Prolapse Repair
Pelvic organ prolapse (POP) repair encompasses native-tissue, mesh-augmented, and obliterative procedures targeting the anterior, posterior, and apical compartments. Surgical planning must account for compartment-specific anatomy (DeLancey Levels I–III), patient goals including uterine preservation and sexual activity, prior surgery, and mesh history.
See POP Overview for pathophysiology, risk stratification, and trial data (OPTIMAL, PEOPLE).
General Principles
- Principles of Prolapse RepairHow to counsel patients and choose a prolapse operation, based on the major trials and core surgical principles.
- Mesh & Graft-Augmented Prolapse RepairWhen mesh or graft augmentation is used in prolapse repair, and its evidence and complications.
- Mesh Complications & RemovalRecognizing and managing mesh complications after prolapse and sling surgery, including when and how to remove mesh.
Decision Framework
Plan around bothersome symptoms, compartment anatomy and patient goals, including uterine preservation, vaginal intercourse, mesh preferences and recovery. Assess and restore apical support when it is deficient; anatomic recurrence, bothersome recurrence and reoperation are different outcomes. The AUGS consensus recommends intraoperative cystoscopy to inspect the lower urinary tract and confirm ureteral efflux during pelvic reconstructive prolapse surgery, except isolated posterior-compartment repair.[5] In ASPIRe (Menefee 2024), 376 women with post-hysterectomy vault prolapse were randomized, and 360 underwent a study operation. Modeled 36-month composite failure was 28% after sacrocolpopexy, 29% after historical transvaginal-mesh repair and 43% after vaginal native-tissue repair.[2] Sacrocolpopexy was superior to native tissue for that endpoint (adjusted HR 0.57; 99% CI 0.33–0.98); the trial's per-protocol mesh-versus-sacrocolpopexy noninferiority result is not equivalence.[2] Vaginal POP mesh products studied there are not marketed in the US. See the source-scoped interpretation and FDA route distinctions.
Uterine-preserving surgery should be offered as an option to surgical candidates without contraindications, after an individualized benefit-risk discussion of preservation and hysterectomy (AUGS Clinical Practice Statement, 2025).[10] In the ten-year SAVE-U follow-up, apical surgical failure (stage ≥2 uterine or vault recurrence with bothersome bulge symptoms, or repeat surgery for apical recurrence) occurred in 3/44 (7%) after sacrospinous hysteropexy versus 7/49 (14%) after vaginal hysterectomy with uterosacral suspension; the difference was not statistically significant.[9] Colpocleisis is a useful obliterative option for a patient who does not intend future penetrative vaginal intercourse. See Principles of Prolapse Repair for the Ruffolo/Brennand and continence-source limits.
POP is diagnosed clinically. Document symptoms, POP-Q compartments, urinary emptying and leakage, bowel and sexual function, prior surgery and goals. Discuss observation, supervised pelvic floor muscle training, pessary and surgery. A pessary trial is an option, not a prerequisite for surgery; NICE recommends offering surgery for pelvic organ prolapse when symptoms have not improved with nonsurgical treatment or when nonsurgical treatment is declined.[1] Assess occult SUI or voiding dysfunction when the result would change a proposed continence plan; urodynamics is not required for every prolapse operation. See the assessment and treatment-selection source review.
Treatment Selection by Clinical Scenario
| Clinical Scenario | Potential approach | Alternative(s) | Important caution |
|---|---|---|---|
| Primary uterine prolapse, desires uterine preservation | Sacrospinous hysteropexy, Manchester procedure or sacrohysteropexy, according to anatomy and route | Uterosacral hysteropexy | Evaluate uterine/cervical pathology and future surveillance |
| Primary uterine prolapse, does not desire uterine preservation | Vaginal hysterectomy with planned apical support (USLS or SSLF) | McCall culdoplasty at vaginal hysterectomy; minimally invasive hysterectomy with sacrocolpopexy for selected patients at high risk of recurrence[6] | Restore apical support with any prolapse hysterectomy; discuss mesh exposure and small-bowel injury if sacrocolpopexy is chosen.[6] |
| Post-hysterectomy vault prolapse, stage II | Vaginal native-tissue USLS or SSLF | Sacrocolpopexy | Discuss mesh and operative trade-offs |
| Post-hysterectomy vault prolapse, stage III–IV | Sacrocolpopexy or vaginal native-tissue suspension according to goals, risk and expertise | USLS or SSLF when vaginal repair is preferred | Discuss stage-specific recurrence and mesh harms; no absolute NTR prohibition from a retrospective stage comparison |
| Anterior compartment prolapse (primary) | Anterior colporrhaphy with apical support when deficient | Paravaginal repair for selected lateral defects | — |
| Posterior compartment prolapse | Posterior colporrhaphy | Site-specific repair | NICE recommends repair without mesh[11]; evaluate bowel symptoms and avoid unnecessary levator tightening |
| Recurrent anterior / apical prolapse after native-tissue repair | Sacrocolpopexy or individualized repeat native-tissue repair | Procedure choice depends on failure compartment, prior repair and goals | Historical transvaginal POP mesh kits are not marketed in the US |
| No desire for future penetrative vaginal intercourse | Colpocleisis (Le Fort or total) | Individualized reconstructive repair | Explain permanent change in vaginal access/function |
| Sexually active, advanced prolapse, durability prioritized | Sacrocolpopexy, with route-specific uterine-preservation discussion | Vaginal native-tissue suspension | Colpocleisis precludes future penetrative vaginal intercourse |
| Concomitant occult SUI | Discuss a concomitant procedure, such as Burch with abdominal sacrocolpopexy or MUS with vaginal repair | Staged approach | During vaginal POP repair for occult SUI, concomitant MUS probably reduces subjective postoperative SUI versus repair alone (RR 0.38, 95% CI 0.26–0.55; 5 trials, 369 women).[8] Staged treatment remains an option and prophylaxis is not automatic in continent patients. |
| Symptomatic, considering conservative care | Surgical choice remains preference-sensitive | Pessary, supervised PFMT and lifestyle measures | Surgery may be discussed when nonsurgical care is ineffective or declined; no mandatory pessary trial |
Apical Suspension Sub-Comparison
| Feature | USLS (Vaginal) | SSLF (Vaginal) | Sacrocolpopexy | Manchester Procedure |
|---|---|---|---|---|
| Approach | Vaginal | Vaginal | Laparoscopic / robotic / open | Vaginal |
| Mechanism | Apex to uterosacral ligaments | Apex to sacrospinous ligament | Mesh from apex to sacral promontory | Cervical amputation + ligament plication |
| Evidence anchor | E-OPTIMAL: modeled first composite failure 61.5% at 5 years in a cohort with planned concomitant slings[3][4] | E-OPTIMAL: modeled first composite failure 70.3% at 5 years; no equivalence demonstrated[3] | ASPIRe: modeled 36-month composite failure 28% in post-hysterectomy vault prolapse[2] | SAM: among patients having first surgery for uterine descent not protruding beyond the hymen, two-year composite success (no prolapse beyond the hymen in any compartment, no bothersome bulge symptoms, and no prolapse retreatment) was 172/197 (87.3%) after Manchester versus 151/196 (77.0%) after sacrospinous hysteropexy; the latter did not meet noninferiority.[7] |
| Advanced-stage context | Recurrence varies by population and endpoint | Recurrence varies by population and endpoint | May offer durability advantages for selected vault prolapse; mesh risks remain | Requires a suitable cervix and uterine-preservation counseling |
| Mesh use | No | No | Yes (type 1 polypropylene) | No |
| Key risks | Ureteral compromise; perform cystoscopy with efflux assessment | Buttock/gluteal pain and hemorrhage | Mesh exposure, visceral injury and route-specific recovery | Cervical stenosis and uterine/cervical surveillance; future pregnancy needs individualized counseling |
| OR time | Varies by repair and expertise | Varies by repair and expertise | Varies by route and concomitant repair | Varies by cervical and compartment work |
| Typical use | Vaginal native-tissue vault suspension | Vaginal native-tissue vault suspension | Vault prolapse when sacral mesh repair fits patient goals and risk | Uterine prolapse with suitable cervical anatomy after counseling |
Compartment Stepwise Approach
Anterior compartment
- Assess anterior and apical support; use anterior colporrhaphy for a suitable central defect and restore apical support when deficient.
- If recurrent, reassess the failed compartment and prior repair; sacrocolpopexy or another native-tissue repair may be considered. Historical vaginal POP-mesh kits are not marketed in the US.
Posterior compartment
- Posterior colporrhaphy (midline plication) ± perineorrhaphy
- NICE recommends posterior repair without mesh; tailor the repair to bowel symptoms and anatomy.
Apical compartment
- Vaginal native-tissue suspension (USLS or SSLF).
- Hysteropexy (sacrospinous, Manchester, or sacral) if uterine preservation is desired
- Sacrocolpopexy. Discuss for selected advanced or recurrent vault prolapse, including mesh and visceral risks.
- Colpocleisis (Le Fort or total) for patients who do not intend future penetrative vaginal intercourse after informed discussion.
| Procedure | Compartment | Use and Considerations |
|---|---|---|
| Pelvic Floor Muscle Training (PFMT) | All | Supervised conservative option, particularly for symptomatic stage I–II POP; a prior trial is not mandatory before surgery. |
| Prolapse Pessaries | All | Reversible nonsurgical treatment or bridge to surgery; fitting, continuation and symptom improvement are different outcomes, and device choice is individualized. |
| Lifestyle Modifications | All | Supportive discussion of weight, bowel symptoms and activity; most individual measures have unproved POP treatment effects. PFMT has separate trial evidence. |
| Anterior Colporrhaphy | Anterior | Repair of a suitable central anterior-wall defect; assess apical support and restore it when deficient. |
| Kelly Plication | Anterior | Historical anterior colporrhaphy + urethrovesical plication for concurrent SUI; supplanted by midurethral slings. |
| Paravaginal Repair | Anterior | Selected lateral-support defect — reattachment to the arcus tendineus fascia pelvis; reported defect prevalence comes from selected cohorts, not all cystoceles. |
| Michigan Four-Wall SSLF | Apical (multicompartment) | Multicompartment vaginal repair with individualized apical suspension; long-term results come from a selected follow-up cohort. |
| Posterior Colporrhaphy | Posterior | Posterior wall rectocele — midline rectovaginal fascial plication. Watch for over-correction dyspareunia. |
| Perineorrhaphy | Posterior | Perineal body laxity or distal rectocele; usually combined with posterior colporrhaphy. |
| Sacrospinous Ligament Fixation (SSLF) | Apical | Native-tissue apical suspension to a sacrospinous ligament; side and suture technique vary. |
| Uterosacral Ligament Suspension (USLS) | Apical | Bilateral native-tissue apical suspension; E-OPTIMAL did not establish equivalence with SSLF. Check ureteral efflux by cystoscopy. |
| McCall Culdoplasty | Apical | Native-tissue apical suspension at hysterectomy; USL plication with cul-de-sac obliteration. |
| Sacrospinous Hysteropexy | Apical | Uterus-preserving vaginal apical suspension; interpret SAVE-U's five-year endpoint in its enrolled population and treatment arm. |
| Manchester-Fothergill Procedure | Apical | Uterus-preserving repair for selected prolapse with cervical elongation; future pregnancy needs individualized counseling. |
| Iliococcygeus Fascia Suspension | Apical | Native-tissue vaginal-apex suspension to medial iliococcygeus fascia caudal to the ischial spine; the 2026 AWMF guideline considers it when no adequate alternative exists. Lower injury risk is unproved. |
| Vaginal Hysterectomy | Apical | Uterine prolapse when hysterectomy is selected; include a plan to restore apical support. |
| Supracervical Hysterectomy at Sacrocolpopexy | Apical | Subtotal hysterectomy at sacrocolpopexy retains the cervix; weigh mesh exposure evidence against bleeding, cervical surveillance and other trade-offs. |
| Sacrocolpopexy | Apical | Sacral mesh suspension of the vaginal apex; discuss route-specific durability and mesh risks. |
| Sacrohysteropexy / Sacrocervicopexy | Apical | Uterine-preserving sacrocolpopexy variant; cervix to sacral promontory. |
| Laparoscopic Lateral Suspension (LLS) | Apical | Anterior-apical prolapse with uterine preservation; avoids sacral dissection. |
| Pectopexy | Apical | Mesh apical suspension to pectineal (Cooper's) ligaments bilaterally; avoids sacral-promontory dissection but does not eliminate operative risk. |
| Cervicosacropexy / Vaginosacropexy (CESA/VASA) | Apical | Bilateral PVDF mesh replacement of the uterosacral ligaments to S1, developed for apical prolapse with coexisting urgency or mixed incontinence; evidence is low-certainty and not directly compared with sacrocolpopexy. |
| Transvaginal Mesh (Apical-Only Kits) | Apical | Historical transvaginal POP-mesh approach for selected prolapse; no FDA-approved transvaginal POP mesh product is currently marketed in the US. |
| Moschcowitz Procedure | Apical | Concentric purse-string cul-de-sac obliteration for enterocele — abdominal, often with SCP / abdominal hysterectomy. |
| Halban Culdoplasty | Apical | Sagittal sutures obliterating cul-de-sac peritoneum — abdominal alternative to Moschcowitz for enterocele prevention. |
| Colpocleisis (Le Fort and Total) | All | Obliterative repair for a patient who does not intend future penetrative vaginal intercourse, after informed discussion. |
References
1. National Institute for Health and Care Excellence. Urinary incontinence and pelvic organ prolapse in women: management (NG123). Recommendation 1.8.1. 2019. Guideline.
2. Menefee SA, et al. "Apical Suspension Repair for Vaginal Vault Prolapse: A Randomized Clinical Trial." JAMA Surg. 2024;159(8):845-855. doi:10.1001/jamasurg.2024.1206
3. Jelovsek JE, et al. "Effect of Uterosacral Ligament Suspension vs Sacrospinous Ligament Fixation With or Without Perioperative Behavioral Therapy for Pelvic Organ Vaginal Prolapse on Surgical Outcomes and Prolapse Symptoms at 5 Years in the OPTIMAL Randomized Clinical Trial." JAMA. 2018;319(15):1554-1565. doi:10.1001/jama.2018.2827
4. Barber MD, et al. "Comparison of 2 Transvaginal Surgical Approaches and Perioperative Behavioral Therapy for Apical Vaginal Prolapse: The OPTIMAL Randomized Trial." JAMA. 2014;311(10):1023-1034. doi:10.1001/jama.2014.1719
5. Cohen SA, Carberry CL, Smilen SW. "American Urogynecologic Society Consensus Statement: Cystoscopy at the Time of Prolapse Repair." Female Pelvic Med Reconstr Surg. 2018;24(4):258-259. doi:10.1097/SPV.0000000000000529
6. Gupta A, Grimes CL, Badlani G, et al. "A Global Consensus Conference on Surgical Management of Primary Uterovaginal Prolapse and Lower Urinary Tract Dysfunction: Combining Evidence with Expert Opinion." Int Urogynecol J. Published online July 2, 2026. doi:10.1007/s00192-026-06758-6
7. Enklaar RA, Schulten SFM, van Eijndhoven HWF, et al. "Manchester Procedure vs Sacrospinous Hysteropexy for Treatment of Uterine Descent: A Randomized Clinical Trial." JAMA. 2023;330(7):626-635. doi:10.1001/jama.2023.13140
8. Baessler K, Christmann-Schmid C, Haya N, et al. "Surgery for women with pelvic organ prolapse with or without stress urinary incontinence." Cochrane Database Syst Rev. 2026;2:CD013108. doi:10.1002/14651858.CD013108.pub2
9. Oegema K, Schulten SFM, Stekelenburg J, Kluivers KB, van Eijndhoven HWF. "Sacrospinous Hysteropexy Versus Vaginal Hysterectomy in Women with Uterine Prolapse: 10-year Follow-up of a Randomised Controlled Trial." Int Urogynecol J. Published online August 13, 2026. doi:10.1007/s00192-026-06822-1
10. 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
11. National Institute for Health and Care Excellence. "Urinary incontinence and pelvic organ prolapse in women: management." NICE guideline NG123. 2019, recommendation 1.8.23. NICE guidance.