Laxity of the anterior vaginal wall leads to the funnelling of the bladder neck and triggering inappropriate micturition reflexes and thus might lead to urinary incontinence. In the upright body position the anatomical support of the anterior vaginal wall (on which urethra and bladder base rest) is mainly ensured by the cervix / uterus, thus an intact apical suspension is mandatory. Thereby, the uterosacral ligaments (USL) play a major role. 
Laparoscopic surgery has advantages for the patient - avoiding of large open incisions, thus a decreasing blood loss and recovery period, as well as early mobilization. We modified the open abdominal cervicosacropexy surgical technique and transferred it into a laparoscopic approach.
In this study we compare clinical outcomes on urinary incontinence and apical fixation between open abdominal and laparoscopic USL replacement using polyvinylidene-fluoride tapes at 1-year follow-up.

Retrospective analysis in a tertiary center of women with POP-Q stages I-IV and urinary incontinence. All patients received a bilateral uterosacral ligament replacement using polyvinylidene-fluoride tapes (PVDF) either open abdominal cervicosacropexy or laparoscopic cervicosacropexy. These PVDF tapes were identical in shape, that is a width of 0.4cm and a length of 8.8cm and fixed between the cut surface of the cervix and within the run of both USL either S2 (in case of open abdominal approach) and S1 (in case of laparoscopic approach) (Table 1). 
Clinical outcome was assessed at 4 and 12 months, pelvic organ prolapse was done according to the POP-Q system. Furthermore, UI was determined on the basis of their subjective complaints rather than by urodynamic studies and urinary incontinence symptoms were assessed with validated questionnaires (ICIQ-SF). The primary outcome measure was defined as the restoration of apical fixation, which was defined as apical POP-Q stage 0 at one year after surgery. The secondary outcome measure was the restitution of urinary continence.

145 patients were evaluable, 75 patients were operated with the abdominal, 70 patients with the laparoscopical approach. No major complications occurred intraoperatively and no mesh erosions were detected within 1-year postoperatively. There was no significant difference in clinical outcome one year after surgeries. Apical support (POP-Q stage 0) was restored in 100% of patients and urinary continence restored in 59% of patients (59% after laparotomy vs 62% after laparoscopy, respectively). After laparoscopic cervicosacropexy, patients stayed 3 days in mean (range of 1 - 5 days) compared to 6 days after open abdominal cervicosacropexy (range of 5 - 8 days). Regarding the operating time, a cervicosacropexy lasted in mean 126 minutes (range of 89 - 191 minutes), whereas a laparoscopic cervicosacropexy lasted in mean 84 minutes (range of 58 - 151 minutes).

Both USL were augmented with a minimum amount of synthetic material, either open abdominal or laparoscopically. Although, the level of fixation at the sacral vertebra (S2 vs. S1) differed between both surgical techniques, no significant differences in clinical outcome were found. Patients operated laparoscopically had shorter operating time, shorter hospital stay, and faster recovery compared to patients operated open abdominally.

The re-strengthening (“tensioning”) of the anterior vaginal wall and, hence, its vesico-urethral junction, led to an anatomical restoration and an improvement of urinary incontinence symptoms. Thereby, the level of fixation at the sacral vertebra did not influence the clinical outcome significantly. The shorter operating time and faster recovery with no major intraoperative complications favor the laparoscopic surgical technique.

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Rexhepi S, Rexhepi E, Stumm M, Mallmann P, Ludwig S. Laparoscopic Bilateral Cervicosacropexy and Vaginosacropexy: New Surgical Treatment Option in Women with Pelvic Organ Prolapse and Urinary Incontinence. J Endourol. 2018;32(11):1058-64.
Ludwig S, Morgenstern B, Mallmann P, Jager W. Laparoscopic bilateral cervicosacropexy: introduction to a new tunneling technique. Int Urogynecol J. 2019;30(7):1215-7.