Prolapse of the uterus in premenopausal women is a concerning condition and therapeutic options are limited especially if uterine preservation is demanded. 
In accordance to laparoscopic cervicosacropexy, we present an advancement of the surgical technique to restore apical suspension under uterine preservation and to “tension” the anterior vaginal wall and thereby the vesico-urethral junction (1, 2). A curved tunneling device was used to replace both uterosacral-ligaments (USL), and a minimum amount of synthetic material (polyvinylidene-fluoride, PVDF) was used between the sacral vertebra (S1) and the anterior cervix under the preservation of the integrity of the peritoneum.

Women with apical prolapse and urinary incontinence 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 laparoscopic uterosacropexy, a pneumoperitoneum was conducted according to institutional standards. 
1.	The bladder was identified on the anterior cervix and their peritoneum was incised laterally until the left and right uterine vessels were displayed. The space lateral to these vessels was prepared bluntly. Thereby, the integrity of the posterior paracervical peritoneum was obtained.
2.	The peritoneum over the promontory was incised for 2 cm on the right side of the rectosigmoid colon in order to prepare both lateral margins of the promontory for posterior fixation; 
3.	For USL replacement, a PVDF-structure of 9.3 cm in length and 0.4 cm in width was used. A semi-circular curved hook was used for insertion. 
4.	The semi-circular tunneler was inserted via the right lateral trocar incision. The rectosigmoid is lateralized to the left and the tunneler´s blunt tip placed in front of S1 at the left side of the sacral vertebra and hold in its position. In order to tunnel the left USL, the rectosigmoid is pulled to the right side and the tunneler´s blunt tip was slightly rotated forward until the tip shined through the peritoneum (below the left internal iliac vessels, ureter and lateral the rectosigmoid meso). The tunneler was then forwarded under the peritoneum along the run of the left USL toward the cervix, paracervical. The lateral end of the PVDF-structure was threaded through the hole of the tunneler´s tip, and then carefully pulled back. Same was done to tunnel the right USL. 
5.	The central fixation part of the PVDF-structure was sutured horizontally to the anterior cervix by using 2 interrupted nonabsorbable sutures.
6.	Each arm of the PVDF-structure was attached (at the allocated mark) with 3 titanium helices to the right and left lateral prevertebral fascia of S1 by using a fixation device.

Apical support was restored in all 10 patients (mean age: 42 years), as well as urinary continence (in all 3 patients with prior mixed urinary incontinence). No intraoperative complications occurred (vessel or ureter injury and bowel or bladder lesions). Blood loss was less than 40 mL, mean operating time was 57 minutes. Within mean follow-up of 13 months, no mesh erosions or relapse of prolapse was detected.

Restoration of apical prolapse under uterine preservation was achieved by bilateral USL replacement. This was technically achieved using a semi-circular tunneling device in order to preserve the integrity of the USL, uterus, and uterine vessels with a minimum amount of alloplastic material. Additionally, this standardized “tensioning” of the anterior vaginal wall and thereby the vesico-urethral junction also restored urinary continence (3). 

This clearly defined surgical technique led to a restoration of apical suspension under preservation of the uterus and USL´s peritoneum. Thereby, the minimum amount of synthetic material, the short operating time and rapid recovery are of advantage.

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.
Ludwig S, Becker I, Mallmann P, Jager W. Comparison of Solifenacin and Bilateral Apical Fixation in the Treatment of Mixed and Urgency Urinary Incontinence in Women: URGE 1 Study, A Randomized Clinical Trial. In Vivo. 2019;33(6):1949-57.