Prolapse surgery: native-tissue repair, vaginal apical suspension, sacrocolpopexy and the mesh controversy

She is 64, post-hysterectomy, and the vault is at the introitus. In theatre you have a choice to defend: a vaginal apical suspension that avoids mesh and recovers quickly, or a laparoscopic sacrocolpopexy that gives the most durable apical support but uses mesh. The examiner wants to hear how you choose — by compartment, by route, by material, by the trials — and how you counsel on recurrence, ureteric injury, mesh exposure and the chance of needing another operation. This topic is that defence.^[4][8]

Overview and definition

Prolapse surgery is the reconstruction or closure of failed vaginal support for symptomatic pelvic organ prolapse that has not responded to, or is unsuited to, conservative management.^[1] It is classified in two orthogonal ways — by route and by material — and the candidate who names both sounds like a consultant.

• By route: abdominal (open, laparoscopic or robotic), vaginal reconstructive, or vaginal obliterative (colpocleisis).^[4]
• By material: native tissue (fascial plication), abdominally placed synthetic mesh (sacrocolpopexy), biological graft, or transvaginal mesh kits (withdrawn for primary prolapse).^[15]

Two numbers anchor the topic: the lifetime surgical risk of 11.1% by age 80, and a reoperation rate of 29.2% with the interval shortening each round.^[3]

^{[3] [4] [6] [7] [15]}

References19ShowHide

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2. [2]DeLancey JO Anatomic aspects of vaginal eversion after hysterectomy Am J Obstet Gynecol, 1992.PMID 1615980
3. [3]Olsen AL, Smith VJ, Bergstrom JO, Colling JC, Clark AL Epidemiology of surgically managed pelvic organ prolapse and urinary incontinence Obstet Gynecol, 1997.PMID 9083302
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6. [6]Jelovsek JE, Barber MD, Brubaker L, 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.PMID 29677302
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10. [10]Schimpf MO, Abed H, Sanses T, et al. Graft and Mesh Use in Transvaginal Prolapse Repair: A Systematic Review Obstet Gynecol, 2016.PMID 27275813
11. [11]Siddiqui NY, Grimes CL, Casiano ER, et al. Mesh sacrocolpopexy compared with native tissue vaginal repair: a systematic review and meta-analysis Obstet Gynecol, 2015.PMID 25560102
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14. [14]Christmann-Schmid C, Baessler K, Yeung E, et al. Surgery for women with anterior compartment prolapse Cochrane Database Syst Rev, 2026.PMID 42029168
15. [15]Yeung E, Baessler K, Christmann-Schmid C, Haya N, Chen Z, Wallace SA, Mowat A, Maher C Transvaginal mesh or grafts or native tissue repair for vaginal prolapse Cochrane Database Syst Rev, 2024.PMID 38477494
16. [16]Haylen BT, Freeman RM, Swift SE, et al. An International Urogynecological Association (IUGA) / International Continence Society (ICS) joint terminology and classification of the complications related directly to the insertion of prostheses (meshes, implants, tapes) & grafts in female pelvic floor surgery Int Urogynecol J, 2011.PMID 21140130
17. [17]Wei JT, Nygaard I, Richter HE, Nager CW, Barber MD, Kenton K, Amundsen CL, Schaffer J, Meikle SF, Spino C A midurethral sling to reduce incontinence after vaginal prolapse repair N Engl J Med, 2012.PMID 22716974
18. [18]Winkelman WD, Modest AM, Richardson ML U.S. Food and Drug Administration Statements About Transvaginal Mesh and Changes in Apical Prolapse Surgery Obstet Gynecol, 2019.PMID 31503162
19. [19]Unger CA, Walters MD, Ridgeway B, Jelovsek JE, Barber MD, Paraiso MF Incidence of adverse events after uterosacral colpopexy for uterovaginal and posthysterectomy vault prolapse Am J Obstet Gynecol, 2015.PMID 25434838