Clinical Results in Laparoscopic Apical Prolapse Repair: A Prospective Comparative Cohort of Sacrocolpopexy, Lateral Suspension and Pectopexy with 312 Women

1. Introduction

Pelvic organ prolapse (POP) affects up to 50% of parous women on examination and remains a major cause of pelvic floor reconstructive surgery worldwide [1]. Apical compartment failure is increasingly recognized as a critical determinant of global prolapse recurrence [2,3].

Laparoscopic sacrocolpopexy (SP) has long been considered the gold standard for apical reconstruction due to its high long-term durability [4,5,6], creating an oblique suspension vector that closely resembles the physiological state [7]. However, concerns regarding the technically demanding dissection of the sacral promontory, along with the associated risks of injury to the presacral vessels, hypogastric nerves and vessels, ureteral damage, and a prolonged learning curve [8,9,10,11] have stimulated the development of promontory-sparing alternatives, including laparoscopic lateral suspension (LLS) [12] and pectopexy (PP) [13].

LLS, first described by Dubuisson, uses a T-mesh placed in the vesico-vaginal space with bilateral arms attached to the posterolateral abdominal wall, creating a lateral support vector for the correction of pelvic organ prolapse. By avoiding presacral dissection, a lower rate of major complications, reduced operative time and a shorter learning curve may be expected [10,14].

PP, introduced by Noé [15], anchors the mesh to both iliopectineal ligaments, without compromising vital structures such as the ureters or bowel [13]. As a result, a correction vector oriented in an anterior-horizontal direction is established.

Recent systematic reviews and meta-analyses suggest comparable short-term anatomical outcomes among these techniques with SP [10,14]. However, high-quality comparative evidence remains limited [11], and recent systematic reviews emphasize persistent uncertainty regarding the superiority of promontory-sparing techniques [16].

Despite increasing adoption of these alternative techniques, genuine clinical equipoise remains unresolved. Most available data derive from heterogeneous retrospective cohorts or short-term randomized comparisons underpowered for recurrence endpoints. Furthermore, compartment-specific failure patterns and clinically stringent recurrence definitions are rarely reported. These gaps limit informed surgical decision-making.

In addition, the definition of anatomical success based solely on POP-Q staging may not fully reflect clinically relevant prolapse recurrence. Guttman et al. demonstrated that the point of maximal descent on POP-Q examination is closely associated with patient-reported bulging symptoms, with a threshold of 0.5 cm distal to the hymen accurately predicting symptomatology [17]. Given that POP-Q stage II encompasses values ranging from 1 cm proximal to 1 cm distal to the hymen [18], this classification may include both clinically significant and asymptomatic cases. Therefore, assessing anatomical outcomes based on the presence of compartment-specific points beyond the hymen (e.g., point C > 0) may provide a more clinically meaningful evaluation of surgical success.

The present study aims to provide a comprehensive prospective comparison of SP, LLS and PP performed within a standardized institutional framework, with emphasis on anatomical outcomes, compartment-specific failure patterns, reintervention rates, operative time, and perioperative complications.

2. Materials and Methods

2.1. Study Design

This is a single-center, prospective observational cohort study including consecutive women undergoing laparoscopic apical POP repair between October 2022 and February 2026

2.2. Participants

The inclusion criteria were: symptomatic anterior or apical POP (POP-Q ≥ II), indication for laparoscopic reconstructive surgery, age ≥ 18 years.

The exclusion criteria were: prior apical mesh repair, active pelvic infection, cervical elongation.

2.3. Surgical Techniques

All procedures were performed by experienced pelvic floor surgeons according to the standard approaches for sacrocolpopexy, pectopexy, and laparoscopic lateral suspension.

In laparoscopic sacrocolpopexy, a DynaMesh®-PRS mesh was placed on the anterior and posterior surfaces of the cervix (if supracervical hysterectomy was performed) or on the vaginal walls and fixed using sutures and/or tack fixation systems (AbsorbaTack™). In selected cases, the posterior mesh was additionally fixed to both puborectalis muscles, a step that remains controversial. The superior portion of the mesh was then sutured to the anterior longitudinal ligament at the level of the sacral promontory.

In laparoscopic pectopexy, a DynaMesh®-PRP mesh was sutured to the anterior cervical wall (if supracervical hysterectomy was performed) or to the vaginal cuff, followed by elevation to its anatomical position without excessive tension. Subsequently, both ends of the mesh were bilaterally fixed to the pectineal ligaments using non absorbable sutures.

For laparoscopic lateral suspension, a TiLOOP®-LLS Dubuisson mesh was introduced into the vesicovaginal space, and its anterior arm was fixed to the uterine isthmus and the fascia of the anterior vaginal wall using sutures and sometimes added AbsorbaTack™. A 5 mm skin incision was then made approximately 2 cm above the iliac crest and 4 cm posterior to the anterior superior iliac spine. Through this incision, forceps were advanced toward the peritoneum without perforating it. Once in the preperitoneal space, dissection continued toward the round ligament, passing beneath it. At this point, the peritoneum was opened and the mesh arm was grasped. This procedure was performed bilaterally, resulting in the uterus being suspended by both mesh arms, which remained in an extraperitoneal position. In patients with hysterectomy (previous or concomitant), the technique was slightly modified, with the anterior and posterior portions of the mesh (TiLOOP®-LLSH Dubuisson mesh) being fixed to the anterior vaginal wall, vaginal cuff, and posterior vaginal wall.

2.4. Outcomes

The primary endpoint was apical recurrence defined as surgical reinterventions for apical failures, apical prolapse POP-Q stage ≥ II and point C of POP-Q > 0.

Secondary endpoints were compartment-specific recurrence (defined as POP-Q stage ≥ II and any POP Q point > 0) operative time and perioperative complications.

2.5. Statistical Analysis

Quantitative variables were described as mean ± standard deviation (SD) and compared across techniques using the Kruskal–Wallis test. When statistically significant differences were identified, post hoc pairwise analyses were conducted using the Mann–Whitney U test.

Categorical variables were expressed as percentages and analyzed using Pearson’s chi-square test. When significant differences were detected, post hoc pairwise comparisons were performed using chi-square or Fisher’s exact tests, as appropriate, with Bonferroni correction (adjusted α = 0.0167) to account for multiple comparisons.

Significance was set at p < 0.05.

Cramér’s V was used to evaluate the strength of association between the type of surgical technique and the presence of postoperative POP-Q values > 0.

2.6. Ethical Approval

Approved by Institutional Review Board (protocol code 2022-3-8-HCUVA and date of approval: 26^th April 2022). Written informed consent was obtained from all participants.

3. Results

3.1. Baseline Characteristics (Table 1)

A total of 312 women were included: SP n=181, LLS n=87, and PP n=44.

Mean age showed a non-significant trend toward older age in the PP group (SP 54.7±9.9; LLS 56.4±8.4; PP 57.6±9.2 years (p=0.052). BMI was similar among the three groups (p=0.658).

Previous hysterectomy was significantly more frequent in the PP group (37.8%) compared with SP (17.9%) and LLS (5.7%) (p<0.001).

A significant difference in preoperative apical prolapse stage was observed among the surgical techniques (p = 0.009). Post hoc analysis with Bonferroni correction (adjusted α = 0.0167) revealed that the comparison SP-PP (p=0.013) and SP-LLS (p=0.019) were statistically significant, with lower preoperative prolapse severity in PP and LLS.

Differences were also observed in the preoperative staging of both the anterior (p = 0.048) and posterior (p = 0.008) compartments. Post hoc analysis with Bonferroni correction revealed that, in both cases, these differences were limited to the comparison between SP and LLS (p = 0.046 for anterior compartment and p = 0.006 for posterior compartment).

Preoperative constipation was more frequent in PP (20.0%) and LLS (11.4%) compared to SP (6.7%) (p=0.025), reflecting that in author´s criteria constipation was a clinical exclusion criterion for SP.

3.2. Surgical Outcomes

Apical recurrence, defined as a POP stage ≥ II, did not differ significantly between groups (p=0.990). Point C of POP-Q exam showed no significant differences (p=0.696).

No significant differences were found in the analysis of the anterior compartment when evaluating the presence of POP-Q stage ≥ II (p=0.074) and Aa > 0 (p=0.107). Differences were observed for Ba > 0 (p=0.005; Cramér’s V=0.185). Post hoc analysis with Bonferroni correction revealed that these differences were between the SP and PP groups (p=0.003).

Significant differences were also observed when the presence of posterior compartment prolapse POP-Q stage ≥ II (p=0.007) and Bp > 0 (p=0.024; Cramér’s V=0.155) were analyzed. In both cases, the differences with post hoc analysis were found between the SP and PP groups (p=0.011; p=0.009). No differences were observed for Ap > 0 (p=0.139).

Postoperative total vaginal length (TVL) was longest after SP (8.62±1.16 cm), followed by LLS (7.96±1.12) and PP (7.55±1.04) (p<0.001). Post hoc analysis revealed significant differences in all pairwise comparisons.

There were no differences in surgical reinterventions for apical failure (p = 0.719). In the SP group, one patient required reintervention for stage IV apical prolapse and was managed with a vaginal approach. In the LLS group, one patient required reintervention for stage III apical prolapse and underwent laparoscopic sacropexy. No reinterventions were observed in the PP group.

Operative time differed significantly among techniques (SP: 202.5 ± 61.2 min, LLS: 113.0 ± 40.3 min, PP: 168.0 ± 48.8 min). Post hoc analysis revealed significant differences in all pairwise comparisons (all p<0.001).

All postoperative complications required surgical intervention (Clavien–Dindo grade III) [19]. No differences were observed in the rate of perioperative complications (p=0.152). Major complications were observed exclusively in the SP group included a postoperative hemoperitoneum of 1500 mL occurring five days after surgery associated with a presacral hematoma, ovarian vein injury with bleeding, bladder injury (<1cm) during vesicovaginal space dissection, and mesh extrusion (two cases). Additional complications in this group included ureteral kinking secondary to peritoneal closure sutures, posterior peritoneal tear and bowel obstruction due to port-site hernia.

In contrast, no major complications were observed in the LLS group. Only one intraoperative event occurred, consisting of loss of tension of the peritoneal arms during Valsalva maneuver at extubation, which required immediate retensioning during the same surgical procedure. No complications were described in PP.

Median follow-up was comparable (SP 17.2 months; LLS 13 months; PP 14.63 months; p=0.050).

4. Discussion

This prospective comparative cohort shows that there are not significant differences in apical recurrences defined as apical POP-Q stage ≥ II (SP 1.10%; LLS 1.15%; PP 0%), point C of POP Q score > 0 (apical prolapse extending beyond the hymen) or reintervention rate between SP compared with promontory-sparing alternatives (Table 2, Table 3).

Very few published studies test the three techniques, making it difficult to compare our results. Our findings in the apical compartment are in line with the meta-analysis of Lombisani et al.[14], which reported comparable anatomical success between LLS and SP based on prolapse staging—although defined heterogeneously across studies, it was consistently not beyond stage II. Likewise, no differences were found in the reintervention rate (3.4% in SP and 4.2% in LLS), which was slightly higher than the rate reported in our cohort (0.55% in SP and 1.15% in LLS). Parsaei et al. also found no differences in apical recurrence or in point C measurements [20].

Similarly, Lin et al. [11] did not report statistically significant differences in anatomical outcomes in their meta-analysis when comparing PP and SP, nor in the specific analysis of point C of the POP-Q examination.

It is important to acknowledge that, owing to the non-randomized design of our study, patients undergoing SP presented with greater preoperative severity (Table 1), likely reflecting the surgical team’s preference for the technique traditionally considered the gold standard. Nevertheless, our results agree with the current body of evidence and confirm the findings of our previous analysis based on an earlier stage of this cohort [21], suggesting that despite the different anchoring points inherent to each technique and the consequent variations in their correction vectors, the anatomical behavior of the apical compartment remains broadly similar.

Randomized controlled studies are warranted to further strengthen these findings. In this regard, our group is currently participating in an ongoing multicenter randomized non-inferiority trial comparing LLS and SP, with preliminary analysis of 106 patients showing comparable anatomical outcomes between both approaches [22].

According to Kinay et al.[23], a total vaginal length (TVL) of less than 8 cm has been associated with apical support defects, although a causal relationship has not been established. In our series, statistically significant differences in TVL were observed (Table 2), with a mean value in SP of 8.62 ± 1.16 cm, whereas LLS and PP showed slightly lower values (7.96 ± 1.12 and 7.55 ± 1.04 cm, respectively). This parameter may represent the only variable suggesting a potential apical advantage of SP over promontory-sparing techniques; however, given the comparable apical outcomes observed across techniques in our study, these differences may not translate into clinically meaningful distinctions.

In our cohort, no significant differences were observed in the prevalence of anterior compartment POP-Q stage ≥ II after surgery (SP 13.26%; LLS 24.14%; PP 20.45%; p=0.074). However, there was evidence of a difference in the proportion of patients with Ba > 0 (p=0.005), which was more frequent in the PP group (9.09%) than in the SP group (0.55%). Lin et al [11]. reported comparable anatomical outcomes following SP and PP, although point Ba was not specifically evaluated and patients undergoing concomitant anterior colporrhaphy were not excluded. Their analysis did include point Aa, with findings that were consistent with those observed in the present study. Parsaei et al. did not observe statistically significant differences in the Aa and Ba points [20].

Given that PP relies on anterior pelvic anchoring, a detrimental effect on anterior compartment support would not be expected. Moreover, the association between PP and Ba > 0 observed in our study was characterized by a small effect size (Cramér’s V = 0.185). Therefore, we believe that the observed difference may be attributable, at least in part, to the relatively small sample size of the PP group (n = 44) and should be interpreted with caution. Although the finding reached statistical significance, its clinical relevance is likely limited. Further studies with larger sample sizes and more robust designs are warranted to clarify the significance of these observations.

LLS did not differ from the reference technique in the assessment of the anterior compartment, either in terms of postoperative prolapse stage or when individual POP-Q points were analyzed. Similar findings were reported by Lombisani et al [14]. This observation is consistent with the underlying surgical principles of LLS, in which the mesh is positioned within the vesicovaginal space, thereby providing direct support to the anterior compartment. Accordingly, anatomical success rates of approximately 86.9% have been reported for anterior POP repair with this technique [10].

When analyzing the results in the posterior compartment, it is important to consider the preoperative distribution of our cohort (Table 1). A trend toward performing SP in patients with more severe rectoceles (stage III/IV) was observed, especially when compared with LLS (p=0.006). This finding is clinically plausible, as alternative techniques primarily address the anterior pelvic compartment without involving the rectovaginal space, and may therefore be less optimal for the correction of posterior pelvic organ prolapse [14], while potentially being more suitable for patients with pre-existing constipation [11] due to avoiding the dissection of the hypogastric nerves.

In our study, outcomes in this compartment were worse in the PP group, both in terms of POP-Q stage ≥ II and Bp point measurements (Table 2, Table 3). Recent studies have reported anatomical outcomes comparable to SP [20], although patients undergoing concomitant posterior colporrhaphy were not consistently excluded [11]. The effect size observed at the Bp point in our study was low (Cramer's V = 0.155), suggesting a weak association between surgical technique and posterior compartment involvement; this finding may also be influenced by the smaller sample size of PP group. Therefore, we believe that further studies focusing specifically on the behavior of this compartment are needed to draw more definitive conclusions.

Regarding LLS, we did not observe differences in outcomes, in line with the findings reported by Lombisani et al [14], although it may not be the optimal technique for severe posterior compartiment defects [10]. The lower preoperative severity of posterior POP in the LLS group compared with SP should be considered (Table 1).

The absence of differences observed in most anatomical outcomes gains further relevance when considering the shorter operative time associated with alternative techniques. According to our results, LLS was associated with a mean 89.5 minutes shorter than SP, exceeding the mean difference of 43.1 minutes reported by Lombisani et al [14], which may be explained by the higher rate of concomitant hysterectomy in the SP group in our cohort (Table 1). With respect to PP, the difference was smaller, at 34.5 minutes, in line with findings reported by Lin et al [11]. We attribute the reduced operative time observed with LLS and PP to the lower technical difficulty in accessing the mesh anchoring point—by avoiding the complex dissection of the sacral promontory—as well as to the lower rate of concomitant hysterectomy observed. These findings are consistent with our previous analysis based on an earlier stage of this cohort [21].

Although no statistically significant differences were found in the overall rate of perioperative complications in our study (SP 4.42%; LLS 1.15%; PP 0%; p=0.152), it is noteworthy that the most severe events were exclusively concentrated in SP, including one case of ovarian vein bleeding, one hemoperitoneum, two cases of mesh extrusion, and one bladder injury, whereas only one case of mesh retensioning was recorded in LLS. As previously mentioned, these findings may be related to the greater technical complexity of the sacral promontory approach, which requires dissection in an anatomically demanding region near critical vascular and neural structures.

Our results are partially in agreement with previous literature. Lin et al. and Parsaei et al. reported a lower incidence of intraoperative bleeding in PP compared with SP, without differences in complications such as bladder injury or mesh erosion, supporting the hypothesis of a potentially more favorable safety profile for promontory-sparing techniques [11,20]. Likewise, descriptive studies have reported mesh-related complication rates of 4.9% in SP series [5] and 2.1% in large LLS cohorts, in which mesh exposure was the most frequent event [10], while bladder perforation was the most common non–mesh-related complication. However, comparative analyses have not demonstrated significant differences between SP and LLS in intraoperative, postoperative, or mesh-related complications [14].

Overall, our findings suggest that although the global incidence of complications may be comparable across techniques, their nature and potential severity may differ. Given the low event rate and the limited sample size, these results should be interpreted with caution; however, they highlight the importance of considering not only the frequency but also the profile of complications when assessing the safety of each surgical technique.

Strengths. This is one of the few studies that directly compare the three available laparoscopic techniques for the correction of POP. Anatomical evaluation not only based on POP-Q staging, but also incorporating the analysis of individual POP-Q measurements. Although this study was not randomized, all procedures were performed within the same institution by experienced pelvic floor surgeons under standardized protocols. This design minimizes inter-center variability and enhances internal consistency.

Limitations. The non-randomized design limits causal inference. Anatomical preoperative heterogeneity also should be considered. Greater technical proficiency in performing SP, due to the increased experience at our center. Lack of standardization in certain surgical steps, particularly in SP. Small sample size in PP. Relatively short follow-up.

Median follow-up ranged from 13 to 17 months. While longer-term data are desirable, the highest rates of anatomic and prolapse recurrence typically occur within 2 years of surgery [24]. Ongoing follow-up will further clarify sustained outcomes.

5. Conclusions

Sacrocolpopexy remains the gold standard laparoscopic technique for apical prolapse but entails greater surgical complexity and increased operative time, whereas laparoscopic lateral suspension and pectopexy could be other options to correct the apical defect. Future multicenter randomized trials with long-term follow-up are required to determine definitive equivalence among techniques. Surgical planning should be individualized based on patient risk profile and anatomical considerations.