SUPeR: Study of Uterine Prolapse Procedures Randomized Trial
SUPeR was a nine-center, participant-masked randomized superiority trial in 183 women with symptomatic uterovaginal prolapse that compared sacrospinous hysteropexy with Uphold LITE polypropylene mesh against vaginal hysterectomy with bilateral uterosacral ligament suspension. Model-estimated composite treatment failure at 36 months was 24% after mesh hysteropexy and 36% after hysterectomy (adjusted hazard ratio 0.61, 95% CI 0.37–1.02; P = .06), a difference that did not reach statistical significance.[1]
- Design and population
- Nine-center, participant-masked randomized superiority trial of vaginal prolapse surgery. Women aged 21 years or older, amenorrheic for at least a year and done with childbearing, who requested vaginal surgery for symptomatic uterovaginal prolapse beyond the hymen (mean age 66).
- Arms
- Sacrospinous hysteropexy with Uphold LITE polypropylene mesh versus vaginal hysterectomy with bilateral uterosacral ligament suspension
- Report and follow-up
- 2019 · 36-month primary analysis with failure modeled through 48 months; 169/175 (97%) completed 3-year follow-up (abstract); 153 attended the 36-month visit
| Endpoint | Results | Effect | Finding |
|---|---|---|---|
| Model-estimated adjusted 36-month failure incidence; adjusted hazard ratio for interval-censored time to failure through 48 months (retreatment, prolapse beyond the hymen, or bothersome bulge) | 24% (95% CI 14–33%) vs 36% (95% CI 24–47%) | HR 0.61; CI 0.37–1.02; P 0.06 | Not met |
| Cumulative (time-to-event, permanent-failure) failure at the 36-month visit, number failed over number assessed; common risk difference in percentage points stratified by site | 24/78 (31%) vs 33/80 (41%) | difference -10; CI -25–4 | Descriptive |
| Usually or always having pain with intercourse at 36 months, number over number sexually active with the item answered; risk difference in percentage points | 5/26 (19%) vs 5/31 (16%) | difference 3; CI -17–23; P 0.76 | Descriptive |
Harms: Hysteropexy mesh exposure: 7/88 (8%) vs not applicable; Midurethral sling mesh exposure: 0/41 vs 2/44 (5%); Ureteral kinking recognized and managed intraoperatively: 0/88 vs 6/87 (7%)
Design
The NICHD Pelvic Floor Disorders Network ran the trial at 9 US sites. Women were 21 years or older, amenorrheic for at least a year, had completed childbearing and requested vaginal surgery for symptomatic prolapse beyond the hymen with uterine descent into the lower half of the vagina. Prior synthetic prolapse mesh, prior uterine suspension, chronic pelvic pain, pelvic radiation, uterine disease that precluded preservation and an increased need for cervical screening excluded women, as did cervical elongation expected to leave point C at stage 2 or greater after hysteropexy.[2] Randomization was 1:1 in the operating room after anesthesia induction, with permuted blocks stratified by site. Participants consented to stay masked to their operation for the study duration, and the POP-Q examiner was not the surgeon.[3]
Treatment failure was a composite of retreatment for prolapse (pessary or surgery), any POP-Q point beyond the hymen, or a positive answer, with any bother, to the PFDI-20 bulge item. It was analyzed as interval-censored time to failure with a piecewise exponential baseline hazard, adjusted for site and prior prolapse surgery, and the primary analysis was planned for when the last randomized participant reached 3 years of follow-up. The significance level for that analysis was alpha = .047, which left alpha = .009 for an interim analysis at 2 years; all other analyses were exploratory or supportive, with descriptive confidence intervals and P values. Visits were every 6 months, questionnaires were administered by staff masked to the operation, and the pelvic examination was done by a clinician other than the surgeon.[1] The 180 planned participants provided power of 0.86 to detect a difference of 12 percentage points in 2-year failure (8% versus 20%); an error in the original sample-size calculation (power 0.89 for 10% versus 20%) was found after every participant had completed at least 4 years of follow-up.[1]
Baseline characteristics were similar between the 88 and 87 analyzed women: mean age 65.5 and 66.2 years, mean BMI 28.9 and 28.2, POP-Q stage 3 in 72% and 68% and stage 4 in 11% and 10%, and median symptom duration 26 and 33 months.[1]
Boston Scientific, which made the Uphold LITE system, gave partial support through an unrestricted grant to the data coordinating center and had no role in the design, analysis or reporting.[3]
Results
Of 183 women randomized (93 to hysteropexy, 90 to hysterectomy), 175 (88 and 87) were analyzed after ineligibility exclusions, and 169 (97%) completed 3-year follow-up.[1] The adjusted hazard ratio for failure with hysteropexy was 0.61 (95% CI 0.37–1.02; P = .06), with model-estimated 36-month failure of 24% (95% CI 14–33%) versus 36% (95% CI 24–47%).[1] The P value did not meet the prespecified significance level of .047. Proportional hazards were not met (P < 0.001): the smoothed hazard was higher with hysterectomy except from about 18 to 30 months, so the ratio is an average over follow-up.[1] Cumulative failure at the 36-month visit, counting a failure as permanent, was 24/78 (31%) versus 33/80 (41%) (risk difference −10 percentage points, 95% CI −25 to 4).[1] Anatomic failure only accounted for 12 (15%) versus 22 (28%) of these, anatomic and symptom failure for 9 (12%) versus 6 (8%), symptom failure only for 3 (4%) versus 4 (5%), and retreatment for 0 versus 1.[3] A February 2021 erratum corrected errors in the Results text, tables and figures without listing the changed values.[4]
Among secondary outcomes at 36 months, patient-reported improvement was similar: 70/78 (90%) versus 67/75 (89%) rated themselves much or very much better (P = 0.93), and the PFDI change was −79.8 versus −80.1 (P = 0.97), with no difference in its prolapse, urinary or colorectal subscales. Point Ba was −1.2 versus −0.7 cm (difference −0.5, 95% CI −0.9 to 0.0; P = 0.05) and total vaginal length 8.5 versus 7.7 cm (difference 0.7, 95% CI 0.4–1.1; P < 0.001), without a difference in point C. Among sexually active women the PISQ-IR improved by 0.4 points after hysteropexy and 0.3 points after hysterectomy (difference 0.0, 95% CI −0.2 to 0.3; P = 0.69), and dyspareunia among them fell from 10/26 (38%) to 5/26 (19%) after hysteropexy and from 17/37 (46%) to 5/31 (16%) after hysterectomy.[1]
At 5 years, cumulative composite failure was 37% after hysteropexy and 54% after hysterectomy (adjusted hazard ratio 0.58, 95% CI 0.36–0.94; P = 0.03); cumulative failure tabulated at the 5-year visit was 29/79 versus 42/78, a risk difference of −18 percentage points (95% CI −33 to −3). The 5-year analysis was a secondary objective with descriptive P values and no multiplicity adjustment, and proportional hazards were again not met (P < 0.001). The risk difference had been −9 points (95% CI −21 to 2) at 1 year. Persistent success through all visits was 66.7% versus 51.2%, and intermittent success and failure was more common than persistent failure in both groups. Prolapse retreatment through 5 years occurred in 8/87 (9%) versus 11/86 (13%), with surgery in 7/87 versus 9/86. Patient-reported prolapse, bowel and pelvic floor outcomes did not differ: 68/76 versus 69/72 (reported as 90% versus 96%) reported being much or very much better, and the Urogenital Distress Inventory improved more after hysterectomy (change −23.7 versus −30.2; difference 6.5, 95% CI 1.4–11.7; P = 0.01, unadjusted). Total vaginal length at 5 years was 8.4 versus 7.5 cm (difference 0.9 cm, 95% CI 0.6–1.3).[3]
In a planned secondary analysis of 173 women who received their randomized operation, higher body mass index (hazard ratio 1.7 per 5 kg/m², 95% CI 1.3–2.2) and symptoms longer than 5 years (hazard ratio 3.0, 95% CI 1.8–5.0) were associated with failure across both operations. Hysteropexy had a lower failure hazard than hysterectomy in women with symptoms of 5 years or less (hazard ratio 0.5, 95% CI 0.2–0.9) but not in women with longer symptom duration (1.0, 95% CI 0.5–2.1; interaction P = 0.07).[5]
At 10 years, 35/88 (40%) women assigned to hysteropexy and 46/87 (53%) assigned to hysterectomy had met the composite failure definition (adjusted hazard ratio 0.64, 95% CI 0.41–1.00; P = 0.05). Only 112 of the 175 analyzed women (64%; 55 and 57) entered the unmasked year 6–10 extension. The additional durability advantage of mesh that was expected in years 6 to 10 was not observed, and no differences were shown in patient-reported prolapse, urinary or bowel symptoms, sexual function, dyspareunia or clinically important complications.[6]
Surgery and treatment delivery
The protocol standardized both operations. For the mesh hysteropexy, surgeons performed hydrodissection with at least 30 mL of 0.25% bupivacaine with epinephrine (or dilute vasopressin), made a 4 cm transverse anterior vaginal incision at least 3 cm from the cervix and approached the sacrospinous ligament extraperitoneally. After confirming the ischial spine, they delivered the tapered lead and mesh assembly into the ligament 1–2 fingerbreadths medial to it, sutured the most cephalic mesh edge to the cervix, avoided cutting the mesh, tensioned the apex without tight mesh arms, closed with 2-0 polyglactin and removed the vaginal pack and catheter on postoperative day 1. For the hysterectomy arm, uterosacral suspension followed vaginal hysterectomy, with one permanent and one delayed-absorbable monofilament suture in each ligament extending to the anterior and posterior fibromuscular vaginal wall, and no midline plication or culdoplasty.[2]
Surgeons had to be board-eligible or board-certified in female pelvic medicine and reconstructive surgery. Uphold LITE certification required at least 20 sacrospinous ligament dissections (including 10 anterior dissections to the ligament and 10 Capio suture applications) and 5 Uphold LITE procedures performed or proctored; hysterectomy certification required 20 vaginal hysterectomies and 20 uterosacral suspensions, with 5 apical procedures in the preceding 12 months. The authors acknowledged that most surgeons had more experience with the hysterectomy arm.[2] Thirty-four such subspecialists operated.[1]
Operative time was shorter with hysteropexy (111.5 versus 156.7 minutes; difference −45.2, 95% CI −57.7 to −32.7; P < 0.001), including concomitant procedures. Native-tissue anterior repair accompanied 79/88 (90%) of hysteropexies and 62/87 (71%) of hysterectomies (P = 0.002) and posterior repair or perineorrhaphy 51/88 (58%) versus 50/87 (57%); concomitant midurethral slings were retropubic in 29/88 versus 31/87 and transobturator in 12/88 versus 13/87. Estimated blood loss was 141.1 versus 147.5 mL (P = 0.68), 0/88 versus 2/87 (2%) received a transfusion, and one hysterectomy participant returned to the operating room. A catheter was still in place at discharge in 29/88 (33%) and 29/87 (33%), and hospital stay averaged 1.1 versus 1.3 days.[1]
Adverse events
Mesh exposure, which applies only to the hysteropexy arm, occurred in 7/88 (8%; exact 95% CI 3.3–15.7%) at 3 years and in 7/91 (8%) through 5 years.[1][3] Three exposures were found at 6 weeks, 3 at 6 months and 1 at 18 months; all were treated with vaginal estrogen, one had office mesh trimming, 2 persisted at 60 months, and none required operating room management. Midurethral sling mesh exposure was 0/41 versus 2/44 (5%) at 3 years and 0/43 versus 2/47 through 5 years.[1][3]
The hysterectomy arm had more suture-related findings after 12 weeks: granulation tissue in 11/91 (12%) versus 1/90 (1%) and suture exposure in 19/91 (21%) versus 3/90 (3%) through 5 years, three patients needed suture removal in the office, and none needed operating room management.[3] Intraoperative ureteral kinking requiring intraoperative management occurred in 6/87 (7%) of hysterectomies and in none of the hysteropexies (P = 0.01).[1][3] At 3 years, new or worsening stress incontinence was reported by 18/88 (20%) versus 12/87 (14%), urgency incontinence by 21/88 (24%) versus 14/87 (16%) and fecal incontinence by 13/88 (15%) versus 6/87 (7%), none significantly different.[1] Among all treated women, urinary tract infection occurred in 34/93 (37%) versus 39/90 (43%), urinary retention in 6/93 (6%) versus 7/90 (8%), bladder injury in 2/93 (2%) versus 1/90 (1%) and constipation in 5/93 (5%) versus 13/90 (14%).[1]
In hospital, modified Dindo grade IIIb, IIIo or IVa events occurred in 5/88 (6%) versus 8/87 (9%) of analyzed women; through 5 years, grade III or higher events occurred in 14/91 (15%) versus 16/92 (17%) (P = 0.71), with no grade V events.[1][3] Urinary tract infection affected 38/91 (42%) versus 43/92 (47%), and pelvic pain after 12 weeks 6/90 (7%) versus 9/91 (10%).[3] New or worsening dyspareunia occurred in 8/87 (9%) versus 2/86 (2%) (risk difference 7 percentage points, 95% CI 0 to 15; P = 0.10); at 3 years any postoperative dyspareunia was reported in 9/93 (10%) versus 2/90 (2%) of all treated women (P = 0.03).[3][1] Through 5 years, new or worsening stress incontinence was reported by 18/88 versus 10/87 (reported as 21% versus 12%) and fecal incontinence by 14/88 (16%) versus 7/87 (8%), neither significant.[3] After hysteropexy, 4/91 women had uterine complications through 5 years (a cervical polyp, an endometrial polyp, hematometra needing dilation and curettage, and a thickened endometrium on imaging with no tissue identified at dilation and curettage or hysteroscopy); at 3 years the authors reported no significant uterine pathology.[1][3]
Limitations
Many women with preconceived views about hysterectomy, mesh or randomization to a masked procedure declined to participate, so participants may differ from other patients, and the findings apply to amenorrheic women who have finished childbearing; 70 of 175 (40%) were sexually active before surgery, which limits the sexual function and dyspareunia comparisons.[1] Masking eroded over time: 131/173 (75%) reported being masked at 36 months, which the authors noted could bias patient-reported outcomes, and 129/183 (70%) remained masked at the last visit within 5 years.[1][3] All surgeons were pelvic medicine and reconstructive surgery subspecialists, with more experience in the hysterectomy arm, and the trial tested a single device. The design cannot separate the effect of mesh from that of hysteropexy, because it had no native-tissue hysteropexy arm. Failure rates were higher under the cumulative approach, which treats failure as permanent, than when status at each attended visit was counted, so the definition of failure affects the rates.[1][2][3]
The primary analysis did not show a significant difference, its confidence interval was wide and proportional hazards were violated; the 5-year result came from a secondary-objective analysis with descriptive P values. The 10-year comparison rests on 112 of 175 analyzed women in the extension, after unmasking.[1][3][6]
In conversation
- Builds on OPTIMAL (2014). Its uterosacral suspension modified the Shull technique, which the same Pelvic Floor Disorders Network had used in OPTIMAL.
- Confirmed by VUE (2020). Same question with a mesh hysteropexy; SUPeR also found no significant reduction in composite failure versus vaginal hysterectomy at 36 months.
- Parallel to SAVE-U (2015). Same comparator, vaginal hysterectomy with uterosacral suspension; SAVE-U tested suture sacrospinous hysteropexy, SUPeR tested mesh hysteropexy.
- Parallel to ASPIRe (2024). Same Pelvic Floor Disorders Network and composite failure definition; ASPIRe enrolled women with vault prolapse after hysterectomy.
- Parallel to ASPIRe (2024). Also tested the Uphold mesh kit, with hysteropexy; ASPIRe cites its mesh-exposure rates for comparison.
- Parallel to SAVE-U (2015). US trial using the same hysterectomy with uterosacral suspension control against a mesh-augmented sacrospinous hysteropexy.
Same setting SAM (2023)
SAVE-U also used vaginal hysterectomy with uterosacral ligament suspension as the comparator but tested suture sacrospinous hysteropexy, which was deemed noninferior at 1 year; SUPeR tested a polypropylene mesh hysteropexy.[3]
Guidelines and approvals
- AUGS Clinical Practice Statement (2025). The statement summarizes the 5-year SUPeR result (failure 37% after mesh sacrospinous hysteropexy versus 54% after vaginal hysterectomy with uterosacral ligament suspension; mesh exposure 8% in the mesh hysteropexy arm) in its review and recommends offering uterine-preserving prolapse surgery to adults with a uterus considering apical prolapse surgery who have no previous or current uterine or cervical pathology and are at low or average risk of current or future pathology .[7]
- FDA (April 16, 2019). The FDA ordered manufacturers of surgical mesh intended for transvaginal repair of pelvic organ prolapse to stop selling and distributing their products, naming the Boston Scientific Uphold Lite system among three devices; the devices had been class III since 2016.[8]
Report history
| Published | Report | Cutoff | Headline results | Citation |
|---|---|---|---|---|
| 2016 | Trial design and surgical standardization · secondary | — | — | Nager CW, Zyczynski H, Rogers RG, et al. The design of a randomized trial of vaginal surgery for uterovaginal prolapse: vaginal hysterectomy with native tissue vault suspension versus mesh hysteropexy suspension (the Study of Uterine Prolapse Procedures Randomized Trial). *Female Pelvic Med Reconstr Surg.* 2016;22(4):182-189. DOI |
| 2019-09-17 | Three-year randomized report · primary | — | Model-estimated adjusted 36-month failure incidence; adjusted hazard ratio for interval-censored time to failure through 48 months (retreatment, prolapse beyond the hymen, or bothersome bulge): 24% (95% CI 14–33%) vs 36% (95% CI 24–47%); HR 0.61; CI 0.37–1.02; P 0.06 Not met Cumulative (time-to-event, permanent-failure) failure at the 36-month visit, number failed over number assessed; common risk difference in percentage points stratified by site: 24/78 (31%) vs 33/80 (41%); difference -10; CI -25–4 Descriptive Mean (SD) operative time in minutes; mean difference: 111.5 (39.7) vs 156.7 (43.9); difference -45.2; CI -57.7–-32.7; P <0.001 PGI-I much or very much better at 36 months; unadjusted risk difference in percentage points: 70/78 (90%) vs 67/75 (89%); difference 0; CI -9–10; P 0.93 PFDI (range 0 to 300) change from baseline at 36 months, adjusted mean; mean difference: −79.8 vs −80.1; difference 0.3; CI -16.3–16.9; P 0.97 Mean (SD) point Ba in cm at 36 months; mean difference: −1.2 (1.4) vs −0.7 (1.5); difference -0.5; CI -0.9–0; P 0.05 Mean (SD) POP-Q total vaginal length in cm at 36 months; mean difference: 8.5 (1.1) vs 7.7 (1.2); difference 0.7; CI 0.4–1.1; P <0.001 PISQ-IR change from baseline among sexually active women at 36 months, adjusted mean; mean difference: 0.3 (95% CI 0.1 to 0.5) vs 0.3 (95% CI 0.1 to 0.5); difference 0; CI -0.2–0.3; P 0.84 Usually or always having pain with intercourse at 36 months, number over number sexually active with the item answered; risk difference in percentage points: 5/26 (19%) vs 5/31 (16%); difference 3; CI -17–23; P 0.76 Descriptive | Nager CW, Visco AG, Richter HE, et al. Effect of vaginal mesh hysteropexy vs vaginal hysterectomy with uterosacral ligament suspension on treatment failure in women with uterovaginal prolapse: a randomized clinical trial. *JAMA.* 2019;322(11):1054-1065. DOI |
| 2021-02-16 | Correction to the Results section · correction | — | — | Error in results section. *JAMA.* 2021;325(7):696. DOI |
| 2021-03-12 | Five-year randomized report · updated | — | Cumulative composite failure at the 5-year visit; adjusted hazard ratio for interval-censored time to failure through 60 months: 37% vs 54%; HR 0.58; CI 0.36–0.94; P 0.03 Cumulative (permanent-failure) count over number assessed or previously failed at the 5-year visit; site-stratified common risk difference in percentage points: 29/79 (37%) vs 42/78 (54%); difference -18; CI -33–-3 Descriptive Any retreatment (pessary or surgery); risk difference in percentage points: 8/87 (9%) vs 11/86 (13%); difference -4; CI -13–6; P 0.45 Met the success definition at every assessed visit through 5 years: 66.7% vs 51.2%; — Descriptive PGI-I much or very much better at 5 years; risk difference in percentage points: 68/76 vs 69/72; difference -6; CI -15–2; P 0.14 Urogenital Distress Inventory change from baseline at 5 years, adjusted mean; mean difference: −23.7 vs −30.2; difference 6.5; CI 1.4–11.7; P 0.01 Pelvic Floor Distress Inventory change from baseline at 5 years, adjusted mean; mean difference: −78.7 vs −83.8; difference 5.2; CI -5.3–15.6; P 0.33 POP-Q total vaginal length at 5 years in cm, adjusted mean; mean difference: 8.4 vs 7.5; difference 0.9; CI 0.6–1.3; P <0.001 | Nager CW, Visco AG, Richter HE, et al. Effect of sacrospinous hysteropexy with graft vs vaginal hysterectomy with uterosacral ligament suspension on treatment failure in women with uterovaginal prolapse: 5-year results of a randomized clinical trial. *Am J Obstet Gynecol.* 2021;225(2):153.e1-153.e31. DOI |
| 2022-08-02 | Risk factors for failure over 5 years · secondary | — | Adjusted hazard ratio for composite failure per 5 kg/m2 increase in BMI: Obesity versus normal or underweight 2.9 (95% CI 1.5–5.8); overweight 1.8 (95% CI 0.9–3.5). Planned secondary analysis; significance judged with Bonferroni correction.; HR 1.7; CI 1.3–2.2; P <0.001 Adjusted hazard ratio for composite failure with symptoms longer than 5 years versus 5 years or less: Per additional year of symptoms the adjusted hazard ratio was 1.1 (95% CI 1.0–1.1; P<0.005).; HR 3; CI 1.8–5 Adjusted hazard ratio for composite failure, hysteropexy versus hysterectomy: Interaction with symptom duration P=0.07. With symptoms longer than 5 years the hazard ratio was 1.0 (95% CI 0.5–2.1).; HR 0.5; CI 0.2–0.9 | Richter HE, Sridhar A, Nager CW, et al. Characteristics associated with composite surgical failure over 5 years of women in a randomized trial of sacrospinous hysteropexy with graft vs vaginal hysterectomy with uterosacral ligament suspension. *Am J Obstet Gynecol.* 2023;228(1):63.e1-63.e16. DOI |
| 2026 | Ten-year follow-up · updated | — | Composite failure through 10 years, number failed over number analyzed; adjusted hazard ratio for time to failure: 35/88 (40%) vs 46/87 (53%); HR 0.64; CI 0.41–1; P 0.05 Prolapse, urinary and bowel symptoms, sexual function and dyspareunia: No group differences were demonstrated, nor in clinically important complications.; — | Nager CW, Visco AG, Richter HE, et al. Sacrospinous hysteropexy with mesh vs vaginal hysterectomy for treatment of uterovaginal prolapse: 10-year results of a randomized clinical trial. *JAMA Surg.* 2026;161(8):764-774. DOI |
References
1. Nager CW, Visco AG, Richter HE, et al. "Effect of Vaginal Mesh Hysteropexy vs Vaginal Hysterectomy With Uterosacral Ligament Suspension on Treatment Failure in Women With Uterovaginal Prolapse: A Randomized Clinical Trial." JAMA. 2019;322(11):1054-1065. doi:10.1001/jama.2019.12812
2. Nager CW, Zyczynski H, Rogers RG, et al. "The Design of a Randomized Trial of Vaginal Surgery for Uterovaginal Prolapse: Vaginal Hysterectomy With Native Tissue Vault Suspension Versus Mesh Hysteropexy Suspension (The Study of Uterine Prolapse Procedures Randomized Trial)." Female Pelvic Med Reconstr Surg. 2016;22(4):182-189. doi:10.1097/SPV.0000000000000270
3. Nager CW, Visco AG, Richter HE, et al. "Effect of Sacrospinous Hysteropexy With Graft vs Vaginal Hysterectomy With Uterosacral Ligament Suspension on Treatment Failure in Women With Uterovaginal Prolapse: 5-Year Results of a Randomized Clinical Trial." Am J Obstet Gynecol. 2021;225(2):153.e1-153.e31. doi:10.1016/j.ajog.2021.03.012
4. "Error in Results Section." JAMA. 2021;325(7):696. doi:10.1001/jama.2021.0535
5. Richter HE, Sridhar A, Nager CW, et al. "Characteristics Associated With Composite Surgical Failure Over 5 Years of Women in a Randomized Trial of Sacrospinous Hysteropexy With Graft vs Vaginal Hysterectomy With Uterosacral Ligament Suspension." Am J Obstet Gynecol. 2023;228(1):63.e1-63.e16. doi:10.1016/j.ajog.2022.07.048
6. Nager CW, Visco AG, Richter HE, et al. "Sacrospinous Hysteropexy With Mesh vs Vaginal Hysterectomy for Treatment of Uterovaginal Prolapse: 10-Year Results of a Randomized Clinical Trial." JAMA Surg. 2026;161(8):764-774. doi:10.1001/jamasurg.2026.2263
7. Chang OH, Carter Ramirez A, Edwards A, et al. "The Role of Uterine Preservation at the Time of Pelvic Organ Prolapse Surgery." Urogynecology (Phila). 2025;31(5):482-495. doi:10.1097/SPV.0000000000001667. AUGS Clinical Practice Statement; recommendation 1.
8. U.S. Food and Drug Administration. "Urogynecologic Surgical Mesh Implants." fda.gov.