Types of uterine prolapse surgery and how to choose

Hysteropexy vs hysterectomy: preserve or remove the uterus

Preservation avoids removing a healthy organ; removal avoids future uterine disease and is sometimes preferred when the cervix is very elongated.

ACOG says there can be benefits to keeping the uterus, including shorter surgery, but your doctor may recommend a hysterectomy if you have a condition such as abnormal bleeding or a family history of cancer of the uterus or cervix.

What NICE lists as choices

For women with uterine prolapse who have no preference about keeping the uterus, NICE guidance lists vaginal hysterectomy and vaginal sacrospinous hysteropexy with sutures. The Manchester repair and sacro-hysteropexy with mesh through the abdomen are also listed.

For women who want to keep the uterus, NICE lists vaginal sacrospinous hysteropexy with sutures or the Manchester repair, unless the woman may wish to have children in the future. In that case it asks for a regional multidisciplinary team to review the plan.

NICE also asks surgeons to discuss the possible complications and the lack of long-term evidence on how well these operations work.

Native tissue or mesh

Native-tissue repairs use the patient's own ligaments and sutures. Mesh adds a synthetic scaffold; its transvaginal use has been restricted in several countries because of complications, while abdominal mesh sacrocolpopexy remains widely used. Ask which your surgeon proposes and why.

In April 2019 the FDA ordered manufacturers to stop selling mesh for transvaginal repair of pelvic organ prolapse. Mesh attached to the sacrum through an abdominal or laparoscopic incision, as in sacrohysteropexy, was not part of that order. ACOG notes that surgery with vaginally placed mesh carries a high risk of severe complications and should be reserved for situations where the benefits may justify the risks.

What the research found

A 2023 Cochrane review of surgery for apical prolapse compared sacrocolpopexy, an operation through the abdomen, with vaginal procedures for prolapse of the vaginal vault. Women were less aware of prolapse and needed fewer repeat operations after sacrocolpopexy, with moderate certainty.

Vaginal hysteropexy and vaginal hysterectomy showed little or no difference in the main outcomes for uterine prolapse, with certainty rated low to moderate.

How measurement guides the choice

The clinic uses vaginal endoscopy imaging to examine the vaginal wall before treatment. Vaginal laxity is measured numerically rather than judged by hand. These findings show which supports have failed, which matters when you are choosing between keeping and removing the uterus.

Vaginal or abdominal approach

Vaginal surgery has no abdominal incisions and a shorter stay; abdominal or laparoscopic approaches allow sacrocolpopexy and may suit recurrent or severe prolapse.

Recovery by option

Most options involve about six weeks of lifting restrictions; at Podo, pelvic ligament suspension asks for no lifting over 10 kg (about 22 pounds) for 8 weeks, and intercourse can usually resume about 8 weeks after surgery, once a check confirms healing. Vaginal native-tissue repairs typically mean one night's stay; laparoscopic procedures one to two nights; open abdominal surgery longer.

Obliterative surgery (colpocleisis)

Obliterative surgery narrows or closes the vagina to support the prolapsed organs. ACOG says it has a high success rate and may suit a woman who does not plan to have vaginal sex in the future and wants an easily done procedure, and that vaginal sex is not possible afterward. NICE advises considering colpocleisis for women with vault or uterine prolapse who do not intend to have penetrative vaginal sex and who have a physical condition that raises their risk of complications.

Pregnancy plans and recurrence

ACOG advises that if you want to get pregnant in the future, you should ideally delay surgery until your family is complete, to avoid the prolapse coming back after repair. NICE asks for a regional multidisciplinary team to review the plan if a woman may want children. ACOG lists being younger than 60, being overweight and having more advanced prolapse before the first operation as risk factors for the prolapse returning, and says it is not known whether anything can be done to prevent that.

Questions for your surgeon

Will my uterus be preserved, and why? Is mesh used? How many of these operations do you perform each year? What is your recurrence rate, and how do you follow patients up? What happens if the prolapse comes back?

After a hysterectomy or earlier mesh surgery

After hysterectomy, the remaining pelvic ligaments are used to restore support around the vagina; for a patient with a previous mesh sacrocolpopexy, whether further repair is possible is decided from the clinical examination.

How Podo approaches it

Podo uses pelvic ligament suspension, which restores support by re-anchoring the patient's own lax pelvic ligaments, without synthetic mesh. Whether the uterus is preserved is discussed with you before surgery.

The same technique treats other support problems. It is used for stress urinary incontinence, cystocele, rectocele and uterine prolapse.

Sources

1. NICE guideline NG123: Urinary incontinence and pelvic organ prolapse in women: management
2. Cochrane review (2023): Surgery for women with apical vaginal prolapse
3. ACOG FAQ: Surgery for Pelvic Organ Prolapse
4. FDA: Urogynecologic surgical mesh, FDA's activities

Read about this at Podo

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