Int Urogynecol J (2017) 28:231–239
DOI 10.1007/s00192-016-3093-6
ORIGINAL ARTICLE
Complications and reoperations after laparoscopic
sacrocolpopexy with a mean follow-up of 4 years
David Vandendriessche 1 & Julie Sussfeld 1 & Géraldine Giraudet 1 & Jean-Philippe Lucot 1 &
Hélène Behal 2 & Michel Cosson 1
Received: 9 May 2016 / Accepted: 1 July 2016 / Published online: 22 August 2016
# The International Urogynecological Association 2016
Abstract
Introduction and hypothesis There is a lack of knowledge
concerning long-term reoperation and complications after lap-
aroscopic sacrocolpopexy (LSCP). We analyzed the rates and
indications and potential risk factors for reoperation after
LSCP in a large series of consecutive patients.
Methods This was a single-center, retrospective study includ-
ing all patients who underwent LSCP between 2003 and 2013.
Data regarding pelvic organ prolapse (POP), surgical modal-
ities and perioperative complications were collected. Patients
were then contacted by telephone or postal letter in 2014. The
main outcome criteria were grade III Dindo classification
complications: reoperation for POP recurrence, mesh compli-
cations, and urinary incontinence (UI).
Results Between January 2003 and December 2013, a total of
464 consecutive patients (mean age, 59 years) underwent
LSCP. Almost all (99.1 %) patients presented with POP ≥
grade 3 (POP-Q classification). Long-term evaluations were
completed for 391 (84.1 %) patients. The median follow-up
was 53.5 ± 28.2 months. The global reoperation rate was
12.5 %. The main reoperation indications were UI-related
surgery in 21 patients (5.5 %), POP recurrence surgery in 20
patients (5.1 %), and mesh-related surgery in 11 patients
(2.8 %). Multivariate analysis showed that older age at the
time of initial surgery and concomitant subtotal hysterectomy
were significant protective factors against global reoperation
* David Vandendriessche
vdddv@live.fr
1
Gynecological Surgery Unit, Jeanne de Flandre Hospital, University
Hospital of Lille, Lille, France
2
Methodology and Biostatistics Unit, EA2694, UDSL2, University
Lille Nord de France, University Hospital of Lille, Lille, France
(HR = 0.606, CI 95 % [0.451–0.815] and 0.367, CI 95 %
[0.193–0.698] respectively) and reduced the risk of POP re-
currence surgery.
Conclusion Prolapse recurrence and mesh-related surgery oc-
curred in 5.1 and 2.8 % of patients respectively, 4 years after
laparoscopic sacrocolpopexy. Age and concomitant subtotal
hysterectomy could play a role in the incidence of long-term
reoperation.
Keywords Prolapse . Laparoscopic sacrocolpopexy .
Complication . Reoperation . Long term
Abbreviations
POP Pelvic organs prolapse
POP-QS Pelvic organs prolapse quantification system
LSCP Laparoscopic sacrocolpopexy
UI Urinary incontinence
GR Global reoperation
PRR Prolapse recurrence reoperation
Introduction
Pelvic organ prolapse (POP) treatment is widely based on
surgical techniques, via the vaginal or abdominal route, and
involves native tissue repair or mesh use. Laparoscopic
sacrocolpopexy (LSCP) is a recently developed, gold-
standard surgery for POP repair. Its technical feasibility, peri-
operative safety and short-term efficiency are widely docu-
mented. Medium-term studies report a high anatomical suc-
cess rate (77–98 %) at 1–2 years’ follow-up [1–4]. However,
there are lack of data regarding long-term changes, prolapse
recurrence rates, and complication rates after LSCP. Long-
term mesh-related complications are not precisely estimated,
232
although there is currently vigorous debate regarding the use
of prosthetic material in vaginal or abdominal POP surgery.
Studies are limited in terms of population size and duration of
follow-up, with a predominance of only small or retrospective
studies limited to 5 years’ follow-up [5–7]. This study thus
focuses on the long-term reoperation and complication rates
after LSCP and explores the potential risk factors for reoper-
ation in a large retrospective cohort.
Materials and methods
Study design
This was a retrospective cohort study of consecutive patients
who underwent LSCP for POP repair between January 2003
and December 2013 in the Department of Gynecological
Surgery in Jeanne de Flandre Hospital (Lille University
Hospital), a major tertiary unit in northern France. Exclusion
criteria were when the first intention was to treat with abdom-
inal (i.e., by laparotomy) sacrocolpopexy and conversion to
laparotomy or vaginal surgery during LSCP. The study proto-
col was approved by the Institutional Review Board of the
French College of Obstetricians and Gynecologists
(#CEROG-2014-GYN-0903).
Surgical procedure
The LSCP procedure was performed as described by Wattiez
and Cosson [8, 9]. Briefly, pneumoperitoneum was
established with a Veress needle. A 10-mm transumbilical
trocar was used for a laparoscope, two 5-mm iliac trocars
and one 10-mm suprapubic trocar were inserted. Additional
procedures such as hysterectomy and/or annexectomy were
performed first. Then, peritoneum overlying the sacrum was
opened and the anterior longitudinal sacral ligament was ex-
posed. Vaginal fornices were dissected by mobilizing the blad-
der anteriorly and the rectum posteriorly, thanks to a curved
metal vaginal manipulator. Anteriorly, dissection reached the
bladder trigone, and posteriorly, the levator ani muscles were
exposed. Anterior and posterior meshes were sutured to the
vaginal wall using absorbable sutures, with a digital control to
avoid transfixing the vagina and to control the level of dissec-
tion. In the case of uterine conservation, the anterior strip
crossed through the right broad ligament before reaching the
promontory. In the case of subtotal hysterectomy, meshes
were fixed onto the cervix using nonresorbable metal tackers.
Two permanent sutures were placed in the anterior sacral lig-
ament to suspend the mesh. Tension was applied with extra-
abdominal knots and checked by the surgeon. The peritoneum
was then closed over the meshes using a continuous
nonlocking suture. During the study period, the surgical tech-
nique was gradually modified, especially concerning the type
Int Urogynecol J (2017) 28:231–239
of mesh used (polyester was progressively replaced by poly-
propylene), and with regard to mesh fixation. Notably, a pos-
terior mesh has usually been fixed in the levator ani muscle
with the use of tackers in recent years, and a single suture is
placed in the sacral ligament to suspend the meshes.
Data collection
Patient demographic and medical data were extracted from elec-
tronic hospital medical files. Preoperative assessments included
histories and physical examinations. Pelvic organ prolapse
(POP) was graded according to a simplified version of the
International Continence Society (ICS) POP-Q classification.
Stress urinary incontinence (SUI) was evaluated by an interrog-
atory and cough test after prolapse reduction in patients with
occult urinary incontinence. Urodynamic evaluations were per-
formed in cases of associated urge symptoms and/or inconti-
nence (UUI). In patients with constipation and/or dyschesia,
gastroenterological explorations, including dynamic MRI,
defecography and anorectal manometry, were added. After mul-
tidisciplinary consultation, concomitant rectopexy was proposed
in the case of established severe rectal prolapse. Significant
peroperative (organ injuries and hemorrhage) and early postop-
erative complications (hemorrhage, infection or early reopera-
tion before hospital discharge) were noted. Short-term anatom-
ical results were observed at 3 months after surgery. Anatomical
failure was defined as POP ≥ grade 2 (POP-Q classification) in
at least one compartment.
Information concerning long-term reoperation was pro-
spectively collected from November to December 2014.
Patients who refused to participate were excluded from the
long-term evaluation. Patients were telephoned to determine
if they had undergone any new surgeries in other hospitals to
limit misinterpretations of the reoperation rate. Patients who
were unreachable by phone were sent a postal questionnaire.
The following information was requested: the existence of
complications and/or the need for reoperation, indications
for and timing of reoperation, name of the hospital where
reoperation occurred, and the presence of POP symptoms.
Operative reports were collected and analyzed to determine
the precise indications for and nature of each reoperation.
The main outcome criterion was grade III complications,
according to the Dindo modified classification (i.e., complica-
tions requiring an invasive procedure and hospitalization).
Additional outcomes of interest included prolapse recurrence
reoperation (PRR), mesh complications (i.e., suburethral
slings and/or mesh prolapse), urinary incontinence, and other
gynecological indications.
Statistical analysis
Quantitative variables are expressed as mean (standard devia-
tion) in the case of normal distribution or median (interquartile
Int Urogynecol J (2017) 28:231–239 233

range) otherwise. The normality of distributions was checked Table 1 Baseline characteristics of the study population
graphically and using the Shapiro–Wilk test. Qualitative var- Overall, N = 464
iables are expressed as number (percentage). Risks for reop-
eration for any indications (global reoperation) and for each Demographics and clinical history
main indication (prolapse recurrence, mesh complications, Age, years, mean ± SD 51.9 ± 8.3
urinary incontinence) were estimated using the Kaplan– BMI, kg/m2, mean ± SD 25.0 ± 4.0
Meier method. We assessed the association of the main risk Number of pregnancies, median (range) 2.8 (0–10)
factors with the risk of global reoperation using univariate Menopause 210 (45.0)
Cox proportional hazard regression models. Proportional haz- Hormonal substitutive treatment 14 (3.0)
ards assumption for each risk factor was checked by plotting Active smoking 44 (9.5)
the Schoenfeld residuals against the rank of survival time. For Diabetes mellitus 26 (5.6)
continuous risk factors, the log-linearity assumption was History of hysterectomy 49 (10.6)
checked using Martingale residuals. Risk factors associated History of POP surgery 63 (13.6)
with global reoperation in the bivariate analysis (p < 0.10) History of UI surgery 50 (10.8)
were introduced into the multivariate Cox proportional hazard Clinical examination
regression model. A similar approach was used to assess the High prolapse grades (POP-Q ≥3)
independent predictors of reoperation for prolapse recurrence. At least one vaginal compartment 460 (99.1)
Statistical testing was carried out at the two-tailed level of All three vaginal compartments 169 (36.4)
0.05. Data were analyzed using the SAS software package, Presence of rectal prolapse 31 (6.7)
version 9.3 (SAS Institute, Cary, NC, USA). Preoperative UI 233 (50.2)
Operative management
Uterine conservation 121 (26.1)
Results Concomitant hysterectomy 294 (63.3)
Subtotal/total type 288 (62.1)/6 (1, 3)
Between January 2003 and December 2013, a total of 492 Concomitant UI surgery 50 (10.8)
patients underwent LSCP for pelvic organ prolapse repair.
Concomitant rectopexy 29 (6.3)
Twenty-eight patients (5.7 %) were excluded because of con-
Polyester/polypropylene mesh 157 (33.8)/307 (66.2)
version to abdominal sacrocolpopexy in 22 patients (4.4 %),
Senior/junior surgeon 363 (78.2)/101 (21.8)
to vaginal surgery in 2 patients (0.4 %), and to the Kapanjii–
Peroperative complication
Dubuisson procedure in 4 patients (0.8 %). Thus, 464 patients
At least one event 21 (4.5)
constituted the study population. Baseline characteristics are
Bladder perforation 9 (1.9)
presented in Table 1. The mean age at the time of intervention
Vaginal perforation 7 (1.5)
was 51.9 ± 8.3 years; 210 patients (45.1 %) were menopausal,
Epigastric vessels injury 5 (1.1)
49 patients (10.6 %) had a history of previous hysterectomy,
and 63 patients (13.6 %) had already undergone surgery for Values are number (percentages) unless otherwise indicated
POP repair. High-grade POP was the most common operative BMI body mass index, LSCP laparoscopic sacrocolpopexy, POP pelvic
indication, with 460 patients (99.1 %) presenting with POP-Q organ prolapse, POP-Q pelvic organ prolapse quantification system, SD
≥ grade 3 in at least one vaginal compartment. The anterior standard deviation, UI urinary incontinence
vaginal compartment was affected in 369 patients (79.5 %),
the apical compartment in 358 patients (77.1 %), and the pos- (5 patients) or cervical elongation (1 patient). UI surgery was
terior compartment in 245 patients (53.8 %). Complete pro- added in 50 patients (10.8 %). Significant perioperative com-
lapse (POP-Q ≥ grade 3 in three compartments) was diag- plications occurred in 21 patients (4.5 %) and required reop-
nosed in 169 patients (36.4 %), 233 patients (50.1 %) also eration, including bladder perforation (9 patients, 1.9 %), vag-
complained of preoperative urinary incontinence (UI) symp- inal perforation (7 patients, 1.5 %), and epigastric vessel injury
toms, and 31 patients (6.7 %) complained of rectal prolapse. (5 patients, 1.1 %). One patient received a blood transfusion,
The surgical procedure was performed by senior surgeons which was related to hemoperitoneum, after injury to the epi-
(i.e., gynecological surgeons who had performed at least 30 gastric vessels.
previous LSCP procedures) in 363 patients (78.2 %). The Follow-up was performed in 397 patients; 359 were
initial intervention included simultaneous anterior and poste- contacted by telephone, and 38 were contacted by postal ques-
rior colpopexy in 445 patients (95.1 %). Concomitant hyster- tionnaire. Six patients were excluded from long-term reoper-
ectomy was performed in 294 patients (63.3 %), and a subtotal ation analysis (5 refusals to participate, 1 death). Information
hysterectomy was performed in 288 patients (62.1 %). about potential reoperations was thus available for 391 of the
Indications for total hysterectomy included cervical dysplasia 464 patients (84.2 %). There was no significant difference
234 Int Urogynecol J (2017) 28:231–239

between the responsive and nonresponsive patients with re-
gard to baseline characteristics or surgical parameters, includ-
ing age (p = 0.05), BMI (p = 0.98), menopause rate (p = 0.12),
POP-Q ≥3 rate (p = 0.75), complete prolapse rate (p = 0.46),
history of hysterectomy (p = 0.85), history of POP surgery
(p = 0.17), concomitant hysterectomy rate (p = 0.26), concom-
itant UI surgery rate (p = 0.15), and perioperative complica-
tion rate (p = 0.39). Information regarding reoperation is pre-
sented in Table 2, and Kaplan–Meier reoperation curves are
presented in Fig. 1. The mean follow-up was 53.5 ±
28.2 months. The global reoperation (GR) rate was 12.5 %
(49 patients) and consisted of UI-related reoperations in 5.3 %
(21 patients, with mean interval of 23.3 ± 16.3 months: 18
interventions for UI, 6 for UI tape complications), for PRR
in 5.1 % (20 patients, mean interval of 33.1 ± 25.3 months),
and mesh complications in 2.8 % (11 patients, mean interval
of 22.1 ± 193 months: 6 vaginal expositions, 1 bladder ero-
sion, 1 ureteral compression, 1 digestive occlusion attributed
to barbed suture use for peritoneal closure, and 1 mesh remov-
al due to chronic pelvic pain). One patient underwent three
consecutive reoperations after vaginal mesh exposition with
bowel exenteration, requiring vaginal closure and Strattice™
reconstructive tissue matrix use. This patient had previously
presented with uterine cancer, which had been treated using
radiotherapy. Only 7 out of 49 (14 %) reoperations were per-
formed in another surgical unit; most of the patients choose to
be managed by the same practitioner in cases of postoperative
complications or POP recurrence. Sixteen percent of patients
who did not undergo reoperation still reported POP symptoms
during their telephone or postal interview. In patients with
uterine conservation, the GR rate was 20.2 % (21 out of 104)
and the PRR rate was 7.7 % (8 out of 104). In patients with
concomitant hysterectomy (236 subtotal, 6 total), the GR rate
was 7.8 % (19 out of 242) and the PRR was 2.9 % (7 out of
242). During the study period, 11 patients also underwent gy-
necological surgeries for diseases unrelated to pelvic floor dis-
ease or mesh complications; these included 3 total hysterecto-
mies for postmenopausal bleeding, 3 cervical conizations, 1
laparoscopic adnexectomy, and 1 ureteral diverticulum surgery.
Potential risk factors for long-term reoperation and PRR after
LSCP are presented in Table 3. In univariate analysis, increased
age at intervention was a linear protective factor for GR risk,
with a risk reduction of HR = 0.583, CI 95 % [0.430–0.792] per
each additional 10 years of age at the initial surgery, and reduced
the risk of PRR (HR = 0.626, CI 95 % [0.388–1.011]).
Concomitant hysterectomy (total and subtotal) was a protective
factor for GR (HR = 0.341, CI 95 % [0.192 0.608]) and for PRR
(HR = 0.310, CI 95 % [0.123–0.781]). History of previous hys-
terectomy increased the GR and the PRR risk (HR = 1.978, CI
95 % [0.959–4.078] and HR = 3.071, CI 95 % [1.113–8.478]
respectively). Concomitant rectopexy during LSCP tended to
increase the risk of GR (HR = 2.052, CI 95 % [0.871–4.837]).
Preoperative vaginal prolapse and a history of prolapse repair
surgery did not correlate with the GR or the PRR risks (data not
shown). The results of the multivariate analysis (which included
variables with p < 0.1 in the univariate analysis) are also present-
ed in Table 3. Age remained a statistically significant linear
protective factor for GR, with a reduction in reoperation risk
of HR = 0.606, CI 95 % [0.451–0.815] per each additional
10 years of age at the initial surgery, and reduced the risk of
PRR (HR = 0.637, CI 95 % [0.400–1.014]). Concomitant (total
and subtotal) hysterectomy was significantly associated with a
reduction in GR risk (HR = 0.367, CI 95 % [0.193–0.698]) and
a reduction in PRR risk (HR = 0.431, CI 95 % [0.151–1.213]).

Table 2 Indications and timing

of reoperation after laparoscopic Patients, N = 464 Follow-up (months), mean ± SD
sacrocolpopexy in patient who
responded in an interview Patients who responded 391/434 (84.2) 53.5 ± 28.2
Overall reoperation 49/391 (5.12) 26.1 ± 21.7
POP recurrence reoperation 20/391 (1.5) 33.1 ± 25.3
Mesh-related reoperation 11/391 (2.8) 22.1 ± 19.3
Vaginal exposition 6/391 (0.8) –
Bladder erosion 1/391 (0.3) –
Ureteral compression 1/391 (0.3) –
Digestive occlusion 1/391 (0.3) –
Chronic pelvic pain 1/391 (0.3) –
UI-related reoperation 21/391 (3.5) 23.3 ± 16.3
UI surgery 18/391 (4.6) 23.7 ± 15.6
UI tape complication 6/391 (1.5) 18.3 ± 17.3
Vaginal exposition 4/391 (1.0) –
Urethral erosion 1/391 (0.3) –
Dysuria 1/391 (0.3) –

Values are number (percentages) unless otherwise indicated

Int Urogynecol J (2017) 28:231–239 235

1.0
Fig. 1 Kaplan-Meier reoperation
curves

0.9

0.8

Survival probability
0.7

0.6 ___ : mesh-related reoperaon

----- : POP recurrence reoperaon
___ : UI-related reoperaon
----- : global reoperaon

0.5
0 12 24 36 48 60 72 84 96

Time (months)

Paents at risk
Time 0 12 24 36 48 60 72 84 96
Mesh-related reoperaon 391 378 319 242 194 147 90 55 27
POP recurrence reoperaon 391 377 316 238 194 147 88 52 24
UI-related reoperaon 391 374 315 237 188 141 83 51 27
Global reoperaon 391 364 300 219 172 126 71 44 21

Discussion The risks of reoperation after LSCP due to POP recurrence

Since it was first described in 1992, LSCP has gradually be-
come a common and more standardized surgical technique for
P O P r e p a i r. L S C P i s n o w p e r f o r m e d b y m o s t
urogynecological teams and is particularly indicated in young
and sexually active women complaining of POP [1, 2, 4]. The
laparoscopic approach has proven to be superior to laparoto-
my in terms of perioperative complications, postoperative
pain, and length of hospital stay, and confers similar rates of
medium-term anatomical and functional success [1, 10].
Sacrocolpopexy is completed laparoscopically in 92–98 %
of cases, corroborating the 4.4 % conversion rate to laparoto-
my reported in this study [3, 4, 7]. However, LSCP is associ-
ated with specific perioperative complications and requires at
least 20–30 procedures for clinicians to overcome its learning
curve [11]. In our study, the main perioperative complication
was bladder perforation (1.8 % of cases); this corroborates the
rates of 0–10 % described in the LSCP literature [2, 10, 12].
We reported 5 cases of epigastric vessel perforation, including
1 case of life-threatening perioperative bleeding requiring
blood transfusion. This specific laparoscopic complication is
described in 0.25–1.2 % of LSCP procedures [2, 4, 10, 13]
and should be cautiously explained to patients before surgery.
Some medium- or long-term complications were absent
from our series, such as spondylodiscitis, whose occur-
rence can be facilitated by robotic procedures and/or
associated rectopexy [14].
and/or mesh complications should be discussed with patients
before surgery. Concerning LSCP, medium-term evaluations
and reoperation rates have been well described by numerous
prospective studies, with median follow-up periods of 1–
2 years [1–4, 15, 16]. Bacle et al. [1] published a prospective
study including 501 patients who underwent LSCP; 69 % of
patients were evaluated by functional interviews and had a
median of 21 months’ follow-up. Of those patients, 86 % were
Bsatisfied^ at evaluation, reporting a POP recurrence reopera-
tion rate of 11.5 %. Sergent et al. also reported an 86 % ana-
tomical success rate in their prospective study of 119 patients,
with a median follow-up of 34 months [16]. Our work focused
on long-term reoperation rates; we reported a global reopera-
tion rate of 12.5 % with a 53.5-month median follow-up peri-
od. POP recurrence was the second indication for reoperation,
preceded by UI-related problems, with 5.1 % patients requir-
ing another surgery after 22 months. Only one prospective
study with a small number of patients has provided informa-
tion regarding POP recurrence 5 years after LSCP [5], and the
results suggest excellent long-term repair, with 93 % anatom-
ical correction. Two large retrospective cohort studies have
also focused on the long-term efficiency of LSCP. Higgs
et al. [6] evaluated 140 consecutive patients at 66 months with
consequent attrition. Sixteen percent of evaluated patients
underwent reoperation, which was related to POP recurrence
in 11 % of cases. Nevertheless, patient satisfaction rates
remained high at 79 %, underlining the difference between
236 Int Urogynecol J (2017) 28:231–239

Table 3 Univariate and multivariate risk factor analysis

Risk factors Global reoperation, Nc = 49 Reoperation for POP recurrence, Nc = 20

nc HR (CI 95 %) p nc HR (CI 95 %) p

Univariate analysis
Age (per additional 10 years) – 0.583 (0.430–0.792) 0.0005 – 0.626 (0.388–1.011) 0.06
BMI – 0.993 (0.923–1.068) 0.85 – 1.001 (0.894–1.120) 0.99
Active smoking
No (reference) 43 1.00 0.56 19 1.00 0.44
Yes 6 1.284 (0.546–3.022) 1 0.459 (0.061–3.436)
Diabetes mellitus
No (reference) 45 1.00 0.55 18 1.00 0.39
Yes 4 1.368 (0.491–3.812) 2 1.877 (0.431–8.165)
History of POP surgery
No (reference) 40 1.00 0.39 16 1.00 0.45
Yes 9 1.373 (0.665–2.832) 4 1.516 (0.506–4.543)
History of hysterectomy
No (reference) 36 1.00 0.06 40 1.00 0.03
Yes 9 1.978 (0.959–4.078) 5 3.071 (1.113–8.478)
Concomitant hysterectomy
No (reference) 30 1.00 0.0001 13 1.00 0.009
Yesa 19 0.341 (0.192–0.608) 7 0.310 (0.123–0.781)
Polyester mesh use
No (reference) 23 1.00 0.12 13 1.00 0.24
Yes 26 1.588 (0.886–2.845) 7 0.560 (0.210–1.493)
Concomitant rectopexy
No (reference) 43 1.00 0.09 17 1.00 0.14
Yes 6 2.052 (0.871–4.837) 3 2.469 (0.720–8.463)
Surgeon’s experience
Senior (reference) 42 1.00 0.27 18 1.00 0.24
Junior 7 0.640 (0.287–1.426) 2 0.426 (0.099–1.840)
Concomitant UI surgery
No (reference) 34 1.00 0.92 13 1.00 0.78
Yes 15 0.970 (0.528–1.782) 7 1.141 (0.454–2.867)
Multivariate analysisb
Age (per additional 10 years) – 1.00 0.0009 – 1.00 0.06
0.606 (0.451–0.815) 0.637 (0.400–1.014)
History of hysterectomy
No (reference) 36 1.00 0.88 40 1.00 0.18
Yes 9 1.068 (0.452–2.522) 5 2.233 (0.692–7.205)
Concomitant hysterectomy
No (reference) 19 1.00 0.002 13 1.00 0.12
Yes 30 0.367 (0.193–0.698) 7 0.431 (0.151–1.213)
Concomitant rectopexy
No (reference) 43 1.00 0.06 – – –
Yes 6 2.404 (0.950–6.086) – –

HR hazard ratio, CI confidence interval, BMI body mass index, POP pelvic organ prolapse, UI urinary incontinence, SUI stress urinary incontinence
a
Number of event
b
Multivariate analysis concerning global reoperation includes age, history of hysterectomy, concomitant hysterectomy, concomitant rectopexy, and
analysis concerning prolapse recurrence includes age, history of hysterectomy, and concomitant hysterectomy
c
n = 6 patients with total hysterectomy (sensitivity analysis excluding these 6 patients found a similar unadjusted HR of global reoperation, HR = 0.314;
95%CI, (0.173–0.570)

POP symptom treatment and clinical assessment. Finally,
Sabbagh et al. analyzed 186 consecutive LSCP patients [7]
with a median follow-up of 60 months and showed 92 %
anatomical correction, with 4.3 % patients requiring reopera-
tion for POP recurrence. The results of this study are similar to
those of Sabbagh et al.; they highlight the long-term efficiency
of LSCP and high patient satisfaction rates in terms of POP
repair.
Prosthetic materials have been developed for POP repair
surgery to reduce long-term POP recurrence rates, which may
reach 30 % with the use of autologous tissue repair techniques
[17]. This development has been accompanied by mesh-
related complications and therefore constitutes a recurring
medical debate. In some published studies, a greater number
of medium- and long-term reoperations have been required for
mesh-related complications than for POP recurrence [2, 5–7,
Int Urogynecol J (2017) 28:231–239
15, 16, 18, 19]. With mesh-related reoperations occurring in
2.8 % of patients (including 1.8 % due to vaginal exposition)
22 months after the initial LSCP, we observed a lower rate
than other 5-year follow-up studies, such as those by Higgs
et al. (9 and 5 % vaginal exposition and effective reoperation
respectively), Ross and Preston (9 and 4.5 % respectively),
and Sabbagh et al. (3.7 % exposition-related reoperations)
[5–7]. Granese et al. [20] reported the results of a prospective
study with a follow-up period of 43 months, showing a 0.7 %
reoperation rate for mesh exposition. It is essential to remem-
ber that our study was designed to report only complications
requiring new surgery and thus underestimates the frequency
of mesh exposition. The aforementioned studies remind us
that although only one patient undergoes another surgery,
two or three are affected by clinical vaginal mesh exposition
[2, 4, 6, 16, 19, 21]. In the context of scientific and medico-
legal mesh use controversies, our study suggests that prosthet-
ic mesh might have a limited impact in reoperations after
LSCP. Because mesh complications were rare events in our
study, we were unable to perform a risk factor analysis of this
outcome, but at-risk situations must be considered when
choosing to perform LSCP. Other authors have specifically
focused on this point. For example, Deng et al. [22] performed
a meta-analysis including 7,084 patients from 85 studies who
underwent mesh procedures, and suggested that diabetes
mellitus, active smoking, multiparity, and hormonal substitu-
tive treatment were risk factors for vaginal mesh extrusion in
all procedures. Concomitant hysterectomy was also consid-
ered a modifiable risk factor for mesh extrusion in this study
(OR 1.46, 95 % CI [1.03–2.07]), but the type of hysterectomy
was not specified. In the precise case of LSCP, findings from
one comparative prospective study suggest that concomitant
total hysterectomy might be associated with an increased risk
for mesh extrusion, but concomitant subtotal hysterectomy is
not currently considered a risk factor for mesh complications
[23, 24]. Stepanian et al. underlined that the absence of a
proven relationship may be attributed to the inadequate sam-
ple size of the reported study, as at least 2,000 patients were
needed to detect a statistically significant difference [25].
Our findings highlight that older age at the time of LSCP
intervention and concomitant hysterectomy independently re-
duced global and POP recurrence-related reoperation rates in a
median follow-up period of 53 months. Concerning age, there
was a 40 % decrease in the global reoperation rate per each
additional 10 years of age at the initial LSCP, and there was a
reduced incidence of POP recurrence in older patients, al-
though we did not determine an age threshold. In published
studies, age has been shown to be an inconsistent risk factor
for POP recurrence. A recent systematic review references
two studies comparing POP-operated women (categorized as
older and younger than 60 years) that showed an increased
incidence of POP recurrence in the younger group [26]. This
may be due to a congenital predisposition to pelvic tissue
237
weakness among younger patients. Recent works suggest that
genetic disparities result in differences in biomechanical tissue
properties, particularly with regard to collagen and elastin
levels and metalloproteinase expression [27]. Predisposed
young patients may thus develop more POP and/or recurrence
after surgery than other women. Other explanations include
differences in lifestyle, as younger patients are more likely to
report performing strenuous activity than older patients, al-
though the role of physical activity in POP occurrence is not
clear. An evaluation bias may also have contributed to an
incorrect estimation of the role of age in this study because
the evaluation criteria were based on reoperation and not clin-
ical recurrence. Older patients may experience limited social/
professional/sexual consequences related to POP recurrence
and thus choose not to undergo another surgery, instead opting
for abstinence or pessary use. Surgeons can also limit surgical
indications in cases of recurrence in older patients due to sub-
sequent comorbidities.
We report 3 patients who underwent total hysterectomy for
postmenopausal bleeding after LSCP during the study period
(excluded from the final analysis). One patient had endome-
trial cancer. These hysterectomies were performed
laparoscopically with a mesh section; no peroperative compli-
cation was noted. Our team proposes concomitant subtotal
hysterectomy during LSCP procedures, which was shown to
be a protective factor against global reoperation in this study
and also tends to reduce the risk of POP-related reoperation. In
addition to the fact that subtotal hysterectomy can reduce
reoperations for uterine bleeding/fibromatosis, subtotal hys-
terectomy appears to play a role in the quality of LSCP and
may thus reduce the risk of POP- or mesh-related
reoperations. Supracervical transection prevents blind passage
across the broad ligament and moves the mesh away from the
ureter. Recent biomechanical studies suggest that the cervix is
the most important point in vertical uterine maintenance,
where the applied tension is greatest. Solid mesh fixation in
the cervix using tackers or knots may play a role in POP
recurrence reduction, mimicking the role of the uterosacral
ligament [28]. A recent comparative study suggests that con-
comitant hysterectomy may improve patient satisfaction and
functional scores after LSCP, even if anatomical correction is
not different in the two groups [29]. Given these results, a
large prospective study focusing on the role of subtotal hys-
terectomy in POP recurrence should be undertaken.
The strengths and weaknesses of our study should be con-
sidered. First, we report one of the largest samples of patients
undergoing LSCP [1, 4, 25]. Long-term mean follow-up of
more than 4 years was achieved, with low attrition and no
significant baseline differences between the responsive and
nonresponsive patients. Surgeries were performed in a single
center over the course of 10 years by an experienced team [9],
guaranteeing relative homogeneity in the procedures.
Telephonic and postal recall facilitates obtaining reliable and
238
prospective information because the binary endpoint of reop-
eration is simple to understand and report for patients. Our
study provides information about the rates of serious compli-
cations and reoperation after LSCP; these conclusions are
comprehensive and are thus useful for patients in the selection
and timing of the initial POP surgery. The limitations of our
study include its retrospective design. Retrospective baseline
data collection usually misestimates adverse events and intro-
duces measurement bias, especially regarding POP grada-
tions. Our study also postulates that surgical technique was
stable over the study period, but that slight changes in surgical
technique have necessarily gradually occurred (such as the
switch in mesh composition from polyester to polypropylene).
Additionally, the main endpoint, reoperation, does not de-
scribe anatomical recurrence or functional impairment, and
thus does not allow measurement of the clinical efficiency of
LSPC or patient functional satisfaction. Finally, statistical
analysis was limited by the incidence of rare events, despite
the large sample size, and required grouping reoperations into
categories, limiting the clinical relevance of the aforemen-
tioned statistically significant relationships.
Conclusion
In this large retrospective cohort study with a prospective
outcome evaluation, reoperation for pelvic floor disorders or
mesh complications occurred in 12.5 % patients after a medi-
an follow-up of 4 years. The incidences of POP recurrence
and mesh-related reoperations were only 5.1 and 2.8 % re-
spectively. Older age at the time of intervention and concom-
itant subtotal hysterectomy could reduce the need for reoper-
ation for prolapse recurrence.
Authors’ contributions D. Vandendriessche: project development, da-
ta collection, manuscript writing; J. Sussfeld: data collection; G. Giraudet:
project development, manuscript editing; J-P Lucot: project development,
manuscript editing; H. Béhal: data analysis, manuscript editing; M.
Cosson: project development, manuscript editing.
Compliance with ethical standards
Conflicts of interest Prof M. Cosson reports participation in a
company-sponsored speaker’s bureau and receipt of honoraria from
Olympus, Boston Scientific, and Allergan. Dr G. Giraudet performs ed-
ucational activities for American Medical Systems, Astora, Boston
Scientific, and Olympus. Dr J.-P. Lucot performs educational activities
for Boston Scientific. D. Vandendriessche, J. Sussfeld, and H. Béhal
report that they have no conflicts of interest.
References
1. Bacle J, Papatsoris AG, Bigot P, Azzouzi A-R, Brychaet P-E,
Piussan J, et al. Laparoscopic promontofixation for pelvic organ
prolapse: a 10-year single center experience in a series of 501 pa-
tients. Int J Urol. 2011;18(12):821–6.
Int Urogynecol J (2017) 28:231–239
2. Claerhout F, De Ridder D, Roovers JP, Rommens H, Spelzini F,
Vandenbroucke V, et al. Medium-term anatomic and functional
results of laparoscopic sacrocolpopexy beyond the learning curve.
Eur Urol. 2009;55(6):1459–67.
3. Maher CF, Feiner B, DeCuyper EM, Nichlos CJ, Hickey KV,
O’Rourke P. Laparoscopic sacral colpopexy versus total vaginal
mesh for vaginal vault prolapse: a randomized trial. Am J Obstet
Gynecol. 2011;204(4):360.e1–7.
4. Rozet F, Mandron E, Arroyo C, Andrews H, Cathelineau X,
Mombet A, et al. Laparoscopic sacral colpopexy approach for
genito-urinary prolapse: experience with 363 cases. Eur Urol.
2005;47(2):230–6.
5. Ross JW, Preston M. Laparoscopic sacrocolpopexy for severe vag-
inal vault prolapse: five-year outcome. J Minim Invasive Gynecol.
2005;12(3):221–6.
6. Higgs PJ, Chua H-L, Smith ARB. Long term review of laparoscop-
ic sacrocolpopexy. BJOG. 2005;112(8):1134–8.
7. Sabbagh R, Mandron E, Piussan J, Brychaert PE, Tu LM. Long-
term anatomical and functional results of laparoscopic
promontofixation for pelvic organ prolapse. BJU Int.
2010;106(6):861–6.
8. Wattiez A, Canis M, Mage G, Pouly JL, Bruhat MA.
Promontofixation for the treatment of prolapse. Urol Clin North
Am. 2001;28(1):151–7.
9. Cosson M, Rajabally R, Bogaert E, Querleu D, Crepin G.
Laparoscopic sacrocolpopexy, hysterectomy, and Burch
colposuspension: feasibility and short-term complications of 77
procedures. JSLS. 2002;6(2):115–9.
10. Coolen AL, van Oudheusden AM, van Eijndhoven HW, van der
Heijden TP, Stokmans RA, Mol BW, et al. A comparison of com-
plications between open abdominal sacrocolpopexy and laparo-
scopic sacrocolpopexy for the treatment of vault prolapse. Obstet
Gynecol Int. 2013;2013:528636.
11. Claerhout F, Verguts J, Werbrouck E, Veldman J, Lewi P, Deprest J.
Analysis of the learning process for laparoscopic sacrocolpopexy:
identification of challenging steps. Int Urogynecol J. 2014;25(9):
1185–91.
12. Paraiso MFR, Walters MD, Rackley RR, Melek S, Hugney C.
Laparoscopic and abdominal sacral colpopexies: a comparative co-
hort study. Am J Obstet Gynecol. 2005;192(5):1752–8.
13. Rivoire C, Botchorishvili R, Canis M, Jardon K, Rabischong B,
Wattiez A, et al. Complete laparoscopic treatment of genital pro-
lapse with meshes including vaginal promontofixation and anterior
repair: a series of 138 patients. J Minim Invasive Gynecol.
2007;14(6):712–8.
14. Unger CA, Paraiso MFR, Jelovsek JE, Barber MD, Ridgeway B.
Perioperative adverse events after minimally invasive abdominal
sacrocolpopexy. Am J Obstet Gynecol. 2014;211(5):547.e1–8.
15. Deprest J, De Ridder D, Roovers J-P, Werbrouck E, Coremans G,
Claerhout F. Medium term outcome of laparoscopic
sacrocolpopexy with xenografts compared to synthetic grafts. J
Urol. 2009;182(5):2362–8.
16. Sergent F, Resch B, Loisel C, Bisson V, Schaal J-P, Marpeau L.
Mid-term outcome of laparoscopic sacrocolpopexy with anterior
and posterior polyester mesh for treatment of genito-urinary pro-
lapse. Eur J Obstet Gynecol Reprod Biol. 2011;156(2):217–22.
17. Maher C, Feiner B, Baessler K, Schmid C. Surgical management of
pelvic organ prolapse in women. Cochrane Database Syst Rev.
2013;4:CD004014.
18. North CE, Ali-Ross NS, Smith ARB, Reid FM. A prospective study
of laparoscopic sacrocolpopexy for the management of pelvic organ
prolapse. BJOG Int J Obstet Gynaecol. 2009;116(9):1251–7.
19. Price N, Slack A, Jackson SR. Laparoscopic sacrocolpopexy: an
observational study of functional and anatomical outcomes. Int
Urogynecol J. 2011;22(1):77–82.
Int Urogynecol J (2017) 28:231–239
20. Granese R, Candiani M, Perino A, Romano F, Cucinella G.
Laparoscopic sacrocolpopexy in the treatment of vaginal vault pro-
lapse: 8 years experience. Eur J Obstet Gynecol Reprod Biol.
2009;146(2):227–31.
21. Paraiso MFR, Jelovsek JE, Frick A, Chen CCG, Barber MD.
Laparoscopic compared with robotic sacrocolpopexy for vaginal
prolapse: a randomized controlled trial. Obstet Gynecol.
2011;118(5):1005–13.
22. Deng T, Liao B, Luo D, Shen H, Wang K. Risk factors for
mesh erosion after female pelvic floor reconstructive surgery:
a systematic review and meta-analysis. BJU Int. 2015;117(2):
323–43.
23. Cundiff GW, Varner E, Visco AG, Zyczynski HM, Nager CW,
Norton PA, et al. Risk factors for mesh/suture erosion following
sacral colpopexy. Am J Obstet Gynecol. 2008;199(6):688.e1–5.
24. Tan-Kim J, Menefee SA, Luber KM, Nager CW, Lukacz ES.
Prevalence and risk factors for mesh erosion after laparoscopic-
assisted sacrocolpopexy. Int Urogynecol J. 2011;22(2):205–12.
239
25. Stepanian AA, Miklos JR, Moore RD, Mattox TF. Risk of mesh
extrusion and other mesh-related complications after laparoscopic
sacral colpopexy with or without concurrent laparoscopic-assisted
vaginal hysterectomy: experience of 402 patients. J Minim Invasive
Gynecol. 2008;15(2):188–96.
26. Vergeldt TFM, Weemhoff M, IntHout J, Kluivers KB. Risk factors
for pelvic organ prolapse and its recurrence: a systematic review. Int
Urogynecol J. 2015;26(11):1559–73.
27. Campeau L, Gorbachinsky I, Badlani GH, Andersson KE. Pelvic
floor disorders: linking genetic risk factors to biochemical changes.
BJU Int. 2011;108(8):1240–7.
28. Rubod C, Lecomte-Grosbras P, Brieu M, Giraudet G, Betrouni N,
Cosson M. 3D simulation of pelvic system numerical simulation for
a better understanding of the contribution of the uterine ligaments.
Int Urogynecol J. 2013;24(12):2093–8.
29. Pan K, Cao L, Ryan NA, Wang Y, Xu H. Laparoscopic sacral
hysteropexy versus laparoscopic sacrocolpopexy with hysterectomy
for pelvic organ prolapse. Int Urogynecol J. 2016;27(1):93–101.
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