Apical pelvic organ prolapse (POP), particularly post-hysterectomy vault prolapse, represents a significant reconstructive challenge in female urology. Robotic sacrocolpopexy (RSC) is widely regarded as the gold standard surgical approach, offering durable anatomical restoration with low long-term recurrence rates [1]. Despite its proven efficacy, RSC carries a reputation for technical complexity and a steep learning curve, often limiting adoption at centres developing minimally invasive pelvic floor programmes [2]. There is a clear need for a structured, reproducible operative framework that demystifies the procedure and enables consistent, safe execution — even in complex multi-compartment prolapse. This video presents such a structured approach through a representative clinical case, illustrating each operative step in a systematic, teachable sequence.

We present a video demonstrating robot-assisted laparoscopic sacrocolpopexy in a 54-year-old woman with Grade III vault prolapse and Stage I anterior compartment prolapse, with a 6-month history of a reducible per vaginal mass and lower urinary tract symptoms (LUTS). She had previously undergone laparoscopic hysterectomy in 2022. Preoperative evaluation included cystopanendoscopy was normal along with standard cardiac, biochemical, and imaging workup.
The operative steps were structured and annotated in the video as follows: (1) patient positioning in low lithotomy and port placement after pneumoperitoneum creation with Veress needle; (2) robotic docking; (3) anterior dissection developing the vesico-vaginal space; (4) posterior dissection creating the recto-vaginal flap; (5) retroperitoneal tunnel formation to the sacral promontory; (6) preparation of polypropylene mesh in Y-configuration (15 × 7 cm); (7) retroperitoneal mesh deployment with anterior and posterior arms secured using V-Loc sutures; (8) mesh fixation at the sacral promontory with 2-0 prolene; (9) peritonealisation and haemostasis; and (10) vaginal packing and wound closure. The use of a Y-configured synthetic mesh for simultaneous anterior and apical compartment support follows established mesh sacrocolpopexy principles [3]. Each step is labelled and narrated to serve as an operative reference.

The procedure was completed without intraoperative complications. The urethral catheter was removed on postoperative day 1; the patient voided satisfactorily with insignificant post-void residual. Upper urinary tract imaging showed no dilatation. She was haemodynamically stable at discharge and reviewed at one week with satisfactory wound healing and resolution of prolapse symptoms. No early complications — including mesh exposure, de novo urgency urinary incontinence, or voiding dysfunction — were recorded. The structured operative approach facilitated smooth execution at each anatomical step, with clear identification of the vesico-vaginal and recto-vaginal planes, safe retroperitoneal tunnelling, and secure sacral fixation.

Robotic sacrocolpopexy, when performed through a clearly defined, stepwise operative framework, is a reproducible and safe procedure for multi-compartment pelvic organ prolapse including complex post-hysterectomy vault prolapse. Our structured approach — covering port configuration, robotic docking, dual-compartment dissection, retroperitoneal mesh placement, and sacral fixation — reduces operative unpredictability and supports surgical training. This video provides a replicable template for surgeons at all stages of robotic pelvic floor reconstructive surgery, with the potential to shorten the learning curve and improve patient outcomes through standardisation of technique.

Maher C, Feiner B, Baessler K, Christmann-Schmid C, Haya N, Brown J. Surgery for women with apical vaginal prolapse. Cochrane Database Syst Rev. 2016;10:CD012376.
Paraiso MF, Jelovsek JE, Frick A, Chen CC, Barber MD. Laparoscopic compared with robotic sacrocolpopexy for vaginal prolapse: a randomized controlled trial. Obstet Gynecol. 2011;118(5):1005-1013.
Nygaard I, Brubaker L, Zyczynski HM, et al. Long-term outcomes following abdominal sacrocolpopexy for pelvic organ prolapse. JAMA. 2013;309(19):2016-2024.