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History of Prolapse Surgery & Urogynecology

Pelvic organ prolapse (POP) and urinary incontinence have afflicted women throughout recorded history. The evolution of their treatment, from pomegranate pessaries and uterine succussion in the Hippocratic writings to robotic sacrocolpopexy and synthetic midurethral slings, mirrors the broader arc of surgery from empiricism, through anatomical understanding, to evidence-based procedural refinement. Urogynecology as an organized specialty dates from the 1970s, yet its roots reach back nearly four millennia.

Ancient and Classical Period (c. 2000 BCE – 200 CE)​

The Earliest Records​

The earliest documented descriptions of pelvic organ prolapse come from ancient Egypt. The Kahun Gynaecological Papyrus (c. 1835 BCE), the oldest surviving gynecological text, describes "falling of the womb," prescribing fumigation, massage, and vaginal pessaries. The text notes: "of a woman whose posterior, belly, and branching of her thighs are painful, say thou as to it, it is the falling of the womb."[1][46]

The Ebers Papyrus (c. 1550 BCE) recommends petroleum ("oil of earth"), manure, and honey rubbed on the body to correct a displaced womb.[46] Among the earliest known cases of vesicovaginal fistula (VVF) is the mummy of Henhenit, a woman of the court of Mentuhotep II (11th dynasty, c. 2050 BCE), in whom Derry (reported 1935) identified a large VVF on examination of the remains, evidence that obstructed labor was already injuring women 4,000 years ago.[2]

Greek Medicine​

In the Hippocratic era (Hippocrates, 460–370 BCE), the uterus was regarded as an animal acting on its own. Polybus, Hippocrates's pupil and son-in-law, described in On Diseases of Women an astringent applied to the prolapsed womb followed by a vinegar-soaked sponge or half a pomegranate. If these measures failed, the woman underwent succussion: she was tied upside down by her feet to a frame and bounced until the prolapse reduced, then kept in bed for three days with her legs tied together.[46]

Soranus of Ephesus (active c. 98–138 CE) rejected these methods, calling fumigation nonsensical, pomegranates bruising and succussion unbearable. He advocated a wool tampon wrapped in thin linen and dipped in vinegar, acacia juice or wine to push the prolapse back into place. He also described excision of gangrenous prolapsed tissue, among the earliest references to surgical intervention.[3][46]

Avicenna (Ibn Sina, 980–1037 CE) described what appears to represent VVF as a complication of obstructed labor in The Canon of Medicine (1025 CE), an early documentation outside Egyptian sources.[4]

Renaissance and Early Modern Period (1500–1800)​

Andreas Vesalius (1514–1564), with illustrations attributed to Jan van Calcar, gave an accurate description of the entire female genital tract, including the uterine ligaments, in De Humani Corporis Fabrica (1543). Berengario da Carpi had already stated that the uterus has a single cavity, against the medieval doctrine of the seven-cell uterus; Vesalius's anatomy provided the foundation for rational pelvic surgery.[46]

Ambroise Paré (c. 1510–1590, France) designed oval pessaries of brass and waxed cork with attached retrieval threads, a step from improvised materials such as lint balls and halved fruit toward purpose-made devices.[46]

Hendrik van Roonhuyse (c. 1625–1672, Netherlands) reported extirpating a prolapsed uterus after pessaries had failed, without describing his technique or any anesthetic; it is one of the earliest accounts of surgical management.[46]

Hugh Hodge (1796–1873, Philadelphia) invented the Hodge lever pessary and in 1860 declared pessaries the "sine qua non" of uterine displacement treatment. Charles Goodyear's 1844 patent for vulcanized rubber provided a material that resisted decomposition, leading to standardized rubber devices by the mid-19th century and modern silicone designs by the 20th.[46]

19th Century: Foundational Surgery​

James Marion Sims and Vesicovaginal Fistula (1813–1883)​

James Marion Sims is among the most influential and most ethically contested figures in the history of operative gynecology. Born in Lancaster, South Carolina in 1813, Sims conducted his experiments between 1845 and 1849 on enslaved African American women with obstetric VVF in Montgomery, Alabama, without informed consent and with minimal or no anesthesia.

His subjects, Anarcha, Betsey and Lucy, endured multiple operations. Anarcha underwent 30 procedures before Sims achieved a consistent repair. Three innovations enabled success:

  1. A duckbill speculum of his own design, enabling direct visualization of the fistula
  2. Silver wire sutures. Silver wire provoked less tissue reaction than the silk then in use, and Sims regarded it as the decisive technical advance.
  3. Positioning the patient in the knee-chest position (later the Sims lateral position)

In 1852, Sims published "On the Treatment of Vesico-Vaginal Fistula" in the American Journal of the Medical Sciences, establishing the modern surgical approach to transvaginal VVF repair.[5]

The ethics of Sims's work have been the subject of sustained historical critique, and his statue in New York's Central Park was removed in 2018. John Peter Mettauer of Virginia also claims priority, having reported successful VVF closure with wire sutures in an 1838 letter to the Boston Medical and Surgical Journal, predating Sims.[6]

Anatomical Foundations​

Alwin Mackenrodt (1859–1925, Berlin) published a comprehensive description of the pelvic connective tissue in 1895, including the transverse cervical (cardinal) ligament, later called Mackenrodt's ligament, and provided the anatomical basis for understanding the cardinal support complex. Fothergill's cardinal-ligament plication (below) was built on this anatomy.[7][46]

Early Vaginal Approaches to Prolapse (1861–1894)​

Samuel Choppin of New Orleans performed the first vaginal hysterectomy for procidentia under anesthesia in the United States in 1861, publishing the operation five years later. James Marion Sims described anterior colporrhaphy for prolapse in 1866. Uterine interposition, fixing the uterus in place to prevent recurrent prolapse without removing it, gained popularity from the 1890s. Alfred Dührssen reported 207 vaginal operations for mobile and fixed uterine retroflexion in Germany in 1894, an early vaginal fixation of the uterus; Watkins and Wertheim separately reported uterine interposition for prolapse in 1899.[43][44][45][46]

The LeFort Colpocleisis (1877)​

Léon LeFort (Paris, 1877) described his eponymous procedure: removal of strips of anterior and posterior vaginal epithelium with suturing of the denuded surfaces together, closing the vaginal lumen while preserving lateral drainage channels. Neugebauer of Warsaw performed the first known partial colpocleisis in 1867 but did not publish until 1881. Of the prolapse operations established in the 19th century, the LeFort colpocleisis is the one that has endured; it remains in use for elderly, medically frail patients who do not plan vaginal intercourse.[8][46]

Abdominal Ventrofixation — Olshausen (1886)​

Robert Olshausen (Germany, 1886) reported a laparotomy performed solely for uterine ventrofixation (abdominal fixation of the uterus to the anterior abdominal wall), establishing the abdominal route as viable for prolapse management.[46]

Manchester-Fothergill Operation (1888–1908)​

Archibald Donald (Manchester) performed his first cases in 1888 using a combined anterior colporrhaphy, cervical amputation, and posterior colporrhaphy in a single procedure, formally described in 1908.

William Edward Fothergill (1907–1908) modified Donald's technique by plicating the cardinal (Mackenrodt's) ligaments onto the cervical stump, enhancing uterine suspension; later sources date his modification variously to 1907, 1915 or 1921. Because Fothergill's publications were more widely read, the original developer's name was largely displaced, and the procedure became known as the Manchester repair or Manchester-Fothergill operation.

Its core components are anterior colporrhaphy, cervical amputation and cardinal ligament plication. It is still performed as a uterus-sparing option.[9][46]

Early Surgical Attempts at Stress Incontinence (1864–1910s)​

Before Kelly's plication, several surgeons attempted direct operative correction of stress incontinence. Isaac Baker Brown described a suprapubic cystostomy for stress incontinence in 1864; he was expelled from the Obstetrical Society of London in 1867 after advocating clitoridectomy for epilepsy, catalepsy and mania. In 1892, Poussan proposed urethral advancement: a bougie was introduced into the urethra, the external meatus and a portion of the urethra were resected, and the urethra was transplanted to a point below the clitoris after 180-degree torsion of the canal. Karl Pawlik (1849–1914) separately suggested apposing and flattening the distal urethral walls and drawing the external meatus forward toward the clitoris; Robert Gersuny (1844–1924, Vienna) performed the first urethral torsion procedure along these lines in 1888, publishing it as an improvement on Pawlik's technique. Comparable torsion and meatal-transfer methods were also practiced by Alfred Pousson and Joaquin Albarran. None of these urethral repositioning operations persisted into later practice.[35][36][37][39][40]

Early 20th Century: Howard Kelly and the Birth of Urogynecology​

Howard Atwood Kelly (1858–1943)​

Howard Kelly is often described as a founder of urogynecology; he held that gynecology and urology were so closely related that a physician could not be trained in one and ignore the other.[38] One of the four founding professors of Johns Hopkins Hospital (the Big Four, with Osler, Halsted, and Welch), Kelly was appointed the first Professor of Gynecology and Obstetrics at Hopkins in 1889.

His main contributions:

  • 1893. Invented the air cystoscope, a handheld hollow tube with a glass partition enabling direct visualization of the female bladder and ureteral orifices, and was the first to insert ureteral catheters under direct vision.[38] An often-repeated account describes a 1900 contest at a surgical meeting in Baltimore in which Kelly catheterized both ureters in a female patient in under 3 minutes.
  • Developed the Kelly clamp, Kelly speculum, and Kelly forceps, instruments still in routine clinical use.
  • 1913. Described the Kelly plication stitch, horizontal mattress sutures placed at the urethrovesical junction to narrow the patulous urethra and elevate the bladder neck. This became the basis of the anterior colporrhaphy with Kelly plication, the dominant gynecological treatment for stress urinary incontinence (SUI) throughout much of the 20th century. In Kelly's first report of bladder-neck suture plication, 16 of 20 patients (80%) were described as well; later evaluations estimated roughly 60% long-term success using those sutures alone.[38]
  • Authored over 550 articles and books over his career, including Operative Gynecology (1898).[10]

Early Sling Procedures​

The biological sling concept predates Kelly's plication stitch. Giordano (1907) performed the first recorded sling procedure for SUI using a gracilis muscle graft wrapped around the urethra. Rudolf Goebell (Germany, 1910) described the pyramidalis muscle placed suburethrally. Paul Frangenheim (Germany, 1914) modified Goebell's technique using the pyramidalis with its attached fascia. Walter Stoeckel (Germany, 1917) combined the two techniques with plication of the vesical neck, the Goebell-Frangenheim-Stoeckel technique, the first comprehensive description of a musculofascial pubovaginal sling.[11][38]

Victor Bonney (1872–1953)​

British gynecological surgeon Victor Bonney, co-author of the Textbook of Gynaecological Surgery (1911, with Comyns Berkeley), advocated uterine conservation. He opposed hysterectomy for fibroids in younger women, developed the modern myomectomy technique and performed over 700 myomectomies (8 deaths, 1.1% mortality; 38% of women who wanted children later conceived).[12] His wife, Annie, whom he married in 1905, had undergone a subtotal hysterectomy for a fibroid in 1907, leaving her sterile, and Chamberlain links this to his commitment to myomectomy. In 1934 Bonney explained the mechanics of fascial pelvic floor support through simple analogies, an in-turned finger of a rubber glove and stove piping secured in a metal box, an early contribution to the conceptualization of prolapse pathophysiology later refined by DeLancey.[12][46]

In 1923, Bonney also described urethral hypermobility in stress incontinence, attributing incontinence to abnormal displacement of the urethra and urethrovesical junction behind the symphysis. The following year, Watson reported a series of anterior colporrhaphy for incontinence, with perfect control in 65.7% of cases, improvement in 21.9%, and no success in 12.4%.[41][42]

Mid-20th Century: The Scientific Foundation​

Richard W. Te Linde (1894–1989)​

Richard Te Linde, director of gynecology at Johns Hopkins, published the first edition of Te Linde's Operative Gynecology in 1946. The 13th edition appeared in 2023, and the book has been a standard reference in operative gynecology since its first edition.[13] At Hopkins, the female urology program begun by Kelly passed to Guy Hunner, who described the ulcer of interstitial cystitis that bears his name, then to Houston Everett, who studied the urinary tract in cervical cancer; Te Linde added water endoscopy to the program.[38]

Aldridge Fascial Sling (1942)​

Aldridge (1942) described the autologous rectus fascia pubovaginal sling: strips of rectus fascia left attached to the anterior abdominal wall, passed bilaterally along the urethra, and sutured beneath the bladder neck. This technique is the direct ancestor of the modern autologous fascial sling.[14]

Marshall-Marchetti-Krantz Procedure (1949)​

Victor F. Marshall, Andrew A. Marchetti, and Kermit E. Krantz described the first retropubic bladder neck suspension in 1949 (Surgery, Gynecology & Obstetrics). Sutures were placed in the periurethral tissue and attached to the periosteum of the pubic symphysis. The suspension was first used in men with incontinence after prostatectomy and was reported for women with stress incontinence in 1949; among 44 suitable cases from the original mixed cohort of 50 patients (including 12 men), results were excellent in 36 (82%), significantly improved in 3 (7%) and unchanged in 5 (11%).[15][38] It opened a new era in SUI surgery, though osteitis pubis (pubic symphysis inflammation) was a recognized complication that limited long-term enthusiasm.[15][38]

First Abdominal Sacrocolpopexy (1962) and the Minimally Invasive Era​

Fredrick Lane (1962) is credited with the first description of abdominal sacrocolpopexy for post-hysterectomy vaginal vault prolapse in a small case series (Obstet Gynecol). The procedure (suspension of the vaginal vault to the sacral promontory via a graft through the abdominal route) became a standard abdominal repair for apical prolapse. Arthure and Savage had described sacral hysteropexy without a graft in 1957.[16][46]

Laparoscopic sacrocolpopexy was first described by Ceana Nezhat, Farr Nezhat, and Camran Nezhat (Mercer University School of Medicine, Macon, Georgia) in 1994, demonstrating feasibility of the abdominal approach without open laparotomy and launching the minimally invasive era of apical prolapse repair.[31]

Robotic sacrocolpopexy was first reported by Di Marco DS and colleagues (Mayo Clinic) in 2004 using the da Vinci Surgical System in five women, with no recurrent prolapse at a mean of 4 months; the authors reported that the robot facilitated precise intracorporeal suture placement at the sacral promontory. The FDA cleared the da Vinci system for gynecologic surgery in 2005.[55] Robotic sacrocolpopexy is now widely performed.[32]

McCall Culdoplasty (1957)​

Milton McCall (1957) described posterior culdoplasty during vaginal hysterectomy, obliterating the pouch of Douglas using permanent sutures through the uterosacral ligaments to prevent enterocele. The McCall culdoplasty is still performed and taught.[17]

First Synthetic Mesh in Pelvic Floor Surgery (1955)​

Moore, Armstrong, and Willis (1955) reported ten cases of cystocele repair with tantalum mesh, an early reported use of synthetic mesh in pelvic floor surgery. Erosion was noted but not considered serious. Tantalum was ultimately abandoned due to metal fatigue, corrosion, and fragmentation. The report preceded the transvaginal mesh controversy by half a century.[18]

Late 20th Century: The Surgical Proliferation Era​

Burch Colposuspension (1961)​

John C. Burch (1961) described a modification of the MMK procedure in which the paravaginal fascia is sutured to Cooper's ligament (the iliopectineal ligament) instead of the pubic periosteum. The modification corrected incontinence and cystocele together while avoiding the risk of osteitis pubis. The Burch colposuspension remained the reference retropubic operation for SUI for approximately 40 years; its use declined as midurethral slings gained use around the turn of the 21st century.[19]

Pereyra Needle Suspension (1959)​

Armand J. Pereyra (1959) introduced a simplified transvaginal needle suspension of the bladder neck, avoiding retropubic dissection. Modified extensively over two decades, the Modified Pereyra Procedure became widely adopted by gynecologists who preferred a vaginal approach. Subsequent modifications by Stamey (endoscopic bladder neck suspension, 1973) and Raz (helical sutures, UCLA 1981) extended the needle suspension approach. Long-term results of needle suspensions later proved inferior to those of retropubic procedures.[20][38] The individual techniques, the bone-anchored variants and the Raz vaginal wall sling are described on Needle Suspensions and In Situ Slings (Historical).

Sacrospinous Ligament Fixation (1958–1971)​

Sederl (1958) first described the sacrospinous ligament as an anchor for prolapse repair. Richter (Germany, 1968) formalized vaginal sacrospinous ligament fixation. Randall and Nichols (USA, 1971) published the first American series of transvaginal sacrospinous ligament fixation, 18 patients treated over four years, establishing the technique in the United States.[21][46]

McGuire and Lytton — Autologous Sling Standardized (1978)​

Edward McGuire and Lytton (1978) standardized the autologous rectus fascia pubovaginal sling in 52 women with poor urethral sphincter function (urethral pressure below 10 cm water), 42 of whom had undergone a previous incontinence operation; 50 had a satisfactory result with good urinary control. The report established the sling's role for what is now termed intrinsic sphincter deficiency, the most severe form of SUI. The autologous fascial sling remains in use for this indication.[22]

DeLancey's Three Levels of Vaginal Support (1992–1994)​

John O.L. DeLancey (University of Michigan) described three levels of vaginal support in 1992:

  • Level I: Apical suspension via the uterosacral and cardinal ligament complex to the pelvic sidewall and sacrum
  • Level II: Lateral attachment of the vaginal walls to the arcus tendineus fasciae pelvis (ATFP), paravaginal support
  • Level III: Distal fusion of the vagina with the levator ani muscles, perineal membrane, and perineal body

DeLancey's three-level framework became the conceptual basis for site-specific repair and rational surgical planning.[23]

He also published the hammock hypothesis of continence (1994), proposing that the urethra is compressed against a suburethral hammock of anterior vaginal wall and endopelvic fascia during stress, which provided the anatomical rationale for the midurethral sling.[24]

The Female Urethroscope (1968)​

Direct visualization of the female urethra lagged behind Kelly's cystoscope by seven decades. Jack Robertson, finding that women were examined for incontinence with instruments designed for men, devised a technique for viewing the bladder with carbon dioxide instead of water and in 1968 worked with the endoscope maker Karl Storz in Germany to produce a female urethroscope built to Robertson's specifications, using fiber optics and carbon-dioxide insufflation. Direct visualization of the female urethra was followed by a sharp rise in the diagnosis of urethral diverticula.[38]

International Continence Society Founded (1971)​

Eric Glen (1971) founded the ICS (originally the Continent Club) in Exeter, UK, with support from Peter Gammelgaard, Peter Caldwell and Richard Turner-Warwick; the inaugural meeting drew over 50 participants from several countries. The ICS grew to approximately 3,000 members from more than 80 countries and established the standardized terminology and classification systems used throughout urogynecological research.[25]

POP-Q Classification System (1995–1996)​

Bump RC and colleagues published the Pelvic Organ Prolapse Quantification (POP-Q) system in 1996, a standardized, objective, site-specific grading system using nine measurements (six vaginal points plus genital hiatus, perineal body and total vaginal length) with the hymen as a fixed reference. Approved by the ICS (1995), AUGS (January 1996), and SGS (March 1996), POP-Q superseded the Baden-Walker system as the international research and clinical standard (see Female Pelvic Examination & POP-Q).[26]

The Midurethral Sling Era (1990–1998)​

Integral Theory of Continence — Petros and Ulmsten (1990)​

Peter E. Papa Petros (Royal Perth Hospital, Australia) and Ulf I. Ulmsten (Uppsala University, Sweden) published "An Integral Theory of Female Urinary Incontinence" in Acta Obstetrica et Gynecologica Scandinavica Supplementum (1990). The theory proposed that:

  1. Continence is maintained by two directional muscle forces acting on the mid-urethra at the level of the pubourethral ligament (PUL)
  2. Lax PULs are the primary anatomical cause of SUI and urgency incontinence
  3. Restoration of PUL function via a suburethral support would restore continence

The practical application was a tension-free tape supporting the mid-urethra.[27]

Tension-Free Vaginal Tape (TVT) — Ulmsten (1996)​

Ulf Ulmsten and colleagues published the first clinical description of the Tension-Free Vaginal Tape (TVT) in International Urogynecology Journal in 1996 (a thin polypropylene mesh tape passed via two small suprapubic stab incisions, placed tension-free beneath the mid-urethra, and fixed by tissue ingrowth instead of suture). See Retropubic Mid-Urethral Sling.

The TVT differed from earlier SUI operations in four respects:

  • Minimally invasive. It was performed as a day case under local or spinal anesthesia.
  • Reproducible. It was adopted rapidly worldwide.
  • Effective. In the original 75-patient series, 63 women (84%) were completely cured at two years; this study did not compare TVT with open Burch.[28]
  • Mechanism. It supports the mid-urethra under stress instead of suspending the bladder neck.

The transobturator tape (TOT) was subsequently described by Delorme (2001) to further reduce bladder perforation risk by passing the tape through the obturator foramen. TVTO (inside-out obturator approach) was described by de Leval (2003).[28]

The Mesh Controversy (2000–Present)​

Synthetic Mesh Prolapse Kits (2000s)​

Following the TVT's success, the pelvic mesh market expanded aggressively in the 2000s. The FDA cleared the first mesh product specifically for prolapse repair in 2002, and industry rapidly developed proprietary kits (Mesh & Graft-Augmented Prolapse Repair)[52]:

DeviceManufacturerCompartmentEra
ProliftGynecare/J&JAnterior/posterior/total2005
PerigeeAMSAnterior2004
ApogeeAMSPosterior2004
ElevateAMSAnterior/apical2008
CapioBoston ScientificCapio suture-capturing device used to place the Pinnacle and Uphold mesh kits (anterior/apical)2000s

These products promised tension-free prolapse repair without autologous tissue harvest and with reduced operating time. However, a systematic review of vaginal prolapse repairs using synthetic or biologic grafts found pooled erosion in 10.3% across 110 studies.[49] Post-marketing surveillance also documented mesh exposure, dyspareunia, chronic pelvic pain, and mesh contraction, complications that proved difficult to treat and in some cases irreversible (see Mesh Complications & Removal).[29]

FDA Regulatory Action (2008–2019)​

  • 2002. The FDA cleared the first mesh product specifically for POP through the 510(k) pathway ("substantially equivalent" to predicate devices); FDA later reported that clinical performance data typically had not been used to support clearance of these mesh products.[53]
  • 2008. The FDA issued its first Public Health Notification regarding serious complications of surgical mesh for POP, the first federal acknowledgment of the problem.
  • 2011. The FDA issued an updated Safety Communication stating that serious complications associated with transvaginal mesh for POP are not rare.
  • 2012. The FDA ordered post-market surveillance (522) studies from manufacturers.
  • 2016. The FDA reclassified transvaginal mesh for POP as a Class III (high-risk) device requiring premarket approval.
  • 2019. The FDA ordered manufacturers to stop selling all transvaginal mesh for POP repair in the United States, a decision that removed the remaining mesh kits from the US market.
  • Australia, the UK (including Scotland) and New Zealand implemented similar restrictions or outright bans between 2017 and 2020.
  • The Cumberlege Review (UK, 2020, First Do No Harm) found that the healthcare system had been slow to respond to and had dismissed patients' safety concerns, and it called for a patient safety commissioner, a central patient database and a redress scheme.

The midurethral sling (TVT and TOT for SUI) remained on the US market, drawing the regulatory distinction between mesh for prolapse repair and mesh for incontinence.[29]

Regulatory Precedent. The transvaginal mesh experience changed how implanted pelvic devices are regulated. The 510(k) clearance pathway, which allowed mesh kits to reach the market without clinical trials on the basis of substantial equivalence to earlier predicate mesh devices, was criticized as inadequate for permanent implants, and transvaginal POP mesh was moved to Class III premarket approval in 2016.

The Native Tissue Renaissance​

In response to mesh complications, native tissue repairs experienced renewed interest: the Manchester repair, sacrospinous ligament fixation, and high uterosacral ligament suspension were re-evaluated in comparative trials. Compared with traditional vaginal native-tissue repair, abdominal sacrocolpopexy with mesh has less recurrent prolapse, although the FDA found no demonstrated reduction in repeat surgery for recurrence. Native-tissue repair avoids mesh exposure from the repair itself.[47]

The Specialty of Urogynecology​

Hamlin Fistula Hospital (1959–Present)​

Outside the academic centers, one of the largest contributions to obstetric fistula care came from Ethiopia. Reginald Hamlin (1908–1993) and Catherine Hamlin (1924–2020), two Australian obstetrician-gynecologists, arrived in Addis Ababa in 1959 on a three-year contract with the Ethiopian government to set up a midwifery school, and never left.

Confronted by large numbers of young women with obstetric fistulas (rendered incontinent, ostracized, and often abandoned), they dedicated their careers to fistula repair. The Addis Ababa Fistula Hospital opened in 1974 and grew into one of the world's largest fistula treatment centers. By the time of Catherine Hamlin's death in March 2020 at age 96, the hospital and its regional centers had treated more than 60,000 women; Hamlin Fistula Ethiopia now reports more than 82,000. In its 2023–24 report, Hamlin Fistula Ethiopia reported 93% fistula closure and 82% fistula cure; treatment is free to patients.[50][51]

The Hamlins established a nationwide fistula training program, trained Ethiopian surgeons, and founded the Hamlin College of Midwives to address the root cause. Catherine Hamlin was nominated for the Nobel Peace Prize and received numerous international honors. Her memoir The Hospital by the River (2001) brought global attention to the ongoing obstetric fistula crisis in sub-Saharan Africa.[33]

Global Fistula Burden. A 2018 WHO summary estimated 50,000–100,000 new obstetric fistulas worldwide each year and more than 2 million untreated cases in Asia and sub-Saharan Africa.[48] The persistence of obstetric fistula reflects lack of timely access to cesarean delivery.

International Urogynecological Association (IUGA) — Founded 1976​

The International Urogynecological Association was formed at the 1976 FIGO (International Federation of Gynecology and Obstetrics) meeting in Mexico City, where Axel Ingelman-Sundberg (Stockholm), then a FIGO vice president, and Jack Robertson (California) organized a new society to advance women's urinary health after FIGO declined to form a urinary incontinence subcommittee. Ingelman-Sundberg was elected IUGA's first president, serving 1976–1980; Ulf Ulmsten (then in Aarhus, Denmark) served as secretary. The ten founding members included Donald Ostergard and Stuart Stanton. Robertson was the second president (1981–1984) and Ostergard the third; later presidents included Harold Drutz (1994–1996), Linda Cardozo and Peter Dwyer. The International Urogynecology Journal was founded at the 1986 IUGA meeting at Yale, and its first issue appeared in September 1989.[38]

American Urogynecologic Society (AUGS) — Founded 1979​

The American society began in a California living room. In 1979, five physicians met in Orange County, California, to found a new society dedicated to the clinical and surgical management of female pelvic floor disorders:

  1. Jack Robertson, who became the first president
  2. Donald R. Ostergard, who became secretary-treasurer
  3. Finis Wiggins
  4. Earl Fuller
  5. Fred Jansen

They initially named the organization the Gynecologic Urology Society (GUS), a name that combined both specialties. The name urogynecology was suggested by Dr. Axel Ingelman-Sundberg, professor and head of obstetrics and gynecology in Stockholm (1949–1979), because "gynecologic urology" was not well accepted.

The GUS was renamed the American Urogynecologic Society (AUGS) in 1986, reflecting its growing membership and broader clinical scope. AUGS became the principal US professional society for female pelvic medicine.[34]

Female Pelvic Medicine and Reconstructive Surgery (FPMRS) Board Certification​

YearMilestone
1979GUS (Gynecologic Urology Society) founded in Orange County, CA
1986GUS renamed American Urogynecologic Society (AUGS)
2000FPMRS (Female Pelvic Medicine and Reconstructive Surgery) adopted as specialty name
2011American Board of Medical Specialties (ABMS) recognizes FPMRS as an official subspecialty
2013First FPMRS board certification examinations administered jointly by ABOG and ABU
2024Subspecialty renamed Urogynecology and Reconstructive Pelvic Surgery (URPS) by ABOG/ABU (announced October 2023, effective January 1, 2024)

Joint ABOG and ABU certification in FPMRS formalized what practitioners had been doing for decades and created a common training framework for gynecologists and urologists. The ABMS approved the change to URPS in June 2023; the boards chose a name that patients, the public and referring clinicians would recognize more readily.[30]

Chronological Timeline​

YearMilestone
c. 2050 BCEMummy of Henhenit — earliest known VVF case (11th dynasty Egypt)
c. 1835 BCEKahun Gynaecological Papyrus — earliest textual description of prolapse
c. 1550 BCEEbers Papyrus — additional gynecological treatments
460–370 BCEHippocratic writings — pomegranate pessaries; succussion for prolapse
c. 98–138 CESoranus of Ephesus — astringent-soaked wool tampons; excision of gangrenous prolapsed tissue
1025 CEAvicenna — description of VVF in Canon of Medicine
1543Vesalius — accurate female genital anatomy in De Humani Corporis Fabrica
c. 1560Ambroise Paré — brass and waxed-cork pessaries with retrieval threads
1844Charles Goodyear vulcanized rubber patent → modern pessary design
1849Sims — first successful VVF repair series (Anarcha, Betsey, Lucy); silver wire sutures
1852Sims — "On the Treatment of Vesico-Vaginal Fistula," Am J Med Sci
1861Choppin — first vaginal hysterectomy for procidentia under anesthesia (published 1866)
1864Baker Brown — suprapubic cystostomy for stress incontinence
1866Sims — anterior colporrhaphy for prolapse described
1867Neugebauer — first partial colpocleisis (unpublished until 1881)
1877LeFort — colpocleisis described; remains in use today
1886Olshausen — first laparotomy for uterine ventrofixation (abdominal approach)
1888Donald — first Manchester repair (cervical amputation + colporrhaphy)
1888Gersuny — urethral torsion for incontinence, improving on Pawlik's procedure
1892Poussan — urethral advancement proposed for incontinence
1893Howard Kelly — invents the air cystoscope (direct bladder visualization in women)
1894Dührssen — vaginal operation for uterine retroflexion described
1895Mackenrodt — describes the cardinal ligament (Mackenrodt's ligament)
1907Giordano — first sling procedure (gracilis muscle)
1908Fothergill — cardinal ligament plication modification → Manchester-Fothergill repair
1910Goebell — pyramidalis muscle suburethral procedure
1913Howard Kelly — Kelly plication stitch for SUI
1917Stoeckel — finalizes Goebell-Frangenheim-Stoeckel musculofascial sling technique
1923Bonney — describes urethral hypermobility in stress incontinence
1924Watson — anterior colporrhaphy outcome series for incontinence (65.7% perfect control) [38]
1942Aldridge — rectus fascia pubovaginal sling (autologous fascial sling)
1946Te Linde — Operative Gynecology, 1st edition
1949Marshall, Marchetti, Krantz — first retropubic bladder neck suspension (MMK)
1955Moore, Armstrong, Willis — tantalum mesh for cystocele (early synthetic mesh in pelvic surgery)
1957McCall — posterior culdoplasty during vaginal hysterectomy
1958Sederl — first describes sacrospinous ligament as anchor for prolapse
1959Pereyra — transvaginal needle suspension
1959Reginald and Catherine Hamlin arrive in Addis Ababa
1961Burch — Cooper's ligament colposuspension
1962Lane — first abdominal sacrocolpopexy
1968Richter (Germany) — formalizes sacrospinous ligament fixation
1968Robertson and Storz — first female urethroscope
1971ICS founded by Eric Glen in Exeter, UK
1971Randall and Nichols — first American sacrospinous ligament fixation series
1973Stamey — endoscopic bladder neck suspension
1974Addis Ababa Fistula Hospital formally founded by the Hamlins
1976IUGA founded; Ingelman-Sundberg elected first president
1978McGuire & Lytton — autologous rectus fascia pubovaginal sling standardized
1979GUS (Gynecologic Urology Society) founded in Orange County, CA
1981Raz — helical suture modification of Pereyra procedure
1986GUS renamed American Urogynecologic Society (AUGS)
1990Petros & Ulmsten — Integral Theory of female urinary incontinence
1992DeLancey — Three Levels of Vaginal Support
1994DeLancey — hammock hypothesis of continence
1994Nezhat CH/F/C — first laparoscopic sacrocolpopexy
1995–1996POP-Q classification published and adopted by ICS/AUGS/SGS
1996Ulmsten — TVT (Tension-Free Vaginal Tape) first published
2000FPMRS adopted as specialty name
2001Delorme — transobturator tape (TOT)
2002FDA clears first POP-specific mesh (510(k))[54]
2003de Leval — TVTO (inside-out obturator approach)
2004Di Marco et al. — first robotic sacrocolpopexy (5 women)
2005FDA clears da Vinci for gynecologic surgery
2008FDA first Public Health Notification on mesh complications
2011FDA updated Safety Communication on transvaginal mesh; ABMS recognizes FPMRS
2013First FPMRS board certification examinations
2016FDA reclassifies transvaginal POP mesh as Class III
2019FDA orders manufacturers to halt all transvaginal mesh for POP
2020UK Cumberlege Review: "First Do No Harm" — systemic failures in mesh surveillance
2020Catherine Hamlin dies, age 96
2024FPMRS renamed Urogynecology and Reconstructive Pelvic Surgery (URPS), announced October 2023

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