Pelvic Organ Prolapse (POP) is the gradual descend of the pelvic structures from its normal anatomical positions to bulge into the vaginal cavity (1–3). This mainly occurs due to a progressive weakening in the pelvic ligaments with a subsequent loss of the apical support (4). The last is thought to predominantly cause anterior and middle compartment prolapse, but also could contribute to a lesser extent to the pathophysiology of the posterior prolapse (5). POP is a common condition affecting about 30.8% of women in the outpatient setting (6). Despite its wide prevalence, it only becomes symptomatic in 2%–3% of patients (7). The incidence of POP surgery peaks in the sixth decade of life, and ranges between 1.5–1.8 per 1,000 women (7, 8). However, with the increase in the living expectancy, it is expected that the number of women with POP and those seeking surgery for POP would increase within the next 20–40 years (9). Patients with symptomatic POP often complain from the sensation of a mass bulging into the vagina, urinary or fecal incontinence, and discomfort during sexual intercourse (10). The consequences of POP extend further to negatively affect the patient's body image and sexuality (11, 12).

Although POP was treated traditionally with hysterectomy (13), there are nowadays more than 40 surgical procedures to restore the normal pelvic anatomy (14). Nevertheless, hysterectomy is not among them anymore because the uterus itself is only a passive structure that has no effect on the prolapse occurrence (15, 16). Sacrocolpopexy was first described in 1957 as attaching the uterus to the sacrum to restore the normal vaginal axis (17). It is now considered the treatment of choice for POP (18, 19), despite the lack of a standardization for this procedure. Currently, laparoscopic sacrocolpopexy is heavily favored over the open approach owing to the comparable outcomes and decreased postoperative morbidity associated with the laparoscopic intervention (19). Another alternative for laparoscopic sacrocolpopexy is laparoscopic colpopectopexy, since it was proven to have comparable outcomes and less postoperative complications compared to sacrocolpopexy (20). One factor that increased the popularity of laparoscopic colpopexy approaches is the ban of transvaginal meshes for POP treatment in April 2019 by the Food and Drug Administration (FDA) due to safety concerns (21). Although the application of surgical meshes seems a safer alternative, a recent study demonstrated that the long-term complications rate of abdominal meshes is around 7%. Those may include pain, dyspareunia, mesh erosion, and small bowel ischemia in some severe cases (22). In light of these events, efforts are being made to eliminate the use of synthetic prostheses (23), or at least to promote the use of lightweight meshes in POP repair surgeries. Therefore, we aim by this paper to describe a modified technique for laparoscopic colpopexy with the use of a double-ended Mersilene suture for the purpose of utero-cervical suspension, and to report the preliminary data of patients who underwent this surgery.

A total of 36 patients met the inclusion criteria and provided consent to participate in this study. About one third of the sample (30.5%) fell in the age range 46–55 years. 16 out of 36 patients (44.4%) were postmenopausal. Table 1 demonstrates the patients’ distribution among different age groups. In our series, 10 patients (27.7%) had a previous repair of rectocele, 8 patients (22.2%) had a previous repair of cystocele and 3 patients (8.3%) had prior colposuspension with mesh. There were only 14 patients (38.8%) who did not have a previous POP surgery. 3 patients (8.3%) with prior mesh colposuspension had recurrence. It occurred after 2 years in 1 patient following childbirth, and after 7 and 10 years in the remaining two patients. Upon clinical examination, all patients had a reducible vaginal lump. Urinary incontinence was observed in 34.15% of cases. Sexual dysfunction was reported by two thirds of the patients (60.61%) and dyspareunia was reported by 41.84% of them.

The modified sacrocolpopexy was performed in 25 patients (69.4%) and the modified colpopectopexy was performed in 11 patients (30.5%). Treatment of cystocele and rectocele using native tissue repair by polypropylene sutures were performed laparoscopically in all cases, besides the modified sacrocolpopexy and colpopectopexy. Table 2 demonstrates the performed procedures. No intraoperative complications were reported, in terms of bowel or bladder injury. Only one patient had a postoperative persistent urinary retention. She was treated with intermittent catheterization for 2 weeks and bladder tonics for a period of 3 months. Thereafter, the bladder shrinkage was reduced and the compartmentalization had disappeared. Erosion or infection were not reported postoperatively by any patient. The mean follow-up time was 3 years, and ranged between 7 months and 5 years.

In this study, we have provided evidence that using a Mersilene suture could be a safe alternative to synthetic meshes in the laparoscopic management of pelvic organ prolapse. The intraoperative complications rate was 0% and only one patient reported urinary retention postoperatively (2.7%). This condition was successfully treated medically. It is noteworthy that major postoperative complications such as erosion, infection, and pelvic pain were not reported by any patient. This is thought to further justify our hypothesis that the presented modified techniques are an alternative to mesh-based sacrocolpopexy and colpopectopexy. Although it is too early to draw conclusions, our sample indicates that these procedures could be helpful for patients with recurrent POP, since the majority of the sample had a previous prolapse surgery. Despite the promising results, it should be noted that this technique could be a feasible but not an easy-to-learn alternative to the traditional approaches. This is mainly attributed to the fact that the dissection of the promontory, pararectal and bladder regions are still needed. Therefore, the same inherent risks of sacrocolpopexy and colpopectopexy should be accounted for. Another drawback of this technique could be the large size of the Mersilene suture, which may hardens its introduction to the abdominal cavity. However, we believe that attaching the Mersilene suture to the cervical and pre-cervical regions is easier and more straightforward than the fixation of traditional meshes to the cervix and upper part of the vagina. On this basis, it is reasonable to postulate that the learning curve of this technique would be higher than the traditional ones. Nevertheless, high suturing skills and precise anatomical knowledge are definitely required for a safe surgery. Of note, a previous study has demonstrated that a surgeon needs to perform 60 laparoscopic sacrocolpopexy to ensure good outcomes and minimal complications rates (25).

The main aim of our modification is promoting native tissue repair and taking a step forward towards a “meshless” pelvic reconstructive surgery. Mesh-based POP surgeries are widely implicated with favorable outcomes, but the short- and long-term mesh-related complications could be the major drawback and a safety concern regarding the use of these prosthetic materials. A recent analysis demonstrated that the complications rate of heavy meshes is 18.8%, which is significantly higher than that of lightweight meshes (2.1%) (22). It is reasonable to consider the use of lightweight meshes instead of the heavier ones, especially when knowing that the recurrence rates were comparable between the two products. However, it should be noted that those complications are serious and worth consideration, especially the ureteric mesh erosion (22). In a different series reporting on the mesh-related complications after the uphold procedure, the erosion and pelvic pain rates were 4% and 5% respectively (26). Another long-term follow up study demonstrated that the 24-month urinary retention rate related to mesh inlay was 2.5% and vaginal adhesions occurred in 1.2% (27). Hospitalization due to mesh-related complications occurred in 7.1% of the followed patients (27). It is already established that some risk factors increase further the risk of vaginal mesh erosion, such as smoking and performing a concomitant total hysterectomy (28). In spite of the protective advantage of supracervical hysterectomy against mesh erosion (29), this procedure could not be always indicated. Therefore, it is quite obvious that the application of abdominal meshes carries inherent risks due to the prosthetic nature of these grafts.

Laparoscopic sacrocolpopexy remains the golden standard for POP surgery (30), as it was reported to carry favorable results in terms of restoring the anterior and middle compartments (31). In their study, Campagna et al. reported that patients undergoing high uterosacral ligament suspension are at 6 times higher risk of prolapse recurrence compared to those who had laparoscopic sacrocolpopexy (8). Similarly, Maher et al. (14) found that vaginal suspension carries an increased risk of subjective failure in comparison with sacrocolpopexy. On the other hand, one randomized controlled trial has demonstrated that both laparoscopic sacrocolpopexy and colpopectopexy carry the same postoperative outcomes in terms of anterior, apical, and posterior objective failure rates (20, 32). It is noteworthy that de novo constipation was significantly more reported by patients receiving sacrocolpopexy (20). In another randomized controlled trial comparing sacrocolpopexy to sacrospinous hysteropexy, Van IJsselmuiden et al. (33) found comparable composite success, anatomical and surgical failure rates between the two groups. However, patients who had sacrocolpopexy reported significantly more fecal incontinence compared to the other study group. Bothersome over-active bladder symptoms were also more frequent among patient receiving sacrocolpopexy (33). Those urinary and fecal complications are thought to result from the presacral and pararectal dissection and a subsequent injury to the hypogastric nerves (34, 35). However, it is not clear whether the mesh-associated fibrosis could contribute to those dysfunctions.

Another feasible approach could be the uterosacral ligaments suspension. Some reports showed promising results of this technique when applied laparoscopically or by vaginal natural transluminal endoscopic surgery (36–38).

Moreover, some authors reported the use of the semitendinosus tendon for uterine suspension in sacrocolpopexy and colpopectopexy. This approach sheds light on the use of autologous materials in POP surgery but it is not studied sufficiently yet (39).

Our study has many limitations that should be accounted for. The sample size is small and the follow up period differed among patients. We did not include a control arm to test the differences between the modified and original procedures. In addition, this study was conducted in a tertiary care centre, which makes our sample prone to selection bias. Additionally, some important variables like the timing of surgery, blood loss, and postoperative pain are missing due to the retrospective design of this study. All surgical procedures were performed by the same surgeon. Although it is believed that this would improve the internal validity of this research, it limits its generalizability by making the outcomes and complications rate questionable when this technique is performed by less experienced surgeons, like residents or general gynecologists. On the other hand, the main strength of this research is introducing a new use of the Mersilene suture and highlighting the potential positive outcomes of replacing synthetic meshes with it. Finally, we need to emphasize the fact that this is a pilot study and it is early to draw conclusions about the effectiveness of this technique or recommend standardizing it instead of the current practices. Although our results are promising, future research should consider the differences in operation times, short and long term outcomes and complication rates between the traditional mesh-based surgeries and the Mersilene modified approaches through larger cohort studies and clinical trials.

The modified technique of sacrocolpopexy and colpopectopexy using a Mersilene suture seems to be a safe alternative to mesh-based pelvic prolapse surgeries. Intraoperative complications were absent and the follow up outcomes were favorable. Future research should investigate the safety, efficacy and the learning curve associated with this modified approach.