Laparoscopic lateral suspension (uterus preservation) and ventral mesh rectopexy for the treatment of multi-compartment pelvic organ prolapse: surgical technique

Introduction

Pelvic organ prolapse (POP) is a condition characterized by the abnormal descent of pelvic organs due to defects or dysfunction in the pelvic floor muscles and fascial support structures, resulting in anatomical displacement and functional impairment. The primary symptoms include protrusion of pelvic organs through the vaginal introitus, often accompanied by urinary dysfunction, anorectal disorders, and sexual dysfunction, all of which can significantly impair quality of life. The pelvic floor compartments work synergistically to maintain pelvic stability and balance; prolapse in one compartment can influence others, and approximately 10% to 55% of patients with POP present with defects in two or more compartments (1). Repairing only a single compartment often leads to high rates of surgical failure and reoperation. Given the involvement of various specialties (such as gynecology, colorectal surgery, and urology), the diagnosis and treatment of multi-compartment POP often require a multidisciplinary approach to develop comprehensive management strategies, thereby improving surgical outcomes and alleviating patient symptoms. For patients presenting with concurrent rectal prolapse, anterior vaginal wall (bladder) prolapse, and uterine prolapse—particularly those who strongly desire uterine preservation and have significant anterior compartment defects—we consider the combination of uterine-preserving lateral suspension and ventral mesh rectopexy to offer considerable advantages. This study reports the first case of a patient with simultaneous rectal prolapse, anterior vaginal wall prolapse, uterine prolapse, and notable constipation symptoms, who achieved satisfactory therapeutic outcomes through laparoscopic lateral suspension (uterus preservation) and ventral mesh rectopexy. This article details the technical procedure involved in this combined surgery and shares our institution’s diagnostic and therapeutic perspective on multi-compartment POP. We present this article in accordance with the SUPER reporting checklist (available at https://gpm.amegroups.com/article/view/10.21037/gpm-2025-1-63/rc).

Preoperative preparations and requirements

All procedures performed in this study were in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Ethics Committee of West China Second University Hospital, Sichuan University (No. 2022207), and informed consent was obtained from the patient for the publication of this article, the accompanying images and video. A copy of the written consent is available for review by the editorial office of this journal.

The patient was a 64-year-old woman (height: 143.5 cm; weight: 65.3 kg; G6P6; menopause at age 58). She was admitted with a 10-year history of anal and vaginal bulging. The patient reported chronic constipation but denied urinary incontinence. This patient experienced spontaneous bowel movements less than three times per week, accompanied by straining during defecation. These symptoms persisted for 5–10 years, and the diagnosis of constipation met the Rome IV criteria. The patient’s constipation symptoms showed no improvement with dietary modifications, and she did not undergo pelvic floor physical therapy or pharmacological management due to personal reasons. Pelvic Organ Prolapse Quantification (POP-Q) assessment revealed: Aa: 0, Ba: +3, C: −1, Gh: 6, Pb: 1.5, TVL: 7.5, Ap: −1, Bp: −1, D: −3. During Valsalva maneuver, rectal prolapse was observed with an 8-cm anterior wall protrusion and a 4-cm posterior wall protrusion beyond the anal verge. The prolapse was reducible in the supine position. On anal contraction, the anal canal admitted two fingers with markedly weak sphincter tone. Preoperative evaluation included pelvic floor ultrasonography, digital X-ray defecography, and pelvic magnetic resonance imaging (MRI) with dynamic pelvic floor imaging. Anorectal manometry indicated decreased rectal wall tone and sensory hypo-responsiveness, hypotonia of both internal and external sphincters, levator ani weakness, and pelvic floor relaxation. Preoperative MRI revealed the following findings: possible injury to the right puborectalis muscle and external anal sphincter, with thinning of the right iliococcygeus muscle; anterior compartment abnormality: bladder prolapse and urethral hypermobility; middle compartment abnormality: uterine prolapse and peritoneocele; posterior compartment abnormality: rectocele and laxity of the pelvic floor structures (Figure 1). Wexner Constipation Score: 15, the Pelvic Floor Impact Questionnaire-7 (PFIQ-7) Score: 66, the Pelvic Floor Distress Inventory-20 (PFDI-20) Total Score: 112.5 (POPDI-6: 25, CRADI-8: 62.5, UDI-6: 25). Vaginal ultrasound showed no significant abnormalities, and the patient expressed a desire for uterine preservation.

Figure 1 Preoperative magnetic resonance imaging.

Preoperative evaluation was conducted by a colorectal surgeon and urogynecologists. A multidisciplinary team discussion conducted by colorectal surgeons, urogynecologists, a radiologist and a sonographer was conducted preoperatively, and the initial surgical plan included: laparoscopic lateral suspension [uterus preservation, using a TiLOOP^® mesh (pfm medical, Cologne, Germany)], transvaginal partial anterior rectal wall resection and anastomosis for posterior vaginal wall prolapse, posterior vaginal wall repair, perineorrhaphy, and anal sphincter repair.

During the procedure, an enlarged and deeply recessed pouch of Douglas forming a hernial sac was observed, with the small intestine and rectum herniated into it. Given these findings, lateral suspension (with uterine preservation) combined with ventral mesh rectopexy was deemed to effectively correct the patient’s multi-compartment prolapse and enterocele, while avoiding simultaneous bowel resection and mesh implantation in the same operation, thereby reducing the risks of infection, mesh erosion, and anastomotic leakage. Consequently, the surgical approach was adjusted to laparoscopic lateral suspension (uterus preservation, using a TiLOOP^® Total4 mesh) combined with rectal prolapse suspension (ventral mesh rectopexy), posterior vaginal wall repair, perineorrhaphy, and anal sphincter reconstruction (Video 1). The surgery was performed jointly by gynecologists and colorectal surgeons.

Step-by-step description (Figure 2)

Figure 2 Key surgical steps.

The patient was placed in the lithotomy position. After satisfactory anesthesia, the surgical field was prepped and draped in a standard sterile fashion. A urinary catheter was inserted, and a cup-shaped uterine manipulator was placed. Pneumoperitoneum was established. A 10-mm trocar was placed 2 cm above the umbilicus for the video laparoscope. Four additional 5-mm trocars were inserted for surgical instruments, positioned as follows: at the junction of the lateral and middle thirds of the line connecting the left anterior superior iliac spine and the umbilicus, and at the corresponding symmetrical location on the right side; as well as slightly lateral to the midpoint of the line connecting the left lower abdominal trocar and the laparoscopic trocar, and at the symmetrical position on the right side. The patient was positioned in Trendelenburg, and the abdominopelvic cavity was explored.

The assistant used the uterine manipulator to gently elevate the uterus cranially. A circumferential incision was made at the bladder reflection of the uterovesical peritoneum, and the bladder was mobilized inferiorly to the level of the bladder trigone (Figure 2A).

The original dimensions of the TiLOOP^® Total4 mesh were 59 cm × 9.5 cm. The two wings (measuring 27 cm × 1.5 cm each) were trimmed and sutured to form a mesh approximately 27 cm × 3 cm in size for ventral mesh rectopexy, while the remaining portion was used for lateral suspension of the uterus (Figure 3). Mesh for lateral suspension was positioned over the upper anterior vaginal wall. It was secured with several sutures of 2-0 absorbable suture at the anterior vaginal wall and the cervico-uterine junction, while three additional sutures using non-absorbable material were placed to fix its superior edge to the cervico-uterine junction, ensuring the mesh lay flat against the vaginal wall without gaps (Figure 2B). Absorbable sutures were used to fix the mesh to the anterior vaginal wall. As the sutures dissolve over time, fibrous adhesion forms between the mesh and the tissue, minimizing the risk of mesh exposure even if the vaginal wall is penetrated. Additionally, several non-absorbable sutures were placed at the cervicouterine junction. The thicker tissue in this region reduces the likelihood of penetration and mesh exposure while providing more secure mesh fixation.

Figure 3 The TiLOOP^® Total4 mesh was trimmed and sutured for use in both lateral suspension and ventral mesh rectopexy.

Abdominal puncture sites were created 4 cm above and 3 cm lateral to the anterior superior iliac spine. A 0.5 cm incision was made, and a vascular clamp was inserted along the abdominal wall toward the round ligament (Figure 2C), passing through the broad ligament. Special attention should be paid to avoiding the external iliac vessels in this area. The mesh was then drawn through and exteriorized through the skin. The mesh should be deployed symmetrically and without tension. The uterus should be positioned correctly in its anatomical location, free of any tension, and well-centered within the pelvis (Figure 2D). The peritoneum overlying the bladder reflection was closed continuously.

The sigmoid colon was mobilized cranially and secured to the left lower abdominal wall. The peritoneum over the avascular area of the sacral promontory was incised, and the uterus was suspended to optimize the surgical field (Figure 2E). From the sacral promontory, a curvilinear inverted “J” incision was made along the right pararectal space down to the lowest point of the pouch of Douglas and then directed leftward. The loose tissue plane between the rectum and vagina was identified and dissected down to the lowest point of the rectovaginal septum (Figure 2F).

Mesh for ventral mesh rectopexy was continuously secured to the anterior rectal wall with barbed sutures, starting at the distal end of the rectum and limiting suture depth to the seromuscular layer (Figure 2G). The rectal hernia sac beneath the sacral ligament was closed. Non-absorbable sutures were used to fix the mesh to the avascular area of the sacral promontory (Figure 2H), and the peritoneum was closed.

The peritoneal depression over the bladder reflection was closed with purse-string absorbable sutures. Routine posterior vaginal wall repair, perineorrhaphy, and anal sphincter reconstruction were performed. In the abdominal portion of the procedure, an ultrasonic scalpel and a bipolar forceps were utilized. For the perineal phase, a high-frequency electrosurgical unit (monopolar) was employed.

Postoperative considerations and tasks

Postoperatively, the patient was kept nil per os, received intravenous fluids, and was given prophylactic antibiotics. She passed flatus on postoperative day 3 and gradually resumed a normal diet. At her first follow-up on postoperative day 17, she reported mild urgency but no fecal or urinary incontinence and denied other discomfort. Anatomical restoration was satisfactory. The patient’s preoperative Wexner constipation score was 15, which decreased to 3 postoperatively, indicating a clinically important difference. At the 6-month postoperative follow-up, the patient reported mild constipation, denied other discomfort, and demonstrated satisfactory anatomical restoration.

Tips and pearls

For complex POP involving multi-compartment defects, a multidisciplinary team approach is recommended. Compared with traditional perineal surgery, laparoscopic exploration provides a clear panoramic view of the intra-abdominal anatomy, such as revealing the retropubic hernia sac and the pouch of Douglas herniation in this patient—findings that should also be evident on MRI. This facilitates the development of a more tailored treatment plan.

Whether performing laparoscopic lateral suspension or ventral mesh rectopexy, it is essential to dissect along the correct tissue planes to minimize bleeding and tissue injury. Bladder dissection should extend down to the level of the trigone, and rectal dissection should reach the lowest point of the rectovaginal septum to ensure effective correction of the prolapse.

During laparoscopic lateral suspension, non-absorbable sutures are recommended to secure the upper edge of the mesh with several stitches at the cervico-uterine junction. In ventral mesh rectopexy, the mesh should be firmly anchored with non-absorbable sutures to the avascular area of the sacral promontory to prevent mesh loosening and reduce the risk of recurrence.

Discussion

Management concepts for multi-compartment POP

Historically, inadequate understanding of the interrelationships among pelvic structures often led to incomplete treatment of multi-compartment defects. Studies report failure rates as high as 58% when only a single compartment is repaired, with up to 33% of patients requiring reoperation for secondary compartment prolapse (2). When pelvic floor dysfunction manifests as multi-compartment prolapse, a comprehensive multi-compartment assessment is essential prior to planning surgical repair. Whenever feasible, addressing all compartment defects in a single procedure is recommended to avoid reoperation for missed or residual prolapse (1). This study presents a case of multi-compartment prolapse, for which a comprehensive preoperative evaluation was conducted, including detailed history-taking, specialized physical examination, and auxiliary investigations. Additionally, a multidisciplinary discussion involving radiology, ultrasonography, colorectal surgery, and urogynecology was held prior to surgery. However, this case also highlights that MRI findings may not always fully align with the patient’s clinical presentation, physical examination results, or the degree of prolapse. Further experience is needed to better analyze MRI data and enhance its utility in clinical assessment and treatment planning. Accurate patient selection, appropriate surgical planning, and highly skilled surgical technique are crucial for long-term patient outcomes, often necessitating collaboration between urogynecologists and colorectal surgeons.

Patient factors, including general health status (e.g., significant comorbidities), associated symptoms (e.g., constipation), and individual preferences (e.g., desire for uterine preservation, sexual function requirements, and acceptance of mesh use) should also be incorporated into surgical design. Beyond anatomical assessment using the POP-Q system, evaluation of treatment outcomes for POP should incorporate the PFDI-20 questionnaire, Wexner constipation score, and subjective measures of patient satisfaction.

Selection of surgical approaches

Given the current ban on transvaginal mesh-based pelvic floor reconstruction procedures in the United States and other countries, pelvic reconstruction via abdominal approach—particularly for multi-compartment defects involving rectal prolapse—encompasses the following categories, divided into two main types: procedures using synthetic mesh and those employing native tissue repair. Mesh-based procedures primarily include: rectopexy combined with sacrocolpopexy (3), ventral mesh rectopexy combined with sacrocolpopexy (4), laparoscopic sacrohysteropexy combined with ventral mesh rectopexy (5), and transvaginal mesh implantation combined with Delorme procedure (6). Native tissue repair includes: rectopexy (with or without sigmoid resection) combined with uterosacral ligament suspension or sacrospinous ligament fixation (7), Joel-Cohen vaginal hysterectomy combined with the Altemeier procedure (transperineal rectosigmoidectomy) (8), and colpocleisis (Lefort procedure) combined with Delorme procedure (9). The choice of surgical approach should be individualized. Some scholars propose that for frail patients at high risk of abdominal surgery, a transvaginal approach may be considered. (I) For healthy post-hysterectomy women with rectal prolapse and anterior or apical vaginal prolapse who are willing to consider mesh use, the preferred approach is ventral mesh rectopexy combined with sacrocolpopexy. (II) For healthy post-hysterectomy women with rectal prolapse and anterior or apical vaginal prolapse who decline mesh use, the primary options include suture rectopexy combined with native tissue vaginal suspension (such as uterosacral ligament suspension or sacrospinous ligament fixation) and/or anterior-posterior colporrhaphy. (III) For healthy post-hysterectomy women with constipation poorly controlled by laxatives and at risk of worsened constipation following rectal dissection, or those with sigmoid colon pathology (e.g., diverticulitis), sigmoid colectomy combined with rectopexy may be considered. If concurrent anterior or apical vaginal prolapse is present, native tissue vaginal suspension (such as uterosacral ligament suspension or sacrospinous ligament fixation and/or anterior-posterior colporrhaphy) should be chosen, avoiding simultaneous bowel resection and mesh implantation. (IV) For healthy women with concurrent rectal and vaginal prolapse who have not undergone hysterectomy, options include ventral mesh or suture rectopexy combined with either total hysterectomy and sacrocolpopexy, or supracervical hysterectomy with sacrocervicopexy, or uterine suspension (i.e., uterus-preserving suspension) (10,11). Reports on laparoscopic (ventral) mesh rectopexy combined with sacrocolpopexy described complications such as intestinal obstruction, lumbar osteomyelitis, hematoma, abscess, infection, and mesh-related complications (10), however, as surgeons have accumulated experience with the combined procedure technique, the incidence of complications and the reoperation rate for recurrent prolapse have declined. Regarding the use of single versus multiple mesh pieces in combined laparoscopic sacrocolpopexy and ventral rectopexy, as well as the techniques for mesh fixation to the anterior longitudinal ligament, no consensus exists; these decisions are often based on surgical preference and experience. Furthermore, no definitive data are available to guide the degree of tension adjustment. Current opinion generally holds that the rectal mesh should be placed without tension when the rectum is restored to its anatomical position. The vagina should be suspended with mild tension, avoiding excessive traction (10).

Laparoscopic ventral mesh rectopexy (LVR) involves anchoring the anterior wall of the lower rectum to the sacral promontory using a mesh. This procedure preserves the pelvic autonomic nerves and is associated with a low complication rate and a reduced incidence of postoperative constipation. It has become the preferred surgical approach for rectal prolapse in Europe and is also a primary technique in China. As a procedure for vaginal apex/uterine suspension, laparoscopic lateral suspension has been widely discussed in recent years. This technique avoids the presacral vascular area, offers straightforward execution, and has a short learning curve. Ewelina Malanowska-Jarema et al. reported that, based on linear regression analysis after 43 procedures, the learning curve for laparoscopic lateral suspension was shorter than that for laparoscopic sacrocolpopexy (operating time: 134.69 min) (12). Recent randomized controlled trials indicate that both sacrocolpopexy and lateral suspension are effective in treating apical prolapse. Furthermore, when uterine preservation is desired, lateral suspension demonstrates an advantage in reducing bladder descent (13,14). The patient in this study presented primarily with constipation. In addition to severe rectal prolapse, she exhibited significant anterior vaginal wall prolapse (cystocele) but mild uterine prolapse. Given her strong desire for uterine preservation, the combined approach of ventral mesh rectopexy with lateral suspension (with uterine preservation) was considered highly appropriate. If sacrohysteropexy were performed with uterine preservation, the mesh would need to pass through both broad ligaments and extend posteriorly to the sacrum. This not only increases surgical complexity and risks but also introduces additional mesh in the presacral area, potentially elevating the risks of mesh erosion, infection, and low back pain. Furthermore, in sacrocolpopexy, the mesh must pass beneath the uterosacral ligaments, where the pelvic splanchnic nerves are closely associated, which may increase the risk of postoperative refractory constipation. In contrast, lateral suspension with uterine preservation is technically simpler than sacrohysteropexy, reduces mesh usage in the presacral area, and maintains an appropriate degree of independence between the posterior vaginal wall and the rectum, thus minimizing the risk of postoperative constipation associated with surgical dissection, and offers greater advantages in reducing bladder descent. Moreover, the main concern regarding lateral suspension—its potential limitation in addressing posterior compartment defects—was effectively resolved in this case through ventral mesh rectopexy. Therefore, even when presacral dissection is necessary, lateral suspension remained advantageous for this patient. Additionally, the surgical approach, which preserved the uterus and involved suturing only at the rectal seromuscular layer, minimized the risk of mesh erosion. The mesh implantation was performed entirely via laparoscopic abdominal surgery, further reducing the risks of infection and vaginal discomfort. To our knowledge, this is the first reported case utilizing the combination of laparoscopic lateral suspension with ventral mesh rectopexy for the treatment of multi-compartment POP involving the rectum, anterior vaginal wall, and uterus. The short-term outcomes were satisfactory, although long-term efficacy requires further follow-up.

Conclusions

With the aging of the population, the importance of POP surgery within the field of gynecology continues to grow. Given the interconnected nature of pelvic structures and the relative complexity of diagnosing and treating multi-compartment POP, urologists, gynecologists, and colorectal surgeons should enhance collaboration. A comprehensive assessment of the condition should be conducted, and appropriate surgical approaches should be formulated based on the extent of prolapse, patient symptoms, and individual needs. By accumulating surgical experience and refining techniques, combined procedures can comprehensively address multi-compartment defects, while striving to reduce the incidence of surgical complications and the rate of prolapse recurrence.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the SUPER reporting checklist. Available at https://gpm.amegroups.com/article/view/10.21037/gpm-2025-1-63/rc

Peer Review File: Available at https://gpm.amegroups.com/article/view/10.21037/gpm-2025-1-63/prf

Funding: This study was supported by the National Key Research and Development Program of China (No. 2021YFC2009100), and the National Natural Science Foundation of China (No. 82571879).

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://gpm.amegroups.com/article/view/10.21037/gpm-2025-1-63/coif). X.N. serves as an unpaid Executive Editor-in-Chief of Gynecology and Pelvic Medicine from May 2018 to May 2028. The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Ethics Committee of West China Second University Hospital, Sichuan University (No. 2022207), and informed consent was obtained from the patient for the publication of this article, the accompanying images and video. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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