Symptomatic pelvic organ prolapse (POP) also affects younger women. If conservative therapies fail, reconstructive surgical therapies come into question, which depends on several factors. In addition to the correction of the affected anatomical structures, the patient's desire or preference with regard to uterine preservation and desire for fertility preservation must also be taken into account.
In the last 2 decades, attitudes toward and interest in uterus-preserving POP surgery have increasingly changed. There are a variety of uterus-preserving surgical options, but few publications on subsequent pregnancy. Uterus-preserving procedures have the advantage of significantly shorter operative time, less blood loss, as well as faster recovery and the possibility of fertility preservation. 
So far, there is also no clear consensus on a uniform surgical procedure in terms of standardization of individual surgical steps for better comparability of clinical outcomes. 

For the first time, we present a uterus-preserving surgical technique with a bilateral apical suspension (replacement of both uterosacral ligaments, USL) in a step-by-step standardized surgical technique with a minimum amount of synthetic material.

Women with symptomatic uterine prolapse were referred to our tertiary unit and were included in this pilot study. These patients have failed or declined conservative management; none of them had undergone previous urogynecological surgery.
For the laparoscopic uterosacropexy, both USLs were replaced with a tape-like synthetic structure made of polyvinylindene-fluoride (PVDF) (Fig. 1). These tapes of defined length (9 cm) and width (0.4 cm) were retroperitoneally implanted within the run of both USL under preservation of the integrity of the peritoneum by using a semi-circular tunneler.

Apical support was restored in all 15 patients (mean age: 41 years), as well as urinary continence (in all 6 patients with prior mixed urinary incontinence). No intraoperative complications occurred (vessel or ureter injury and bowel or bladder lesions). Blood loss was less than 30 mL per patient, and the mean operation time was 56 minutes. Over a mean follow-up period of 24 months, no mesh erosions or relapse of prolapse was detected. One patient became pregnant and was delivered by cesarean section in the 39th week without complications. Also the 1-year follow-up showed an anatomically good result.

This laparoscopic bilateral uterosacropexy represents one alternative treatment option for uterus-preserving standardized apical reconstruction in premenopausal patients, which is based on anatomic structures and bilateral suspension. This uterosacropexy also offers the advantage of fertility preservation in addition to shorter surgical time, low blood loss, and faster convalescence. This clearly defined surgical technique leads to a better comparability of clinical outcomes.

To date, there are only 8 case series in the literature of reported pregnancies after unilateral hysteropexy. However, there is no described case of bilateral uterosacropexy with subsequent successful pregnancy. Nevertheless, further studies need to provide long-term data on anatomic recurrence, and in the case of subsequent pregnancy, especially on the risk of intrapartum complications as well as postpartum anatomic recurrence.

Laparoscopic bilateral cervicosacropexy: introduction to a new tunneling technique. 	Ludwig S, Morgenstern B, Mallmann P, Jäger W  Int Urogynecoll J, doi:10.1007/s00192-019-03911-2
Laparoscopic Bilateral Cervicosacropexy and Vaginosacropexy: New Surgical Treatment Option in Women with Pelvic Organ Prolapse and Urinary Incontinence. 	Rexhepi S, Rexhepi E, Stumm M, Mallmann P, Ludwig S Journal of Endourology, 2018 Nov;32(11):1058-1064