1.Severe uterine or vaginal vault prolapse surgical options There are many different methods of treatment for severe pelvic organ prolapse with mainly mid-pelvic defects, with a high recurrence rate after negative hysterectomy plus anterior and posterior vaginal wall repair, and the incidence of vaginal vault prolapse can be as high as 30%; some new procedures such as sacrospinous ligament fixation (SSLF), iliococcygeal muscle Some new procedures such as sacrospinous ligament fixation (SSLF), iliocostal slingplasty (PIVS), sacrocolpopexy (SC), total pelvic floor reconstruction (prolift), and posterior intravaginal slingplasty (PIVS) are available. (SSLF is mainly used in cases of uterine prolapse with laxity of the main ligament and sacral ligament, which is less invasive and especially suitable for elderly and frail patients. However, the point-to-point suture fixation is usually difficult, sometimes the anatomical positioning is not exact and special suturing instruments are needed. In addition, the curvature of the vaginal angle changes after suturing, which increases the chance of postoperative recurrence and bladder bulge, with a lower overall efficiency than SC. HUS is mainly used in patients with uterine or vaginal vault prolapse or utero-rectal fossa hernia, but it has a high recurrence rate when used alone and the results are not long lasting. PIVS is especially suitable for those who cannot tolerate complex surgery, and is usually performed by inserting an 8 mm wide polypropylene sling between the perineal body and the vaginal vault, using an IVS guide rod that enters through the pararectal space and penetrates from the tip of the vagina to form a new “ligament” to strengthen the atrophied uterosacral ligament. The effectiveness of this procedure remains to be proven. Autopsies have revealed that this procedure is supported by the mid-posterior vaginal wall rather than the vaginal vault and may have a higher postoperative failure rate. With the advent of the Prolift procedure, a breakthrough in the surgical treatment of severe pelvic organ prolapse has been achieved, with good clinical results and a holistic reconstruction of the pelvic floor from the anterior, middle, and posterior regions, with a success rate of 92% to 94.7%, a subjective cure rate of 97.6% to 98%, and a recurrence rate of only 2.4% to 4.0%. However, the complications associated with mesh implantation became more and more prominent, and the US FDA raised two warnings on this issue until the withdrawal of the Prolift series of mesh products, for which the surgical treatment of severe pelvic organ prolapse was faced with new options.Nezhat et al. first reported LSC based on transabdominal sacrocolpopexy (ASC) for the treatment of vaginal vault prolapse, after which this procedure has been continuously improved, not only to achieve better clinical outcomes but also to reduce the complications associated with transvaginal mesh surgery, and has gradually become one of the classic methods for the treatment of mid-pelvic defects, and is now used to treat patients with vault prolapse, moderate and severe POP, and failed previous pelvic floor reconstruction surgery. Therefore, through the continuous improvement of LSC, LSC has the potential to become another option for the treatment of severe pelvic organ prolapse after Prolift procedure. With the popularization of laparoscopic techniques in gynecology, the advantages of LSC such as aesthetic incision, clear visual field exposure, no alteration of pelvic floor physiological anatomy, few complications and preservation of uterus have gradually emerged, and the same clinical efficacy of ASC has been achieved.Thibault F study concluded that LSC can significantly improve the anatomical and functional outcomes of severe pelvic organ prolapse in the short to medium term. Anatomical recovery was more desirable than functional recovery. In this study, LSC was performed in 22 patients with severe pelvic organ prolapse mainly with mid-pelvic defects, among which 15 patients (68%) had anterior and posterior wall bulge of grade II or higher, and the length of the bladder-vaginal gap and recto-vaginal gap mesh were adjusted according to the degree and location of anterior and posterior wall bulge, and the anterior and posterior vaginal walls were reinforced at the same time, and TVT-O was performed at the same time in one patient with severe SUI. The success rate of the operation was 100% without intermediate opening. At 6-32 months follow-up, satisfactory anatomical recovery was obtained, with significant improvement in Aa, Ba, C, Ap, and Bp sites compared to the preoperative period, and the anatomical cure rate was 100%, with no recurrence during the follow-up period. The results of PFIQ-7, PFDI-20 and PISQ-12 questionnaires showed significant improvement in overall life and sexual life quality after surgery, but the improvement of some unidirectional indicators of urination and defecation was not satisfactory, and urination mainly showed the improvement of obstructive symptoms, and the improvement of urinary incontinence was not satisfactory, with 4 new cases of mild incontinence after surgery, including 1 case of Four of the six cases of urinary incontinence had worsened postoperative symptoms, one of which was treated with TVT-O. It has been suggested that the induction of urinary incontinence after LSC may be related to the relaxation of the patient’s systemic fascial support structures and the postoperative release of the obstruction by the preoperative prolapsed organ compression. We believe that the mesh retraction fixation may have caused a change in the angle between the bladder and the mid-superior urethra, inducing or exacerbating urinary incontinence, and does not exclude the appearance of occult incontinence after anatomical repositioning, the exact cause of which needs to be confirmed by further clinical studies. This result suggests that we can treat stress incontinence in patients with severe pelvic organ prolapse in combination with stress urinary incontinence at the same time. In addition, this study found no statistical difference between the preoperative and postoperative CRADI-8 scores, indicating that the relief of rectal symptoms after LSC was not satisfactory enough, and two patients experienced postoperative defecation weakness and a sense of incomplete defecation, which may be related to excessive tension during mesh fixation or postoperative mesh contracture on rectal compression. Anatomical recovery is closely related to functional recovery, but our study found that functional recovery is less satisfactory than anatomical recovery, especially the single index of functional recovery, which indicates that functional recovery is the result of the joint action of multiple mechanisms, and mere anatomical recovery does not mean functional recovery, which must be clearly explained to patients and families before surgery. For severe pelvic organ prolapse which is combined with anterior and posterior vaginal wall bulge of moderate degree or more, how to strengthen the anterior and posterior vaginal walls and prevent the recurrence of anterior and posterior wall bulge while strengthening the apical vaginal support with LSC is a problem that needs to be explored by the majority of gynecologists. In the study of Khan A, the incidence of reoperation for anterior vaginal wall bulge was found to be 3.4% with LSC, and the chance of mesh exposure may be increased with LSC after hysterectomy. In the present study, there were no cases of anterior and posterior wall bulge during the follow-up period, but the number of cases is still small, the follow-up time is short, and the study is self-control, so the above results, especially some single indicators of pelvic floor function recovery, need to be confirmed by further studies. 3, the main complications of LSC and prevention LSC complications have two kinds of complications: immediate and long-term. The recent complications are mainly bleeding and urinary tract and intestinal injuries. Bleeding caused by injury to the anterior sacral vessels is a more difficult intraoperative complication, because this area is rich in vascular traffic branches and it is difficult to stop bleeding. For small vessels, electrocoagulation, local compression, suture, silver clip closure, bone wax and other methods are mostly used to stop bleeding, and for those who are not treated with electrocoagulation and compression, suture or titanium clip should be used to stop bleeding after fully freeing and exposing the bleeding site, and bone wax should be applied to stop bleeding if necessary. If the thick common iliac vein and internal iliac vein on both sides of the anterior sacral region are injured, gauze strips can be quickly delivered through the poke card hole for compression while surgical assistance is requested for treatment, and if necessary, open sutures can be transferred. No injury to the presacral vessels, ureter and intestine occurred in this study, and we used a combination of blunt separation as the main method and sharp separation to fully expose the presacral area, expose the vessels in the presacral area, select sutures within the platform area of approximately 3 cm × 3 cm on the surface of the sacral promontory with no or little vascular distribution, and select angled needle sutures to avoid slipping of the needle holder with excessive suture force and causing large vascular lacerations. In addition, the retroperitoneum should be kept away from the ureter when incising under direct vision, and the rectal gap should be separated as far as possible on the outside of the yellow fat of the right rectal gap to fully protect the ureter and intestinal tube. However, one case of postoperative bleeding from the vaginal stump and vascular bleeding from the abdominal wall puncture hole occurred, which were related to the incomplete suturing of the vaginal stump and the abdominal wall puncture hole, and were relieved by compression to stop the bleeding. long-term complications after LSC mainly included mesh erosion, exposure, urinary incontinence, intestinal obstruction, and infection, etc. The incidence of mesh erosion and exposure after LSC ranged from 3.4% to 7.6%, which was related to the operator’s surgical technique and whether the uterus was removed or not. No mesh erosion, exposure, or intestinal obstruction occurred during the follow-up period of this study. We believe that the key to preventing mesh erosion and exposure is to find the correct gap, free the vaginal wall in its entirety, free the lateral rectal gap sufficiently, bury the mesh flat and tension-free in the gap on the outside of the rectal fat layer from top to bottom, fix it in the vaginal stump, and close it tightly to avoid the chance of mesh exposure.