Pectopexy
Pectopexy (also called pectocolpopexy or pectocervicopexy) is a laparoscopic apical-prolapse repair that suspends the vaginal vault or cervix to the bilateral iliopectineal (Cooper's) ligaments with mesh or suture, instead of to the sacral promontory as in sacrocolpopexy. First described by Banerjee and Noé in 2011, it was developed as an alternative that avoids presacral dissection and its associated risks.[1][2][3][4]
For the sacral-fixation alternative, see Sacrocolpopexy. For the uterus-preserving sacral variant, see Sacrohysteropexy. For the broader prolapse decision framework, see Prolapse Repair.
Definition and Rationale
The iliopectineal ligament (Cooper's ligament) is a strong, well-defined anatomic structure familiar to surgeons from hernia repair. Pectopexy uses it as a bilateral fixation anchor for apical suspension.[1][2][3]
Theoretical advantages over sacrocolpopexy:
- Avoids presacral dissection — eliminates risks of presacral venous plexus hemorrhage, middle sacral vessel injury, and hypogastric nerve damage.
- Avoids the rectosigmoid mesentery — reduces postoperative bowel dysfunction and constipation.
- Surgical field limited to the anterior pelvis — technically simpler with a shorter learning curve.
- Bilateral fixation along pelvic sidewalls — a more physiologic, symmetric suspension.
- Shorter operative time — consistently reproduced across studies.
Indications and Patient Selection
Pectopexy is indicated for women with POP-Q stage ≥ 2 apical prolapse (uterovaginal or post-hysterectomy vault prolapse).[2][5] Particularly advantageous in:
- Patients where presacral dissection is high risk — prior pelvic radiation, sacral anomalies, severe adhesions, deep pelvis.[3]
- Obese patients — the anterior pelvic field is more accessible than the sacral promontory.[4][6]
- Patients who desire uterine preservation (pectouteropexy / pectohysteropexy).[4][7]
- Settings where shorter operative time is desirable.[1][8]
Surgical Technique — Banerjee-Noé Standard Laparoscopic Pectopexy
Positioning and ports[9]
- Dorsal lithotomy with hip extension and knee flexion; 45° Trendelenburg.
- One 10-mm umbilical optical trocar + three 5-mm accessory trocars (two placed 2 cm above and medial to the ASIS bilaterally; one 5 cm below the umbilicus).
Step-by-step
- Bilateral identification and exposure of the iliopectineal ligaments. Begin on one side (typically left). Incise peritoneum in the center of a V-shaped area bordered laterally by the round ligament and medially by the obliterated umbilical artery (medial umbilical ligament). Dissect soft tissue to expose the iliopectineal ligament, which lies immediately beneath the external iliac vein. Repeat contralaterally.[9][2]
- Critical structures to preserve: external iliac vein (directly overlying), obturator nerve, obturator vessels.
- Vaginal / cervical dissection. If hysterectomy planned, perform supracervical hysterectomy at this point. Dissect the vesicovaginal space anteriorly to expose the anterior vaginal wall / cervical stump. A vaginal retractor or assistant's finger tents the vaginal wall for identification.[9][4]
- Mesh fixation to vaginal wall / cervix. Suture the central portion of the mesh to the anterior vaginal wall and / or cervical stump with interrupted absorbable tacks or sutures; non-absorbable sutures may be added at the cervical stump. For the inverted T-mesh technique, extend the anterior arm along the vesicovaginal septum to address concurrent cystocele.[9][10]
- Bilateral mesh fixation to the iliopectineal ligaments. Bring the lateral arms of the mesh to Cooper's ligaments bilaterally; fix with non-absorbable tacks (e.g., ProTack) or non-absorbable sutures. Place tension-free — vaginal apex elevated to its anatomic position without excess traction.[9][12]
- Peritonization. Close peritoneum completely over the mesh bilaterally with running absorbable sutures (e.g., Vicryl 2-0); critical to prevent bowel adhesion to mesh.[9]
- Concomitant procedures (as needed).
Mesh configurations
| Configuration | Dimensions | Material | Vaginal / cervical fixation | Lateral fixation | Best for |
|---|---|---|---|---|---|
| Horizontal strip (standard Noé) | 3 × 15 cm prefabricated strip | PVDF (DynaMesh PRP) or polypropylene | Central portion to vaginal cuff or anterior / posterior cervix; ~4 cm² fixation footprint per side | Bilateral iliopectineal ligaments at ~S2 level | Isolated apical prolapse[1][3][11][19][20] |
| T-shaped mesh | 8 × 15 cm sheet cut to a T on the back table | Polypropylene | Short (vertical) arm to anterior vaginal wall + cervical stump | Two lateral (horizontal) arms to bilateral Cooper's ligaments | Standard pectopexy / apical + anterior prolapse[1][9] |
| Inverted T-mesh | Custom cut | PVDF or polypropylene | Anterior arm extended along the vesicovaginal septum + cervix | Bilateral iliopectineal ligaments | Advanced uterine + anterior prolapse[2][3][10] |
| Y-shaped mesh | ~15 × 10 cm cut, or prefabricated (e.g., ARTISYN, DynaMesh PRS) | Polypropylene or PVDF | Two distal leaves to anterior + posterior vaginal walls | Single stem split / extended to bilateral ligaments (pectopexy adaptation) or sacral promontory (sacrocolpopexy) | Multi-compartment prolapse[5][21][23][24] |
Material choice. Type-1 macroporous polypropylene is the most commonly used mesh (46.7% of studies), followed by PVDF.[2][3] PVDF offers superior shape stability and a "memory effect" that aids intracorporeal handling.[21] In uterus-preserving procedures the strip may sit anterior or posterior to the cervix with similar recurrence and reoperation rates.[22]
Preparation and delivery. The mesh is rolled tightly, introduced through a 10-mm trocar, and unrolled intracorporeally with the apical portion over the vaginal wall.[21] When cutting a T- or Y-shape, trim edges smoothly to avoid sharp corners (an erosion risk) and reinforce the bifurcation junction with a stay suture to prevent tearing. The two Y-leaves are sized to cover the anterior and posterior walls respectively; the single stem becomes the lateral / cranial fixation arm.[21][23] The transvaginal single-port adaptation of Chen et al. used a Y-shaped ARTISYN mesh (posterior arm to posterior vaginal wall, anterior arm to anterior wall and descending pubic ramus) with no recurrence or mesh exposure across 93 patients.[23][24]
Fixation to the iliopectineal ligament can use a continuous or single interrupted suture with no significant difference in ultimate load or displacement at failure; the mesh itself remains the limiting factor (see Biomechanical fixation note).[12]
Biomechanical fixation note
A single interrupted suture provides equivalent ultimate load and displacement-at-failure to a continuous suture (35 ± 12 N vs 48 ± 7 N, NS). The mesh itself is the limiting factor — single-suture fixation is adequate and may shorten operative time.[12]
Mesh-Free (Non-Mesh) Variants
| Variant | Technique | Outcomes |
|---|---|---|
| Laparoscopic Non-Mesh Cerclage Pectopexy (LNMCP) — Zhang / Lyu | Permanent cervical cerclage sutures (non-absorbable) embedded along the round ligament bilaterally to the iliopectineal ligament; firm cervical suspension | OR time 67.8 ± 15.5 min; EBL 73.1 ± 51.1 mL; objective success 100%, subjective 93.8%[13] |
| LNMCP — uterine-preserving variant (LNMCPUP) | Uterine preservation while retaining cerclage approach | Objective success 100%; subjective 92.86%[7] |
| Meshless pectopexy (Salman's modification) | Monofilament non-absorbable sutures (no mesh) to suspend uterus to bilateral iliopectineal ligaments | n = 40, stage 3–4: mean C-point improvement −8.21 ± 3.03 cm at 1 yr; apical recurrence 7.9%[14] |
LESS and Robotic Pectopexy
| Variant | Notes |
|---|---|
| Laparoendoscopic Single-Site (LESS) pectopexy | Single umbilical port; identical key steps; OR time ~80 min; particularly useful in obese patients[6] |
| Robot-assisted pectouteropexy | Better maneuverability, 3D visualization, reduced OR time; particularly useful in obese patients[4] |
Learning Curve
The learning curve is shorter than for sacrocolpopexy. The turning point was observed at the 12th case in one study, vs the well-known steeper curve for sacrocolpopexy — attributable to the surgical field being limited to the anterior pelvis.[1]
Outcomes and Efficacy
| Endpoint | Result |
|---|---|
| Objective anatomical success | 78.6–100%[1][2][3][4][5] |
| Subjective success (PGI-I) | 75.5–93.8%[2][6] |
| Apical recurrence | 0–7.9%[3][7][8] |
| 10-yr recurrence-free survival (median) | 9.34 yr[16] |
| 10-yr apical re-fixation success | 94.9%[16] |
| Reoperation rate (10-yr) | 9.7%[16] |
| OR time (pectopexy alone) | 43–80 min[9][10] |
| OR time (with concomitants) | 150–183 min[6][7] |
| QoL (PFDI-20, PFIQ-7, PISQ-12) | Consistent improvement across studies[5][6][11][12][13] |
Comparative Outcomes
vs Sacrocolpopexy (2025 meta-analyses + comparative studies)
| Parameter | Pectopexy | Sacrocolpopexy | Significance |
|---|---|---|---|
| Operative time | 34.4 min shorter | — | p < 0.01[1][2] |
| Blood loss | 13.3 mL less | — | p < 0.01[1][2] |
| Hospital stay | 0.15 d shorter | — | p < 0.01[1] |
| Postoperative bowel dysfunction | Less frequent | More frequent | p < 0.01[1] |
| Postoperative low back pain | Absent | Present | —[3] |
| Prolapse recurrence | No significant difference (or favoring pectopexy) | — | NS or p = 0.01[1][2] |
| Anatomical outcomes | Comparable | — | NS[1][4] |
| Satisfaction | Comparable | — | NS[1] |
| Sexual function | Comparable / superior | — | NS[1][5] |
| QoL (PFDI-20, IQoL) | Better improvement at 1 yr | — | p < 0.05[4] |
Caveat: Yang 2023 reported higher urinary symptom recurrence after pectopexy (13.7% vs 5.0%, OR 3.1, p = 0.032) — warrants attention.[17]
vs Sacrospinous Ligament Fixation
Both produce good anatomical and subjective outcomes. Pectopexy has longer OR time (151.8 vs 69 min) but offers a protective effect on the anterior compartment and better preserves total vaginal length vs SSLF (which causes more vaginal shortening, p = 0.01).[15]
vs High Uterosacral Ligament Suspension (HUSLS)
Pectopexy with hysterectomy gave better posterior compartment reduction (Ap, Bp) and longer total vaginal length vs HUSLS with hysterectomy. Uterine-preserving pectopexy had the shortest OR time and best PISQ-12 scores.[5]
Three-way comparison (Sánchez-Ferrer 2025, n = 180)
Sacropexy vs pectopexy vs lateral suspension — no difference in surgical failure. Pectopexy and lateral suspension had substantially shorter OR times than sacropexy without increased complications.[18]
Complications
| Complication | Rate |
|---|---|
| Major intraoperative complications (bladder, bowel, ureteral injury) | 0–1.8%[1][2] |
| Mesh exposure | 2.5%[3] |
| Chronic pelvic pain | 5.0%[3] |
| Urinary retention | 2.5%[3] |
| De novo SUI | 0–13.7%[4][5][17] |
| Postoperative constipation / bowel dysfunction | Significantly less than sacrocolpopexy[1][8] |
| Postoperative low back pain | Absent (vs present in sacrocolpopexy)[1] |
| Presacral hemorrhage | N/A — no sacral dissection |
Long-Term Durability — 10-Year Data
The largest long-term series (Noé 2026, n = 832) provides the most mature data:[16]
- Median recurrence-free survival: 9.34 yr (IQR 7.36–10.60).
- Median reoperation-free survival: 9.56 yr (IQR 7.68–10.71).
- 87.9% of recurrences within first 4 years — supports a minimum 4-yr surveillance window.
- Apical re-fixation 94.9% long-term success over 10 years.
- Lateral defect severity is the strongest predictor of failure.[10][11]
Biomechanical Considerations
Cadaveric biomechanical testing of the iliopectineal ligament:[12]
- Mesh + single interrupted suture: 35 ± 12 N.
- Mesh + continuous suture: 48 ± 7 N (NS).
- The mesh is the limiting factor for overall stability — single-suture fixation is adequate.
Limitations and Evidence Gaps
- Most evidence is from observational studies and small RCTs — only 4 RCTs (13.3%) among 30 eligible studies in the most recent scoping review.[2]
- Studies are dominated by Asian centers (66.7%) and tertiary referral practice (86.7%).[2]
- PROMs underreported — no studies reported recurrence of prolapse symptoms as a primary outcome.[2]
- Long-term data > 10 years remain limited.
- Higher urinary-symptom recurrence in one comparative study warrants further investigation.[17]
Key Principles
- Pectopexy uses bilateral Cooper's-ligament fixation as an alternative to sacrocolpopexy — same mesh-augmented apical-suspension principle, different anchor.[1][3]
- Avoids presacral dissection — eliminates presacral hemorrhage and hypogastric nerve risks.[1][3]
- Shorter operative time (mean 34 min less than sacrocolpopexy) and shorter learning curve (~12 cases).[1][8]
- Less postoperative bowel dysfunction and low back pain than sacrocolpopexy.[1]
- Critical anatomic landmark: iliopectineal ligament lies just beneath the external iliac vein — preserve the vein, obturator nerve, and obturator vessels.[9]
- Single-suture fixation is biomechanically adequate; the mesh is the limiting factor.[12]
- 10-year apical re-fixation success ~95%; 87.9% of recurrences within first 4 years — survey closely during that window.[16]
- Higher urinary-symptom recurrence vs sacrocolpopexy in one comparative cohort — counsel and follow accordingly.[17]
- Mesh-free and meshless variants (cerclage pectopexy, Salman's modification) are emerging options for mesh-averse patients.[7][13][14]
Videos
References
1. Chuang FC, Chou YM, Wu LY, et al. Laparoscopic pectopexy: the learning curve and comparison with laparoscopic sacrocolpopexy. Int Urogynecol J. 2022;33(7):1949-1956. doi:10.1007/s00192-021-04934-4.
2. Jongjakapun A, Temtanakitpaisan T, Sothornwit J, Pattanittum P, Ngamjarus C. Pectopexy for pelvic organ prolapse: a scoping review. Int Urogynecol J. 2025. doi:10.1007/s00192-025-06232-9.
3. Noé KG, Spüntrup C, Anapolski M. Laparoscopic pectopexy: a randomised comparative clinical trial of standard laparoscopic sacral colpo-cervicopexy to the new laparoscopic pectopexy. Short-term postoperative results. Arch Gynecol Obstet. 2013;287(2):275-80. doi:10.1007/s00404-012-2536-7.
4. Usta T, Karacan T, Kale A, Mutlu S, Tıryakı T. Robot-assisted laparoscopic pectouteropexy: an alternative uterus-sparing technique for pelvic organ prolapse surgery. Int Urogynecol J. 2017;28(11):1751-1753. doi:10.1007/s00192-017-3326-3.
5. Peng J, Li S, Wang L, et al. Comparison of efficacy between laparoscopic pectopexy and laparoscopic high uterosacral ligament suspension in the treatment of apical prolapse — short-term results. Sci Rep. 2023;13(1):18519. doi:10.1038/s41598-023-45871-0.
6. Wang Q, Guan Z, Guo X, et al. Stepwise laparoendoscopic single-site pectopexy for pelvic organ prolapse. J Minim Invasive Gynecol. 2021;28(6):1142-1143. doi:10.1016/j.jmig.2020.10.008.
7. Lyu C, Cheon WC, Sheung Ngan HY, Wei Y, Zhang W. Laparoscopic non-mesh cerclage pectopexy with uterine preservation for pelvic organ prolapse. J Vis Exp. 2024;(212). doi:10.3791/67239.
8. Lin Y, Liu JJ, Fang K, Wu H, Li N. Pectopexy compared with sacrocolpopexy for the treatment of pelvic organ prolapse: a systematic review and meta-analysis of clinical outcomes. Eur J Obstet Gynecol Reprod Biol. 2025;312:114091. doi:10.1016/j.ejogrb.2025.114091.
9. Pirtea L, Balint O, Secoșan C, Grigoraș D, Ilina R. Laparoscopic pectopexy with Burch colposuspension for pelvic prolapse associated with stress urinary incontinence. J Minim Invasive Gynecol. 2020;27(5):1023-1024. doi:10.1016/j.jmig.2019.10.022.
10. Yang E, Tsai CP, Shen PS, et al. One-year outcomes of an innovative laparoscopic pectopexy procedure using inverted T-mesh for treatment of advanced uterine and anterior vaginal prolapse. Sci Rep. 2026;16(1):11202. doi:10.1038/s41598-026-40730-0.
11. Chang YT, Yang E, Tseng JJ, et al. Comparison of 1-year outcomes after uterine-preserving laparoscopic pectopexy using an inverted T-shaped mesh versus the horizontal DynaMesh: a retrospective, multicenter cohort study. Int J Gynaecol Obstet. 2026. doi:10.1002/ijgo.70915.
12. Sauerwald A, Niggl M, Puppe J, et al. Laparoscopic pectopexy: a biomechanical analysis. PLoS One. 2016;11(2):e0144143. doi:10.1371/journal.pone.0144143.
13. Zhang W, Cheon WC, Ngan HYS, Wei Y, Lyu C. Laparoscopic non-mesh cerclage pectopexy for pelvic organ prolapse. J Vis Exp. 2022;(187). doi:10.3791/64388.
14. Erdem B, Salman S, Usta ZK, et al. A novel approach for apical prolapse surgery: meshless pectopexy (Salman's modification). Int Urogynecol J. 2025. doi:10.1007/s00192-025-06107-z.
15. Szymczak P, Grzybowska ME, Sawicki S, Futyma K, Wydra DG. Perioperative and long-term anatomical and subjective outcomes of laparoscopic pectopexy and sacrospinous ligament suspension for POP-Q stages II-IV apical prolapse. J Clin Med. 2022;11(8):2215. doi:10.3390/jcm11082215.
16. Noé G, Farsaki E, Anapolski M, Pitsillidi A. Ten years of laparoscopic pectopexy: a case series analysis. Int Urogynecol J. 2026;37(3):757-764. doi:10.1007/s00192-025-06377-7.
17. Yang Y, Li Z, Si K, et al. Effectiveness of laparoscopic pectopexy for pelvic organ prolapse compared with laparoscopic sacrocolpopexy. J Minim Invasive Gynecol. 2023;30(10):833-840.e2. doi:10.1016/j.jmig.2023.06.011.
18. Sánchez-Ferrer ML, Ñíguez-Sevilla I, Ruiz-Cotorruelo VL, Arense-Gonzalo JJ. A cohort-based comparative study of three minimally invasive apical prolapse surgeries: sacropexy, pectopexy, and lateral suspension. J Clin Med. 2025;14(17):6073. doi:10.3390/jcm14176073.
19. Noé GK, Schiermeier S, Papathemelis T, et al. Prospective international multicenter pelvic floor study: short-term follow-up and clinical findings for combined pectopexy and native tissue repair. J Clin Med. 2021;10(2):217. doi:10.3390/jcm10020217.
20. Szymczak P, Grzybowska ME, Wydra DG. Comparison of laparoscopic techniques for apical organ prolapse repair — a systematic review of the literature. Neurourol Urodyn. 2019;38(8):2031-2050. doi:10.1002/nau.24115.
21. Kavallaris A, Zygouris D. Laparoscopic sacrocolpopexy comparing polypropylene mesh with polyvinylidene fluoride mesh for pelvic organ prolapse: technique description and long-term outcomes. Neurourol Urodyn. 2020;39(8):2264-2271. doi:10.1002/nau.24480.
22. Biyik I, Gezer S, Karatas S, Grigoriadis G. Comparison of surgical outcomes of mesh placement anterior versus posterior to the cervix uteri in laparoscopic pectopexy with uterine preservation. Int Urogynecol J. 2026;37(3):749-755. doi:10.1007/s00192-025-06382-w.
23. Chen Y, Li J, Hua K. Transvaginal single-port laparoscopy pelvic reconstruction with Y-shaped mesh. J Minim Invasive Gynecol. 2018;25(7):1138-1141. doi:10.1016/j.jmig.2018.01.030.
24. Li J, Hu C, Wang X, Hua K, Chen Y. Transvaginal single-port laparoscopic pelvic reconstruction with Y-shaped mesh: experiences of 93 cases. Int Urogynecol J. 2021;32(4):905-911. doi:10.1007/s00192-020-04418-x.