Laparoscopic fixation to the uterosacral ligaments [1, 2]. Instead of using meshes, you can use the uterosacral ligaments to suspend the vaginal wall or the cervix or shorten the uterosacral ligaments with sutures. This may be associated to a Douglassectomy or a culdoplasty. There are only few reports of results in literature and no serious comparison to other techniques. In fact, if the uterosacral ligaments are of poor quality, this procedure is not feasible. In some POP patients, the uterosacral ligaments are even not visible because of distension or atrophy. This technique should be considered when a rectal injury occurs during posterior dissection, contra indicating the use of a synthetic mesh.

Laparoscopic fixation to the pelvic sidewall [3]. This is the technique promoted since years by my old friend Jean Bernard Dubuisson from Geneva. It is based on an old open procedure that had been abandoned because of the high rate of enterocele occurring after this operation due to the axis of tension that opens the Douglas pouch. JB Dubuisson wanted to find a procedure that could avoid the dissection of the promontory and of the recto vaginal plane. A pre cut mesh is introduced through a lateral skin incision and pushed through the extra peritoneal space under laparoscopic view control from one side to the other and sutured to the vault or the isthmus. In order to prevent the high risk of enterocele, a culdoplasty has to be performed in order to close the Douglas pouch. This technique could be useful when the promontory is not accessible.

Anterior hysteropexy (ventrofixation) [4, 5]. This is a very old operation (but easy and quick to perform) has been described since the nineteenth century and published in 1915 [4]. It has been abandoned because the fixation of the uterus to the abdominal wall modifies the vaginal axis and opens widely the Douglas pouch. Consecutive enterocele is almost systematic inducing pain and defecation problems as seen in unintentional uterine ventrofixation due to repeated caesarian section. Some authors [5] have suggested that a poor open operation could be a good laparoscopic operation mainly because it’s easy to perform. That’s not our way of thinking. We don’t recommend uterine ventrofixation in any situation.

Vaginal sacrospinous ligament fixation [1, 6, 7]. Initially described by Richter, this fixation of the vaginal vault to the sacrospinous ligament is usually done unilaterally and with sutures. Many variations exist. It can be performed bilaterally. It can be reinforced by a mesh. It can be done under direct view of the ligament presented with three retractors or under “fingertip control”, blindly with the help of a device. Many devices, reusable (Miya Hook, SeraPro) or not (Digitex, Capio), are on the market. Results are very satisfying. A recent meta analysis [1] seems to indicate that sacrospinous ligament fixation is slightly less effective than SCP on the results but sacrospinous ligament fixation has less complications and a lower cost. It remains an excellent technique for level 1 defect and we recommend this technique in vault prolapse as a first line. It is also very useful in level 1 recurrence after LSCP because the dissection remains extra peritoneal, avoiding the abdominal adhesions around the mesh. Frequently, vaginal dissection may lead you to find the abdominal mesh and you can suture it to the vaginal vault or the uterine cervix instead of fixing to the sacrospinous ligament.

Vaginal fixation to the uterosacral ligaments [8–10]. Again an old but efficient technique. Vaginal uterosacral ligament suspension seems to be as effective as vaginal [8]. The main risk is the proximity of the ureters that may lead to ligature or kinking. The poor quality of the uterosacral ligaments in many POP patients may also impair the long term results. We prefer to do a sacrospinous ligament fixation for all these reasons.

Lefort’s procedure (or other vaginal closure technique) [11–13]. This is a very effective operation for patients above 70 or 80 years old having no more desire for vaginal intercourse. Colpocleisis can be performed safely without vaginal hysterectomy, on a day surgery and under local anesthesia. The technique (photos below) is very elegant with an effectiveness of almost 100% and very few side effects.

Laparoscopic rectopexy [14] is indicated in case of obstructed defecation due to rectal intussusceptions (see picture below), associated or not to a rectocele or a total rectal prolapse. More than an alternative technique, laparoscopic rectopexy can be an additional step to LSCP after a multidisciplinary approach of heavy defecation dysfunction. The technique and the dissection are very similar to LSCP (see picture below).