pectopexy is a novel promising technique to manage pelvic organ prolapse with minimal intraoperative and postoperative complications. It is a safe and feasible alternative to sacropexy. So, it should be considered as a first-line surgery for management of apical prolapse. However, larger number of multicenter studies with more cases and longer follow-up time are required to be done to further strengthen our conclusion.
Funding
No.
Declarations
Conflict of interest
The author(s) declare that they have no competing interests
Ethical Approval
Ethical permission the study was conducted after taking approval from institution ethical committee.
Informed consent
After informed consent, patients were taken for surgery. All surgeries were done by same surgical team.
Footnotes
Dr Nidhi Jain MBBS, MS (Ex associate professor); Dr Jyotsna Kamra MBBS MD (Ex HOD); Dr Shruthi Munjal MBBS MS (Assistant professor)
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
References
- 1.ErdemI S. Intermediate-term follow-up of laparoscopic pectopexy cases and their effects on sexual function and quality of life: a cross-sectional study. Sao Paulo Med J. 2022;4:140. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Carolien KM, Vermeulen CK, Veen J, Adang C, van Leijsen SA, Coolen AL, Bongers MY. Pelvic organ prolapse after laparoscopic hysterectomy compared with vaginal hysterectomy: the POP-UP study. Int Urogynecol J. 2021;32:841–50. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Kurz J, Borello-France D. Movement system impairment-guided approach to the physical therapist treatment of a patient with postpartum pelvic organ prolapse and mixed urinary incontinence: case report. Phys Ther. 2017;97(4):464–77. [DOI] [PubMed] [Google Scholar]
- 4.Sarah M, Moore CK. Minimally invasive urology: robotic abdominal sacrocolpopexy. Cham Springer; 2020.
- 5.Noé KG, Schiermeier S, Alkatout I, Anapolski M. Laparoscopic pectopexy: a prospective, randomized, comparative clinical trial of standard laparoscopic sacral colpocervicopexy with the new laparoscopic pectopexy-postoperative results and intermediate-term follow-up in a pilot study. J Endourol. 2015;29(2):210–5. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Biler A, Ertas IE, Tosun G, Hortu I, Turkay U, Gultekin OE, Igci G. Perioperative complications and short-term outcomes of abdominal sacrocolpopexy, laparoscopic sacrocolpopexy, and laparoscopic pectopexy for apical prolapse. Int Braz J Urol. 2018;44(5):996–1004. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Biler A, Ertaş İE, Tosun G, Hortu İ, Demir A, Taner CE, Özeren M, Şendağ F. Perioperative complications and short-term outcomes of abdominal sacrocolpopexy, laparoscopic sacrocolpopexy, sacrospinous ligament fixation, and iliococcygeus fixation procedures. Turk J Med Sci. 2018;48(3):602–10. [DOI] [PubMed] [Google Scholar]
- 8.Okcu NT, Gürbüz T, Uysal G. Comparison of patients undergoing vaginal hysterectomy with sacrospinous ligament fixation, laparoscopic hysterectomy with sacrocolpopexy and abdominal hysterectomy with sacrocolpopexy in terms of postoperative quality of life and sexual function. J Gynecol Obstet Hum Reprod. 2021;50(4): 101977. [DOI] [PubMed] [Google Scholar]
- 9.Costantini E, Mearini L, Lazzeri M, Bini V, Nunzi E, di Biase M, et al. Laparoscopic Versus Abdominal Sacrocolpopexy: A Randomized. Controlled Trial J Urol. 2016;196:159–65. [DOI] [PubMed] [Google Scholar]
- 10.Banerjee C, Noe KG. laparoscopic pectopexy: a new technique of prolapse surgery for obese patients. Arch Gynecol Obstet. 2011;284:631–5. [DOI] [PubMed] [Google Scholar]
- 11.Pulatoğlu Ç, Doğan O, Medisoğlu MS, Yassa M, Ellibeş Kaya A, Selçuk İ, Bayık RN. Surgical anatomy of the pectineal ligament during pectopexy surgery: the relevance to the major vascular structures. Turk J Obstet Gynecol. 2020;17(1):21–7. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Noe K-G, Scheimeier S, Alkatout I, Anapolski M. Laparoscopic pectopexy: a prospective, randomized, comparative clinical trial of standard laparoscopic sacral colpocervicopexy with the new laparoscopic pectopexy-postoperative results and intermediate-term follow up in a pilot study. J Endourol. 2015;29:210–5. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Biler A, Ertas E, Tosun G, Hortu I, Turkay U, Gultekin OE, et al. perioepartive complications and short-term outcomes of abdominal sacrocolpopexy, laparoscopic sacrocolpopexy and laparoscopic pectopexy for apical prolapse. Int Braz J Urol. 2018;44:996–1004. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14.Kale A, Biler A, Terzi H, Usta T, Kale E. Laparoscopic pectopexy: initial experience of single center with a new technique for apical prolapse surgery. Int Braz J Urol. 2017;43:903–9. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15.Noé GK, Schiermeier S, Papathemelis T, Fuellers U, Khudyakov A, Altmann H-H, Borowski S, Morawski PP, Gantert M, De Vree B, et al. Prospective international multicenter pelvic floor study: short-term follow-up and clinical findings for combined pectopexy and native tissue repair. J Clin Med. 2021;10:217. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16.Winget VL, Gabra MG, Addis IB, Hatch KK, Heusinkveld JM. Laparoscopic pectopexy for patients with intraabdominal adhesions, lumbar spinal procedures, and other contraindications to sacrocolpopexy: a case series. AJOG Glob Rep. 2021;2(2): 100034. [DOI] [PMC free article] [PubMed] [Google Scholar]