Evidence - Supracervical hysterectomy, cervicosacropexy with gyno-mesh, bilateral adnexectomy, and anterior colporrhaphy, laparoscopic

Genital prolapse refers to the descent of the internal female genital organs, particularly the vagina and uterus, due to a weakness or damage to the supportive and connective tissue in the pelvis. This condition is common and increases with age. With the demographic trend of an aging population, a further increase in prevalence is expected in the coming decades. A mild prolapse can remain asymptomatic and does not necessarily have to be considered pathological. However, in cases of significant descent, a variety of symptoms can occur, significantly affecting quality of life. In such cases, various conservative and surgical treatment options are available.

Epidemiological data on pelvic organ prolapse vary depending on the definition and examination method. In population studies, a prevalence of about 3–6% is reported when only women with noticeable symptomatic prolapse complaints are counted, whereas clinical examination shows that up to ~50% of women exhibit some degree of pelvic floor prolapse. In other words, pelvic organ prolapse (POP) is estimated to affect up to half of all women after childbirth and about one-third of women overall during their lifetime. Approximately 50% of all women are estimated to develop urogenital prolapse at some point, but only about 10–20% of those affected actually seek medical help.

The cumulative probability that a woman will need surgery for prolapse is about 7–19% (lifetime risk). This corresponds to approximately one in eight women undergoing a surgical procedure to correct a prolapse during their lifetime. The annual incidence of prolapse surgeries is reported to be about 1.5–1.8 per 1000 woman-years, peaking in the age group between 60 and 69 years. Due to increasing life expectancy and demographic changes, an overall increase in cases and surgical numbers is expected in the coming decades.

Reference:

1. Bhat M, Acharya S, Agur W. Vesico-vaginal fistula presenting as overactive bladder in a case of Gellhorn pessary for vault prolapse. BMJ Case Rep. 2021 Mar 3;14(3):e240331. doi: 10.1136/bcr-2020-240331. PMID: 33658219; PMCID: PMC7931760.
2. Galan LE, Bartolo S, De Graer C, Delplanque S, Lallemant M, Cosson M. Comparison of Early Postoperative Outcomes for Vaginal Anterior Sacrospinous Ligament Fixation with or without Transvaginal Mesh Insertion. J Clin Med. 2023 May 25;12(11):3667. doi: 10.3390/jcm12113667. PMID: 37297862; PMCID: PMC10253670.
3. ACOG Practice Bulletin No.185: Pelvic organ prolapse. Obstetrics and Gynecology 2017; 130(5): e234-e250
4. Barber M.D., Maher C. Epidemiology and outcome assessment of pelvic organ prolapse. Int. Urogynecol. J. 2013;24:1783–1790. doi: 10.1007/s00192-013-2169-9.
5. Fialkow M.F., Newton K.M., Lentz G.M., Weiss N.S. Lifetime risk of surgical management for pelvic organ prolapse or urinary incontinence. Int. Urogynecol. J. 2008;19:437–440. doi: 10.1007/s00192-007-0459-9.
6. Olsen A.L., Smith V.J., Bergstrom J.O., Colling J.C., Clark A.L. Epidemiology of surgically managed pelvic organ prolapse and urinary incontinence. Obstet. Gynecol. 1997;89:501–506. doi: 10.1016/S0029-7844(97)00058-6.
7. Nygaard I, Barber MD, Burgio KL, et al. Prevalence of symptomatic pelvic floor disorders in US women. JAMA 2008; 300:1311.
8. Barber MD, Walters MD, Bump RC. Short forms of two condition-specific quality-of-life questionnaires for women with pelvic floor disorders (PFDI-20 and PFIQ-7). Am J Obstet Gynecol 2005; 193:103.

The cause of pelvic organ prolapse is a weakness or damage to the muscular and connective tissue support structures of the pelvic floor. Central to this is often a birth trauma: Repeated vaginal deliveries—especially complicated or very long births—can lead to overstretching and tears of the pelvic floor muscles (e.g., levator ani) and fascia, which permanently impairs the static stability of the pelvic floor. The most important risk factors therefore include multiparity (multiple pregnancies and vaginal births) and advanced age (age-related connective tissue weakness). Other contributing factors include obesity, chronically increased intra-abdominal pressure—such as from chronic cough (e.g., COPD) or chronic constipation—as well as heavy physical labor over many years. Previous surgeries in the pelvis (e.g., hysterectomy or other pelvic floor surgeries) also increase the risk of later genital prolapse, as they can weaken the integral support structure. However, this is not entirely consistent in studies. In addition to mechanical factors, constitutional and neurological aspects also play a role. A familial connective tissue weakness (genetic predisposition) or certain ethnic backgrounds can increase susceptibility to prolapse. For example, studies have observed a higher prevalence of prolapse in women of European descent compared to women of African descent. Neurological damage that impairs the innervation of the pelvic floor muscles (such as lesions of the pudendal nerves or spinal cord injuries) can also contribute to the pathogenesis. Overall, a genital prolapse usually arises multifactorially through the interaction of several risk factors on an individually variably resilient muscular and fascial support tissue.

Reference:

1. Bazi T et al.: Prevention of pelvic floor disorders: international urogynecological association research and development committee opinion. Int Urogynecol J 2016; 27(12): 1785-95
2. Nygaard I, Barber MD, Burgio KL, et al. Prevalence of symptomatic pelvic floor disorders in US women. JAMA 2008; 300:1311.
3. Sze EH, Sherard GB 3rd, Dolezal JM. Pregnancy, labor, delivery, and pelvic organ prolapse. Obstet Gynecol 2002; 100:981.
4. Mant J, Painter R, Vessey M. Epidemiology of genital prolapse: observations from the Oxford Family Planning Association Study. Br J Obstet Gynaecol 1997; 104:579.
5. Jelovsek JE, Maher C, Barber MD. Pelvic organ prolapse. Lancet 2007; 369:1027.
6. Vergeldt TF, Weemhoff M, IntHout J, Kluivers KB. Risk factors for pelvic organ prolapse and its recurrence: a systematic review. Int Urogynecol J 2015; 26:1559.
7. Hendrix SL, Clark A, Nygaard I, et al. Pelvic organ prolapse in the Women's Health Initiative: gravity and gravidity. Am J Obstet Gynecol 2002; 186:1160.
8. Giri A, Hartmann KE, Hellwege JN, et al. Obesity and pelvic organ prolapse: a systematic review and meta-analysis of observational studies. Am J Obstet Gynecol 2017.
9. Si K, Yang Y, Liu Q, et al. Association of Central and General Obesity Measures With Pelvic Organ Prolapse. Obstet Gynecol 2025; 145:108.
10. Whitcomb EL, Rortveit G, Brown JS, et al. Racial differences in pelvic organ prolapse. Obstet Gynecol 2009; 114:1271.
11. Weber AM, Walters MD, Ballard LA, et al. Posterior vaginal prolapse and bowel function. Am J Obstet Gynecol 1998; 179:1446.
12. Iglesia CB, Smithling KR. Pelvic Organ Prolapse. Am Fam Physician 2017; 96:179.
13. Lince SL, van Kempen LC, Vierhout ME, Kluivers KB. A systematic review of clinical studies on hereditary factors in pelvic organ prolapse. Int Urogynecol J 2012; 23:1327.

A mild descent often proceeds asymptomatically and is often only discovered incidentally during gynecological examinations. However, as the descent progresses, characteristic symptoms appear. Most commonly, patients complain of a sensation of pressure and a foreign body in the lower abdomen or vagina – many describe the feeling of a "balloon" or a bulge that can extend to the vaginal entrance. This sensation typically intensifies when standing and in the evening, while it subsides when lying down.

Accompanying bladder dysfunctions may occur. These include a decrease in urinary stream strength, the feeling of incomplete bladder emptying, or a residual urine sensation. Occasionally, urinary incontinence (often stress incontinence) occurs, although paradoxically, this may initially be masked by the descent – a higher-grade prolapse can kink the urethra and thus conceal existing incontinence. Conversely, after surgical correction of a prolapse, previously hidden incontinence may become apparent. Some patients also report irritative symptoms such as frequent urination or recurrent urinary tract infections due to incomplete emptying.

Bowel-related symptoms are also possible, especially with a rectocele (descent of the posterior vaginal wall due to bulging of the rectum). A typical symptom is a sensation of obstruction during defecation: bowel movements are difficult, and the patient may need to strain or assist manually. The so-called "splinting" is a characteristic behavior where the woman presses with her fingers against the posterior vaginal wall or perineal tissue to facilitate bowel movements. Additionally, a feeling of incomplete evacuation or rectal pressure may occur. In severe cases, accompanying constipation is present.

Sexual dysfunctions can also be caused or exacerbated by a pronounced descent. Some women report a loss of sexual sensation or mechanical obstruction during intercourse, for example, if the bulge is bothersome. Less commonly, patients complain of pain during intercourse (dyspareunia) due to the descent – this is more likely to occur if there are already mucosal ulcerative changes or accompanying inflammations due to a far-protruding uterus/vaginal stump. Importantly, the extent of symptoms often correlates with the severity of the prolapse. Significant symptoms usually appear only from a prolapse stage II–III, when the tissue has descended to the level of the hymen or beyond. In cases of very far-protruding organs (total prolapse), complications such as pressure ulcers on exposed vaginal mucosa or – rarely – kidney obstruction (hydronephrosis due to ureteral kinking) may occur.

Reference:

1. Tan JS, Lukacz ES, Menefee SA, et al. Predictive value of prolapse symptoms: a large database study. Int Urogynecol J Pelvic Floor Dysfunct 2005; 16:203.
2. Bradley CS, Nygaard IE. Vaginal wall descensus and pelvic floor symptoms in older women. Obstet Gynecol 2005; 106:759.
3. Barber MD, Neubauer NL, Klein-Olarte V. Can we screen for pelvic organ prolapse without a physical examination in epidemiologic studies? Am J Obstet Gynecol 2006; 195:942.
4. Ellerkmann RM, Cundiff GW, Melick CF, et al. Correlation of symptoms with location and severity of pelvic organ prolapse. Am J Obstet Gynecol 2001; 185:1332.
5. Marinkovic SP, Stanton SL. Incontinence and voiding difficulties associated with prolapse. J Urol 2004; 171:1021.
6. Jelovsek JE, Maher C, Barber MD. Pelvic organ prolapse. Lancet 2007; 369:1027.
7. Heit M, Rosenquist C, Culligan P, et al. Predicting treatment choice for patients with pelvic organ prolapse. Obstet Gynecol 2003; 101:1279.
8. Mouritsen L, Larsen JP. Symptoms, bother and POPQ in women referred with pelvic organ prolapse. Int Urogynecol J Pelvic Floor Dysfunct 2003; 14:122.
9. Whitcomb EL, Lukacz ES, Lawrence JM, et al. Prevalence of defecatory dysfunction in women with and without pelvic floor disorders. J Pelvic Surg 2009; 15:179.
10. Weber AM, Walters MD, Schover LR, Mitchinson A. Sexual function in women with uterovaginal prolapse and urinary incontinence. Obstet Gynecol 1995; 85:483.
11. Barber MD, Visco AG, Wyman JF, et al. Sexual function in women with urinary incontinence and pelvic organ prolapse. Obstet Gynecol 2002; 99:281.

The treatment of prolapse primarily depends on the symptomatology rather than the objective findings. Asymptomatic or mildly symptomatic cases often do not require interventional therapy. Conservative measures are initially prioritized. These primarily include targeted pelvic floor training (physiotherapy) to strengthen the muscles and the use of pessaries. A pessary (e.g., ring or cube pessary) is inserted into the vagina and can mechanically prevent further descent of organs, often alleviating the sensation of pressure. Conservative therapies can improve symptoms and slow progression, but they require motivation and, in the case of pessaries, regular cleaning/replacement (every few months, usually by a physician). If conservative therapy is insufficient or the prolapse is very pronounced, surgical correction may be considered. According to current guidelines, surgery should generally only be performed for symptomatic prolapse. The choice of the appropriate procedure depends on various factors, particularly which compartments are affected, the severity of the prolapse, and the patient's needs (e.g., desire to preserve the uterus).

Reference:

1. Culligan PJ. Nonsurgical management of pelvic organ prolapse. Obstet Gynecol 2012; 119:852.
2. Hagen S, Stark D. Conservative prevention and management of pelvic organ prolapse in women. Cochrane Database Syst Rev 2011; :CD003882.
3. Braekken IH, Majida M, Engh ME, Bø K. Can pelvic floor muscle training reverse pelvic organ prolapse and reduce prolapse symptoms? An assessor-blinded, randomized, controlled trial. Am J Obstet Gynecol 2010; 203:170.e1.
4. Hagen S, Stark D, Glazener C, et al. Individualised pelvic floor muscle training in women with pelvic organ prolapse (POPPY): a multicentre randomised controlled trial. Lancet 2014; 383:796.
5. Wiegersma M, Panman CM, Kollen BJ, et al. Effect of pelvic floor muscle training compared with watchful waiting in older women with symptomatic mild pelvic organ prolapse: randomised controlled trial in primary care. BMJ 2014; 349:g7378.
6. Li C, Gong Y, Wang B. The efficacy of pelvic floor muscle training for pelvic organ prolapse: a systematic review and meta-analysis. Int Urogynecol J 2016; 27:981.
7. Sansone S, Sze C, Eidelberg A, et al. Role of Pessaries in the Treatment of Pelvic Organ Prolapse: A Systematic Review and Meta-analysis. Obstet Gynecol 2022; 140:613.
8. Klein J, Stoddard M, Rardin C, et al. The Role of Pessaries in the Treatment of Women With Stress Urinary Incontinence: A Systematic Review and Meta-Analysis. Female Pelvic Med Reconstr Surg 2022; 28:e171.

The most common form of genital prolapse affects the anterior compartment, i.e., the descent of the bladder with bulging of the anterior vaginal wall (cystocele). Cystoceles account for approximately 80% of surgical indications in prolapse surgery. The standard operation for this is the anterior colporrhaphy (anterior vaginal repair). Through a vaginal approach, the weakened fascia vesicovaginalis (connective tissue layer between the bladder and vagina) is exposed and plicated in the midline to lift the bladder wall and tighten the anterior vaginal wall. Excess vaginal skin is usually removed. Anterior colporrhaphy is a relatively short, tissue-sparing procedure and can often be performed under regional anesthesia. This can also be done laparoscopically. However, native tissue repair alone in the anterior compartment shows a comparatively high recurrence rate. Studies report that depending on the definition and observation period, up to 30-40% of patients experience a significant cystocele recurrence. This is partly because the underlying connective tissue weakness persists. To increase the success rate, it is now recommended to always perform apical suspension in higher-grade cystoceles—e.g., by simultaneous fixation of the vaginal stump or uterus (see middle compartment)—as an untreated defect in the middle compartment often contributes to a recurrence of the cystocele.

In the past, synthetic mesh implants were often used to reinforce the anterior wall repair. These mesh-reinforced anterior repairs show significantly fewer anatomical recurrences compared to colporrhaphy alone but were associated with increased complications. Following warnings from regulatory authorities and negative publicity, the use of transvaginal meshes for cystocele correction has significantly declined. Today, anterior colporrhaphy is usually performed again as a pure "native tissue" technique (without mesh), possibly combined with an additional support suture to ligaments or a colposuspension, if indicated. In cases of pronounced recurrent prolapse in this compartment, mesh augmentation may be considered in exceptional cases, but only after strict indication assessment.

Reference:

1. Galan LE, Bartolo S, De Graer C, Delplanque S, Lallemant M, Cosson M. Comparison of Early Postoperative Outcomes for Vaginal Anterior Sacrospinous Ligament Fixation with or without Transvaginal Mesh Insertion. J Clin Med. 2023 May 25;12(11):3667. doi: 10.3390/jcm12113667. PMID: 37297862; PMCID: PMC10253670.
2. Shi W, Guo L. Risk factors for the recurrence of pelvic organ prolapse: a meta-analysis. J Obstet Gynaecol. 2023 Dec;43(1):2160929. doi: 10.1080/01443615.2022.2160929. PMID: 36645334.
3. Chen L, Ashton-Miller JA, Hsu Y, DeLancey JO. Interaction among apical support, levator ani impairment, and anterior vaginal wall prolapse. Obstet Gynecol. 2006;108(2):324-32.
4. Feldner PC, Jr., Castro RA, Cipolotti LA, Delroy CA, Sartori MG, Girao MJ. Anterior vaginal wall prolapse: a randomized controlled trial of SIS graft versus traditional colporrhaphy. Int Urogynecol J Pelvic Floor Dysfunct. 2010;21(9):1057-63.
5. Guerette NL, Peterson TV, Aguirre OA, Vandrie DM, Biller DH, Davila GW. Anterior repair with or without collagen matrix reinforcement: a randomized controlled trial. Obstet Gynecol. 2009;114(1):59-65.
6. Altman D, Vayrynen T, Engh ME, Axelsen S, Falconer C. Anterior colporrhaphy versus transvaginal mesh for pelvic-organ prolapse. N Engl J Med. 2011;364(19):1826-36.

The middle compartment includes the upper portion of the vagina – thus, prolapses of the cervix or uterus (cervical or uterine prolapse) or a vaginal vault prolapse following a previous hysterectomy. The surgical challenge here is to restore the apical fixation of the vagina. Both vaginal and abdominal surgical procedures are available, depending on patient factors and preferences.

Vaginally, for example, a fixation of the vaginal apex to the sacrospinous ligament can be performed – a procedure also referred to in the literature as the Amreich-Richter operation (after the first describers) and corresponds to sacrospinous fixation in English. Here, the upper vaginal edge (with uterus preservation, the cervix) is unilaterally attached to the sacrospinous ligament in the area of the right ischial spine. This measure is often performed directly following a vaginal hysterectomy (if the uterus is still present) to immediately fix the resulting vaginal stump. The sacrospinous fixation has the advantage of being performed vaginally and thus relatively gently, without an abdominal incision. The operation duration is moderate, and no foreign material is required. A disadvantage can be a slight asymmetry of the vaginal axis (pull to the fixed side), and occasionally temporary buttock pain or paresthesias occur due to irritation of the sciatic nerve or its branches. Overall, sacrospinous fixations achieve good symptom control; however, the objective success rates are somewhat lower compared to abdominal procedures. Randomized comparisons have shown that sacrocolpopexy (abdominal surgery with suspension of the vaginal apex to the promontory) has fewer recurrences and a higher anatomical correction rate in the long term than vaginal fixation techniques. Also, the subjective feeling of a prolapse recurs less frequently after sacrocolpopexy. Therefore, abdominal sacrocolpopexy (or sacrohysteropexy with preserved uterus) is considered the gold standard for treating vaginal vault prolapse today. Here, a synthetic mesh is usually attached to the front and back of the vagina and anchored to the bony promontory (sacrum) to achieve stable suspension. This procedure shows excellent anatomical results and low recurrence rates but requires a larger intervention (conventional open or laparoscopic) and the implantation of foreign material. There is also the possibility of using autologous tissue. In this case, an autologous tendon of the semitendinosus muscle from the thigh is harvested and replaces the controversial synthetic meshes.

A newer alternative procedure in the middle compartment is laparoscopic pectopexy (unilateral or bilateral, with mesh or non-absorbable suture). Instead of attaching the vaginal apex to the sacrum, a mesh band is placed on the two pectineal ligaments (Cooper's ligaments) on the right or both sides in the lateral pelvis, and the vagina or uterus is suspended from it. Theoretically, pectopexy offers advantages for patients for whom sacrocolpopexy would be riskier – for example, in cases of extensive adhesions in the pelvis or severe obesity, as the narrow promontory area is avoided. Initial studies suggest that pectopexy achieves comparable results to sacrocolpopexy in terms of success rate and functionality. An analysis found no significant differences in anatomical success rates, postoperative vaginal length, or the need for re-operations between sacrocolpopexy and pectopexy. While classic sacrocolpopexy remains the standard, pectopexy can be a sensible alternative for selected patients with contraindications to sacral fixation. However, as with all newer techniques, long-term results are awaited before final recommendations can be made.

Reference:

1. Benson JT, Lucente V, McClellan E. Vaginal versus abdominal reconstructive surgery for the
   treatment of pelvic support defects: a prospective randomized study with long-term outcome evaluation.Am J Obstet Gynecol. 1996;175(6):1418-21.
2. Morgan DM, Rogers MA, Huebner M, Wei JT, Delancey JO. Heterogeneity in anatomic outcome
   of sacrospinous ligament fixation for prolapse: a systematic review. Obstet Gynecol. 2007;109(6):1424-33.
3. Beer M, Kuhn A. Surgical techniques for vault prolapse: a review of the literature. Eur J Obstet
   Gynecol Reprod Biol. 2005;119(2):144-55.
4. Nygaard IE, McCreery R, Brubaker L, Connolly A, Cundiff G, Weber AM, et al. Abdominal
   sacrocolpopexy: a comprehensive review. Obstet Gynecol. 2004;104(4):805-23.
5. Maher CF, Qatawneh AM, Dwyer PL, Carey MP, Cornish A, Schluter PJ. Abdominal sacral
   colpopexy or vaginal sacrospinous colpopexy for vaginal vault prolapse: a prospective randomized study. Am J Obstet Gynecol. 2004;190(1):20-6.
6. Lo TS, Horng SG, Huang HJ, Lee SJ, Liang CC. Repair of recurrent vaginal vault prolapse using
   sacrospinous ligament fixation with mesh interposition and reinforcement. Acta Obstet Gynecol Scand. 2005;84(10):992-5.
7. Barber MD, Maher C. Apical prolapse. Int Urogynecol J. 2013;24(11):1815-33.
8. Liu CK, Tsai CP, Chou MM, Shen PS, Chen GD, Hung YC, et al. A comparative study of
   laparoscopic sacrocolpopexy and total vaginal mesh procedure using lightweight polypropylene meshes for prolapse repair. Taiwan J Obstet Gynecol. 2014;53(4):552-8.
9. Chan CM, Liang HH, Go WW, To WW, Mok KM. Laparoscopic sacrocolpopexy for uterine and
   post-hysterectomy prolapse: anatomical and functional outcomes. Hong Kong Med J. 2011;17(4):301-5.
10. Heusinkveld J, Khandekar M, Winget V, Tigner A, Addis I. Pectopexy vs sacrocolpopexy: an analysis of 50 cases in a North American hospital. AJOG Glob Rep. 2023 Jul 17;3(3):100254. doi: 10.1016/j.xagr.2023.100254. PMID: 37600747; PMCID: PMC10432240.
11. 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 doi: 10.1002/14651858.CD012376.
12. Hornemann, A., Weissenbacher, T., Hoch, B. et al. From thigh to pelvis: female genital prolapse repair with an autologous semitendinosus tendon transplant. Int Urogynecol J 34, 2373–2380 (2023). https://doi.org/10.1007/s00192-023-05512-6

A descent of the posterior compartment involves the posterior vaginal wall and the adjacent rectum. Typically, it is a rectocele, where weakness of the rectovaginal septum leads to a bulging of the rectum into the vagina (sometimes accompanied by an enterocele, which is a protrusion of the peritoneum/small intestine into the posterior vaginal wall area). The standard therapy for a symptomatic rectocele is the posterior colporrhaphy (posterior vaginal repair). Through a vaginal approach, the rectovaginal fascia is exposed and tightened or duplicated with sutures to strengthen the posterior vaginal wall and push the rectum back to its anatomical position. Rarely, an additional levatorplasty is performed, where the medial edges of the levator ani muscles are brought closer together to reduce the pelvic floor outlet and strengthen the perineal support tissue, although this can lead to de novo dyspareunia. Excess vaginal skin on the posterior wall is removed.

The posterior colporrhaphy generally shows good functional results: Many patients report postoperative relief in bowel movements and the disappearance of the bothersome foreign body sensation. The anatomical success rates are high.

However, it is important to avoid excessive narrowing. If the posterior wall repair is too tight, it can lead to pain during intercourse, especially in sexually active women. Literature reports the rate of newly occurring dyspareunia after posterior repair to be about 8–15% depending on the study​ – significantly lower than the dyspareunia rates reported for mesh-augmented procedures, but still noteworthy.

Reference:

1. Kahn MA, Stanton SL. Posterior colporrhaphy: its effects on bowel and sexual function. Br J Obstet Gynaecol. 1997;104(1):82-6.
2. Sand PK, Koduri S, Lobel RW, Winkler HA, Tomezsko J, Culligan PJ, et al. Prospective randomized trial of polyglactin 910 mesh to prevent recurrence of cystoceles and rectoceles. Am J Obstet Gynecol. 2001;184(7):1357-62.
3. Mouritsen L, Kronschnabl M, Lose G. Long-term results of vaginal repairs with and without xenograft reinforcement. Int Urogynecol J. 2010;21(4):467-73.
4. Abramov Y, Gandhi S, Goldberg RP, Botros SM, Kwon C, Sand PK. Site-specific rectocele repair compared with standard posterior colporrhaphy. Obstet Gynecol. 2005;105(2):314-8
5. Paraiso MF, Barber MD, Muir TW, Walters MD. Rectocele repair: a randomized trial of three surgical techniques including graft augmentation. Am J Obstet Gynecol. 2006;195(6):1762-71.
6. Committee Opinion No. 694: Management of Mesh and Graft Complications in Gynecologic Surgery. Obstetrics and Gynecology 2017; 129(4): e102-e8
7. The Scottish Independent Review of the use, safety and efficacy of transvaginal mesh implants in the treatment of stress urinary incontinence and pelvic organ prolapse in women. 2015

The assessment of surgical success in prolapse surgery significantly depends on the definition: If a strict anatomical criterion is applied (e.g., "no prolapse >1 cm below the hymen"), recurrence rates are significantly higher than when clinical success (symptom relief) is evaluated. Overall, it must be assumed that the long-term recurrence rate after a single operation is relatively high. A meta-analysis of 29 studies estimated the average recurrence rate (in terms of an objective prolapse) after prolapse surgeries at around 38%. Accordingly, failure rates in the literature vary depending on the procedure and follow-up between about 10% and over 50%. This wide range is explained by different definitions and follow-up times as well as varied surgical techniques in the studies.

Tendentially, an anterior colporrhaphy is the most prone to recurrence. Thus, after isolated anterior colporrhaphy, a cystocele recurs sooner or later in up to one-third of cases.

Apical fixations show better long-term results: After abdominal sacrocolpopexy, objective recurrence rates in studies are often below 10%. In direct comparison with vaginal techniques (e.g., sacrospinous fixation), sacrocolpopexy performs significantly better in terms of anatomical durability and subjective prolapse freedom. However, the use of synthetic mesh in sacrocolpopexy involves other risks that need to be weighed.

The use of transvaginal meshes in vaginal surgery led to a reduction in anatomical recurrences and fewer repeat prolapse surgeries compared to classical colporrhaphy in randomized studies. However, higher rates of complications and side effects were observed, particularly erosion events and dyspareunia. Due to these risks, mesh-based procedures are now used much more restrictively.

Reference:

1. Shi W, Guo L. Risk factors for the recurrence of pelvic organ prolapse: a meta-analysis. J Obstet Gynaecol. 2023 Dec;43(1):2160929. doi: 10.1080/01443615.2022.2160929. PMID: 36645334.
2. Lensen EJM, Withagen MIJ, Kluivers KB, Milani AL, Vierhout ME. Surgical treatment of pelvic organ prolapse: a historical review with emphasis on the anterior compartment. Int Urogynecol J. 2013;24:1593–1602. doi: 10.1007/s00192-013-2074-2.
3. Weber AM, Walters MD. Anterior vaginal prolapse: review of anatomy and techniques of surgical repair. Obstet Gynecol. 1997;89:311–318. doi: 10.1016/S0029-7844(96)00322-5.
4. Lensen EJ, Stoutjesdijk JA, Withagen MI, Kluivers KB, Vierhout MB. Technique of anterior colporrhaphy: a Dutch evaluation. Int Urogynecol J. 2011;22:557–561. doi: 10.1007/s00192-010-1353-4.
5. Maher C, Feiner B, Baessler K, Schmid C. Surgical management of pelvic organ prolapse in women. Cochrane Database Syst Rev. 2013;4:CD004014.
6. Maher CF. Qatawneh AM., Dwyer PL. Abdominal sacrocolpopexy or vaginal sacrospinous colpopexy for vaginal vault prolapse: A prospective randomized study. Am J Obstet Gynecol 2004;190:20-26.
7. Barber MD, Maher C. Apical prolapse. Int Urogynecol J. 2013;24(11):1815-33
8. Liu CK, Tsai CP, Chou MM, Shen PS, Chen GD, Hung YC, et al. A comparative study of laparoscopic sacrocolpopexy and total vaginal mesh procedure using lightweight polypropylene meshes for prolapse repair. Taiwan J Obstet Gynecol. 2014;53(4):552-8.
9. Chan CM, Liang HH, Go WW, To WW, Mok KM. Laparoscopic sacrocolpopexy for uterine and post-hysterectomy prolapse: anatomical and functional outcomes. Hong Kong Med J. 2011;17(4):301-5.

The use of synthetic meshes in prolapse surgery has been a subject of controversial discussions for years. In principle, polypropylene meshes can replace weakened fascial structures and thus improve anatomical outcomes, especially in the anterior compartment where conventional techniques often fail to hold adequately. However, in practice, significant complications have been observed with transvaginal meshes. These include primarily mesh erosions (exposure of the mesh in the vaginal skin), chronic pain due to mesh contraction or shrinkage, and dyspareunia. Guidelines indicate the following approximate frequencies for such complications: de novo dyspareunia in 3-13% of cases, painful mesh shrinkage in 3–19%, and vaginal erosions of the mesh in about 0–30%. Infections (3%), chronic inflammations, or fistula formations (rare) have also been described. These problems often necessitate further surgical intervention for (partial) removal of the mesh.

Due to these safety concerns, regulatory authorities have responded. The U.S. FDA warned in 2008 and 2011 that complications with transvaginal prolapse meshes were "not rare," and tightened regulations. In 2016, transvaginal prolapse mesh was reclassified as high-risk (Class III) in the U.S., and manufacturers were required to demonstrate long-term safety and effectiveness. As this proof was not provided to the agency's satisfaction, the FDA withdrew approval for all remaining transvaginal mesh products for POP repair in April 2019 and prohibited their distribution. Similar restrictions or moratoriums have been imposed in many countries (including the UK and Australia).

Current guidelines and professional societies now recommend restricting the use of meshes to specific situations. The German-Austrian-Swiss guideline (DGGG/OEGGG/SGGG) advises using transvaginal mesh implants only in cases of recurrent prolapse or certain risk constellations, and even then only by experienced surgeons after thorough patient counseling. Whenever possible, native tissue techniques should be preferred. Overall, the answer to "Mesh – yes or no?" today is rather: generally no, except in selected cases with careful benefit-risk assessment. It is important to inform the patient about the potential risks (erosion rate, possible pain, etc.) before a planned mesh implantation and to discuss alternative options (e.g., repeat native repair or ultimately a pessary-supported life with the prolapse). The FDA has clarified that no transvaginal mesh has yet demonstrated superiority over traditional surgical techniques in long-term outcomes without unacceptable risks.

Reference:

1. El-Nazer MA, Gomaa IA, Ismail Madkour WA, Swidan KH, El-Etriby MA. Anterior colporrhaphy versus repair with mesh for anterior vaginal wall prolapse: a comparative clinical study. Arch Gynecol Obstet. 2012;286(4):965-72.
2. Delroy CA, Castro Rde A, Dias MM, Feldner PC, Jr., Bortolini MA, Girao MJ, et al. The use of transvaginal synthetic mesh for anterior vaginal wall prolapse repair: a randomized controlled trial. Int Urogynecol J. 2013;24(11):1899-907.
3. Sivaslioglu AA, Unlubilgin E, Dolen I. A randomized comparison of polypropylene mesh surgery with site-specific surgery in the treatment of cystocele. Int Urogynecol J Pelvic Floor Dysfunct. 2008;19(4):467-71.
4. Abed H, Rahn DD, Lowenstein L, Balk EM, Clemons JL, Rogers RG, et al. Incidence and management of graft erosion, wound granulation, and dyspareunia following vaginal prolapse repair with graft materials: a systematic review. Int Urogynecol J. 2011;22(7):789-98.
5. Sung VW, Rogers RG, Schaffer JI, Balk EM, Uhlig K, Lau J, et al. Graft use in transvaginal pelvic organ prolapse repair: a systematic review. Obstet Gynecol. 2008;112(5):1131-42.
6. Menefee SA, Dyer KY, Lukacz ES, Simsiman AJ, Luber KM, Nguyen JN. Colporrhaphy Compared With Mesh or Graft-Reinforced Vaginal Paravaginal Repair for Anterior Vaginal Wall Prolapse: A Randomized Controlled Trial. Obstet Gynecol. 2011.
7. Committee Opinion No. 694: Management of Mesh and Graft Complications in Gynecologic Surgery. Obstetrics and Gynecology 2017; 129(4): e102-e8
8. Scottish Government, Scottish Independent Review of the Use, Safety and Efficacy of Transvaginal Mesh Implants in the Treatment of Stress Urinary Incontinence and Pelvic Organ Prolapse in Women: Interim Report, 2 October 2015; Scottish Government, Scottish Independent Review of the Use, Safety and Efficacy of Transvaginal Mesh Implants in the Treatment of Stress Urinary Incontinence and Pelvic Organ Prolapse in Women: Final Report, 27 March 2017.
9. NHS England, Mesh Working Group, Interim Report, December 2015; NHS England, Mesh Oversight Group Report, 25 July 2017
10. RANZCOG, Submission 36, p. 1; RANZCOG Communique, Use of mesh for the surgical treatment of vaginal prolapse and urinary incontinence, updated 29 October 2017: https://www.ranzcog.edu.au/news/Use-of-mesh-for-the-surgical-treatment-of-vaginal (accessed 17 January 2017).
11. Urogynecologic Surgical Mesh Implants. U.S. Food and Drug Administration. April 2019. www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/ImplantsandProsthetics/UroGynSurgicalMesh/default.htm (Accessed on April 18, 2019).
12. Urogynecologic surgical mesh: Update on the safety and effectiveness of transvaginal placement for pelvic organ prolapse. US Food and Drug Administration, 2011.
13. Maher C, Feiner B, Baessler K, et al. Transvaginal mesh or grafts compared with native tissue repair for vaginal prolapse. Cochrane Database Syst Rev 2016; 2:CD012079.
14. Chughtai B, Barber MD, Mao J, et al. Association Between the Amount of Vaginal Mesh Used With Mesh Erosions and Repeated Surgery After Repairing Pelvic Organ Prolapse and Stress Urinary Incontinence. JAMA Surg 2017; 152:257.
15. Glazener CM, Breeman S, Elders A, et al. Mesh, graft, or standard repair for women having primary transvaginal anterior or posterior compartment prolapse surgery: two parallel-group, multicentre, randomised, controlled trials (PROSPECT). Lancet 2017; 389:381.
16. Chughtai B, Mao J, Asfaw TS, et al. Long-term Device Outcomes of Mesh Implants in Pelvic Organ Prolapse Repairs. Obstet Gynecol 2020; 135:591.
17. Reid FM, Aucott L, Glazener CMA, et al. PROSPECT: 4- and 6-year follow-up of a randomised trial of surgery for vaginal prolapse. Int Urogynecol J 2023; 34:67.
18. Hung MJ, Liu FS, Shen PS, Chen GD, Lin LY, Ho ES. Factors that affect recurrence after anterior colporrhaphy procedure reinforced with four-corner anchored polypropylene mesh. Int Urogynecol J Pelvic Floor Dysfunct. 2004;15(6):399-406; discussion
19. Handel LN, Frenkl TL, Kim YH. Results of cystocele repair: a comparison of traditional anterior colporrhaphy, polypropylene mesh and porcine dermis. J Urol. 2007;178(1):153-6; discussion 6.
20. DGGG-Leitlinie: Descensus genitalis der Frau. AWMF-Leitlinien-Register Nr. 015/006

As with any surgical therapy, the surgical risks must also be considered in prolapse surgery. In addition to the general risks (anesthesia complications, thrombosis/embolism, infections), there are some specific potential complications:

Injury to adjacent organs: In vaginal procedures, there is a slight risk of injuring the bladder or urethra (e.g., bladder injury in about 1–2% of anterior colporrhaphies, depending on the study). Ureteral injuries are also possible in rare cases, especially with extensive fixation sutures in the parametrium area. In posterior repairs, rectal or anal canal injury can occur in exceptional cases. Abdominal/laparoscopic approaches carry a (very low) risk of bowel lesions or vascular injuries in the pelvis.

Bleeding: Intraoperative bleeding of larger vessels is rare but possible. Particularly in sacrospinous fixations, the proximity to the superior gluteal artery and the venous plexus in the pelvis can become relevant. Postoperative bleeding or hematoma formation in the vaginal wall can cause pain. Overall, blood loss in most pelvic floor procedures is moderate; transfusions are only needed in exceptional cases.

Infections: Wound infections in the vaginal area are rare. However, vaginal infections or abscesses can occur. A bladder catheter also promotes the occurrence of a urinary tract infection postoperatively. Perioperative antibiotic prophylaxis is often given to prevent infections.

Thrombosis/Embolism: As with all major surgeries, there is a risk of thrombosis in pelvic floor operations. Early mobilization of the patient and thrombosis prophylaxis (heparin, compression stockings) counteract this. Overall, the risk is considered low.

Postoperative bladder emptying disorder: After a prolapse operation (especially after anterior repair or combined fixation), there may be temporary voiding problems. Causes include swelling, altered anatomy, or temporary neural impairment. Typically, bladder function normalizes within a few days. In ~5–15% of cases, a temporary indwelling catheter or intermittent self-catheterization is required for a few days until spontaneous voiding is adequate. Permanent voiding problems are rare.

New onset urinary incontinence: By eliminating the prolapse, previously hidden stress incontinence sometimes becomes apparent. Studies show that about 10–20% of patients experience stress incontinence for the first time after prolapse surgery. To prevent this, a so-called "cough test" with elevated prolapse is performed preoperatively; if hidden incontinence is detected, a suburethral sling (e.g., TVT) can be placed intraoperatively if necessary. If significant incontinence develops postoperatively, it can be corrected in a second step with a sling procedure.

Sexual function and dyspareunia: Although deterioration of sexual function after prolapse surgery is feared, data show that most women do not experience this – on the contrary, long-term studies often show stable or improved sexual satisfaction after prolapse correction, as the disturbing sensation of prolapse is eliminated. However, some patients may experience new-onset dyspareunia. Causes include scarring in the vagina, tightening/narrowing of the vaginal skin (especially after posterior repair), or – in mesh operations – chronic pain from the material. Rates of de-novo dyspareunia vary depending on the surgical procedure: around 8–15% after native-tissue repairs alone, while higher rates up to ~20% are reported after transvaginal mesh augmentation. Important are gentle surgical techniques (no unnecessary tightening of the vagina) and good postoperative local estrogenization to keep the mucosa elastic.

Mesh-specific complications: If a synthetic mesh was used (especially in sacrocolpopexy or previously in transvaginal mesh kits), there are additional risks. These include mesh erosions into the vagina or adjacent organs (bladder, rectum), which sometimes occur years after the procedure. Smaller erosions can be treated conservatively or by trimming the exposed mesh portion, but extensive erosions may require surgical mesh excision. Other mesh-specific problems include chronic pain, scar formation with shrinkage, and possibly organ-crossing fistulas. These complications are overall rare but serious, which is why mesh use has been significantly limited.

Recurrent prolapse: Despite initially successful surgery, a prolapse can recur in the long term – either in the same compartment (true recurrence) or in a previously unaffected other compartment. Overall, the anatomical recurrence rate is around 20–30% according to studies, but the clinically relevant recurrence rate is significantly lower. If a recurrent prolapse causes symptoms, conservative (pessary, physiotherapy) or surgical treatment can be pursued again, depending on the severity and health status of the patient. Patients should be informed that a once-operated pelvic floor does not have to be "cured forever," and further interventions may be necessary over the course of life (in about every 10th patient) – however, repeat surgeries are usually less extensive and can specifically address the newly affected compartment.

References:

1. Paine M, Harnsberger JR, Whiteside JL. Transrectal mesh erosion remote from sacrocolpopexy: management and comment. Am J Obstet Gynecol. 2010;203(2):e11-3.
2. Nicolson A, Adeyemo D. Colovaginal fistula: a rare long-term complication of polypropylene mesh sacrocolpopexy. J Obstet Gynaecol Res. 2009;29(5):444-5.
3. Karateke A, Cam C, Ayaz R. Unilateral hydroureteronephrosis after a mesh procedure. J Minim Invasive Gynecol. 2010;17(2):232-4.
4. Huffaker RK, Shull BL, Thomas JS. A serious complication following placement of posterior Prolift. Int Urogynecol J Pelvic Floor Dysfunct. 2009 20(11):1383-5.
5. Kahn MA, Stanton SL. Posterior colporrhaphy: its effects on bowel and sexual function. Br J Obstet Gynaecol. 1997;104(1):82-6.
6. Ugianskiene A, Kjaergaard N, Inger Lindquist AS, Larsen T, Glavind K. Retrospective study on de novo postoperative urinary incontinence after pelvic organ prolapse surgery. European journal of obstetrics, gynecology, and reproductive biology. 2017;219:10-4. 
7. Alas AN, Chinthakanan O, Espaillat L, Plowright L, Davila GW, Aguilar VC. De novo stress urinary incontinence after pelvic organ prolapse surgery in women without occult incontinence. International urogynecology journal. 2017;28(4):583-90
8. Lo TS, Bt Karim N, Nawawi EA, Wu PY, Nusee Z. Predictors for de novo stress urinary incontinence following extensive pelvic reconstructive surgery. International urogynecology journal. 2015;26(9):1313-9
9. Wihersaari O, Karjalainen P, Tolppanen AM, Mattsson N, Nieminen K, Jalkanen J. Sexual Activity and Dyspareunia After Pelvic Organ Prolapse Surgery: A 5-Year Nationwide Follow-up Study. Eur Urol Open Sci. 2022 Oct 12;45:81-89. doi: 10.1016/j.euros.2022.09.014. PMID: 36353662; PMCID: PMC9637561
10. Shi W, Guo L. Risk factors for the recurrence of pelvic organ prolapse: a meta-analysis. J Obstet Gynaecol. 2023 Dec;43(1):2160929. doi: 10.1080/01443615.2022.2160929. PMID: 36645334