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 RepairACOG PB 214 framework, SUPeR trial 2024 (sacrocolpopexy 28% / TVM 29% / native tissue 43% composite failure at 36 months), the 2026 Cochrane anterior-compartment update, hysteropexy-vs-hysterectomy meta-analyses (Ruffolo 2025; Brennand 2025), concomitant continence procedure trade-offs (CARE / OPUS / 2026 Cochrane), and a 10-row summary of core principles.
25 of 25 procedures
| Procedure | Compartment | Approach | Notes |
|---|---|---|---|
| Prolapse Pessaries | All | Non-surgical | First-line non-surgical management for all prolapse stages and compartments. Ring, dish, Gellhorn, cube, and Gehrung types address different anatomical patterns. Requires ongoing fitting, follow-up, and patient ability to manage insertion/removal. |
| Anterior Midline Colporrhaphy | Anterior | Vaginal | Central defect repair via midline plication of pubocervical fascia beneath the bladder. Addresses central cystocele. High recurrence at 5 years for isolated central repair; often combined with apical support. |
| Kelly Plication | Anterior | Vaginal | Historical anterior colporrhaphy with urethrovesical angle plication for concurrent SUI. Largely supplanted by suburethral slings; retained for context as a combined continence-prolapse repair. |
| Vaginal Paravaginal Repair | Anterior | Vaginal | Reattachment of lateral vaginal wall to the arcus tendineus fascia pelvis (ATFP) via vaginal approach. Targets lateral paravaginal defect cystocele; technically demanding with limited long-term data. |
| Transvaginal Paravaginal Anterior Repair (Lattice Technique) | Anterior | Vaginal | Fascial patch or lattice repair of paravaginal defect via vaginal approach. Uses autologous or allograft tissue in a grid pattern to reinforce the lateral attachment; alternative to abdominal paravaginal repair. |
| Michigan Four Wall | Anterior | Vaginal | Four-wall vault support combined with sacrospinous fixation. Emphasizes apical anchoring during anterior colporrhaphy to prevent vault descent contributing to anterior recurrence. |
| Posterior Midline Colporrhaphy | Posterior | Vaginal | Central plication of rectovaginal fascia to address posterior wall prolapse (rectocele). High anatomic success; functional results variable with risk of dyspareunia from over-correction. |
| Perineorrhaphy | Posterior | Vaginal | Repair and reconstruction of the perineal body, reapproximating the bulbocavernosus and transverse perineal muscles. Addresses distal rectocele and perineal laxity; frequently combined with posterior colporrhaphy. |
| Sacrospinous Ligament Fixation (SSLF) | Apical | Vaginal | Vaginal apex sutured to the right sacrospinous ligament via posterior colpotomy and rectovaginal dissection. Native tissue apical repair; high apical success but associated with anterior recurrence due to posterior axis shift. |
| Uterosacral Ligament Suspension (USLS) | Apical | Vaginal | Vaginal apex suspended bilaterally to the uterosacral ligaments at the level of the ischial spines. OPTIMAL trial: equivalent to SSLF at 2 years (63.1% vs 64.5%). Risk of ureteral kinking; cystoscopy mandatory. |
| Vaginal McCall's Culdoplasty | Apical | Vaginal | High posterior culdoplasty at the time of vaginal hysterectomy — uterosacral ligaments and posterior peritoneum plicated to suspend the vaginal apex and obliterate the cul-de-sac. Standard adjunct to vaginal hysterectomy. |
| Sacrospinous Hysteropexy | Apical | Vaginal | Uterus suspended to the sacrospinous ligament preserving the uterus. Increasingly preferred alternative to hysterectomy for uterine prolapse in patients desiring uterine preservation. Similar outcomes to VH+SSLF in short-term data. |
| Manchester-Fothergill Procedure | Apical | Vaginal | Anterior colporrhaphy with cervical amputation and cardinal ligament plication for apical support while preserving the uterus. Uterus-conserving procedure for uterine prolapse when patient desires fertility or uterine retention. |
| Iliococcygeus Fascia Suspension | Apical | Vaginal | Vaginal apex sutured bilaterally to the iliococcygeus fascia just below the ischial spine. Alternative native tissue apical repair when sacrospinous or uterosacral fixation is not feasible; avoids the sacrospinous neurovascular bundle. |
| Vaginal Hysterectomy | Apical | Vaginal | Removal of the uterus via vaginal approach with concurrent apical repair (McCall's culdoplasty, SSLF, or USLS). Standard surgical treatment for symptomatic uterine prolapse when uterine preservation is not desired. |
| Supracervical Hysterectomy at Sacrocolpopexy | Apical | Robotic | Subtotal hysterectomy preserving the cervix as the mesh anchor at concomitant sacrocolpopexy. Mesh exposure ~0.5% (supracervical) vs ~4.7% (total) — Linder 2018 Mayo n=814. Standard preference among contemporary urogynecologists when hysterectomy is performed at sacrocolpopexy. |
| Sacrocolpopexy | Apical | Robotic | Polypropylene mesh attached from anterior and posterior vaginal walls to the sacral promontory (S1). CARE trial gold standard; 5-year objective success ~78%. Avoids posterior vaginal axis shift. Robotic approach now standard. |
| Pectopexy | Apical | Abdominal | Mesh-based apical suspension to the pectineal (Cooper's) ligament bilaterally. Avoids sacral dissection and risk of presacral hemorrhage. European technique gaining adoption; comparable apical outcomes to sacrocolpopexy in prospective data. |
| Abdominal McCall's Culdoplasty | Apical | Abdominal | McCall-type culdoplasty performed abdominally at the time of abdominal hysterectomy. Obliterates the cul-de-sac with high uterosacral plication to prevent future enterocele formation. |
| Moschcowitz Procedure | Apical | Abdominal | Concentric purse-string sutures obliterating the pouch of Douglas to prevent or repair enterocele. Performed abdominally; frequently combined with sacrocolpopexy or abdominal hysterectomy. |
| Halban Culdoplasty | Apical | Abdominal | Sagittal sutures (anterior-posterior) obliterating the cul-de-sac peritoneum to prevent enterocele. Abdominal approach; alternative to Moschcowitz for enterocele prevention at hysterectomy. |
| Raz Transvaginal Enterocele Repair | Apical | Vaginal | High transvaginal ligation and excision of the enterocele sac with plication of the uterosacral-cardinal complex. Targets enterocele sac excision with concurrent high apical support. |
| CRISP Technique | Apical | Vaginal | Continuous running suture peritoneal closure incorporating uterosacral plication for vault suspension. Technical variation of native tissue apical repair emphasizing simplicity and reproducibility. |
| Le Fort Colpocleisis | All | Vaginal | Partial colpocleisis — anterior and posterior vaginal epithelium denuded and approximated with lateral channels preserved for cervical drainage. Highly effective obliterative procedure for elderly, medically fragile patients not desiring intercourse. 90%+ anatomic success. |
| Colpocleisis | All | Vaginal | Total vaginal obliteration for severe prolapse in patients who have completed sexual activity. Shorter operative time and lower morbidity than reconstructive alternatives; definitive treatment with high satisfaction in appropriately selected patients. |