A Novel Approach for Apical Prolapsus Surgery: Mesh-less Pectopexy

Objectives: Cooper’s ligament (iliopectineal ligament) is stronger than the sacrospinous ligament or arcus tendinous of the pelvic fascia. Pectopexy is a surgical technique that has recently developed as a simple and efficient procedure for the treatment of apical prolapse, especially for patients who have high body mass index or with previous pelvic surgeries which could make presacral dissection difficult. Most commonly, pectopexy is performed by using a polypropylene mesh, however, some surgeons are cautious about the use of synthetic meshes in pelvic organ prolapse (POP) surgery. Therefore, alternative methods to replace synthetic meshes should be investigated. Here we describe a novel approach to pectopexy without using mesh.

Methods: In this video presentation, we wanted to describe mesh-less pectopexy step by step, outline the important anatomic landmarks, and emphasize potential hemostatic challenges that can happen. Our patient was a 45-year-old lady G2P2 with stage 3 apical prolapse according to POP-Q classification without accompanying anterior or posterior defect and she desired her uterus to be preserved. First, we dissected the vesicouterine fold to open the anterior of the cervix. Then the paravesical space was opened between the round and medial umbilical ligaments to reach Cooper’s ligament. The proximity of corona mortis is clearly defined to be cautious during suturing. A non-absorbable, size 1 suture passed through Cooper’s ligament at the level approximately corresponds to S2, ipsilateral round ligament, and cervix respectively. Then suture progressed to imbricate the vesicouterine peritoneum. After completing the same technic on the other side, we tested the anatomy of the uterus regarding asymmetry and the level of correction.

Clinical Relevance: Pectopexy constitutes a promising approach in POP surgery with the advantages of having a wide area for a surgeon to operate in the pelvis, being one of the strongest ligaments in the pelvic floor, and being away from the ureter, intestines, and presacral arteries and veins. Eliminating the use of mesh can be a novel approach to this surgical technique, especially for those who have concerns about using mesh.