Uterine preservation vs hysterectomy in pelvic organ prolapse surgery: a systematic review with meta-analysis and clinical practice guidelines
Abstract
Objective We aimed to systematically review the literature on apical pelvic organ prolapse surgery with uterine preservation compared with prolapse surgeries including hysterectomy and provide evidence-based guidelines.Data sources The sources for our data were MEDLINE, Cochrane, and clinicaltrials.gov databases from inception to January 2017.Study eligibility criteria We accepted randomized and nonrandomized studies of uterine-preserving prolapse surgeries compared with those involving hysterectomy.Study appraisal and synthesis methods Studies were extracted for participant information, intervention, comparator, efficacy outcomes, and adverse events, and they were individually and collectively assessed for methodological quality. If 3 or more studies compared the same surgeries and reported the same outcome, a meta-analysis was performed.Results We screened 4467 abstracts and identified 94 eligible studies, 53 comparing uterine preservation to hysterectomy in prolapse surgery. Evidence was of moderate quality overall. Compared with hysterectomy plus mesh sacrocolpopexy, uterine preservation with sacrohysteropexy reduces mesh exposure, operative time, blood loss, and surgical cost without differences in prolapse recurrence. Compared with vaginal hysterectomy with uterosacral suspension, uterine preservation in the form of laparoscopic sacrohysteropexy improves the C point and vaginal length on the pelvic organ prolapse quantification exam, estimated blood loss, postoperative pain and functioning, and hospital stay, but open abdominal sacrohysteropexy worsens bothersome urinary symptoms, operative time, and quality of life. Transvaginal mesh hysteropexy (vs with hysterectomy) decreases mesh exposure, reoperation for mesh exposure, postoperative bleeding, and estimated blood loss and improves posterior pelvic organ prolapse quantification measurement. Transvaginal uterosacral or sacrospinous hysteropexy or the Manchester procedure compared with vaginal hysterectomy with native tissue suspension both showed improved operative time and estimated blood loss and no worsening of prolapse outcomes with uterine preservation. However, there is a significant lack of data on prolapse outcomes >3 years after surgery, the role of uterine preservation in obliterative procedures, and longer-term risk of uterine pathology after uterine preservation.Conclusion Uterine-preserving prolapse surgeries improve operating time, blood loss, and risk of mesh exposure compared with similar surgical routes with concomitant hysterectomy and do not significantly change short-term prolapse outcomes. Surgeons may offer uterine preservation as an option to appropriate women who desire this choice during apical prolapse repair.
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These findings contrast with previous observational studies that reported higher mesh exposure rates when total hysterectomy or vaginal mesh procedures were included.
“These findings contrast with previous observational studies that reported higher mesh exposure rates when total hysterectomy or vaginal mesh procedures were included [15–24, 29].”
From Perioperative complications of laparoscopic sacrohysteropexy versus sacrocolpopexy with subtotal hysterectomy for pelvic organ prolapse (2026) · cites this paper as [17]
A systematic review found only two randomised controlled trials comparing abdominal hysteropexy with vaginal hysterectomy with apical suspension, and both reported only short-term outcomes.
“A systematic review found only two randomised controlled trials comparing abdominal hysteropexy with VH with apical suspension, and both reported only short-term outcomes [12].”
From Laparoscopic sacrohysteropexy versus vaginal hysterectomy and apical suspension: 7-year follow-up of a randomized controlled trial (2022) · cites this paper as [12]
A recognized clinical advantage of uterine-sparing procedures is the reduced risk of mesh erosion.
“A recognized clinical advantage of uterine-sparing procedures is the reduced risk of mesh erosion [12, 17, 25].”
From Perioperative complications of laparoscopic sacrohysteropexy versus sacrocolpopexy with subtotal hysterectomy for pelvic organ prolapse (2026) · cites this paper as [17]
These findings are consistent with those of Sato et al. and align with meta-analytic data suggesting that increased blood loss associated with hysterectomy-based repair is primarily attributable to total rather than subtotal hysterectomy.
“These findings are consistent with those of Sato et al. [19] and align with meta-analytic data suggesting that increased blood loss associated with hysterectomy-based repair is primarily attributable to total rather than subtotal hysterectomy [17, 19, 25].”
From Perioperative complications of laparoscopic sacrohysteropexy versus sacrocolpopexy with subtotal hysterectomy for pelvic organ prolapse (2026) · cites this paper as [17]
Whether concurrent hysterectomy increases the risk of mesh exposure remains a controversial issue.
“Whether concurrent hysterectomy increases the risk of mesh exposure remains a controversial issue.”
From Mesh Exposure After Laparoscopic Sacrocolpopexy with Concomitant Total Hysterectomy or Uterine Preservation: A Retrospective Cohort Study (2026) · cites this paper as [11]
Meriwether et al. reported reduced risk of mesh exposure and similar objective success rate in women with uterine-preserving surgery compared with hysterectomy plus sacrocolpopexy.
“Meriwether et al. compared hysterectomy plus SC with sacrohysteropexy in a meta-analysis and reported reduced risk of mesh exposure and similar objective success rate in women with uterine-preserving surgery [11].”
From Mesh Exposure After Laparoscopic Sacrocolpopexy with Concomitant Total Hysterectomy or Uterine Preservation: A Retrospective Cohort Study (2026) · cites this paper as [11]
Variations in repair techniques for the anterior and posterior compartments may further influence these results.
“Moreover, variations in the repair techniques for the anterior and posterior compartments may further influence these results [34–37”
From The uterus debate in vaginal native tissue repair for pelvic organ prolapse: Hysteropexy versus hysterectomy – A systematic review and meta-analysis (2025) · cites this paper as [37]
Advantages of uterine-preserving procedures include shorter operative time, reduced intraoperative blood loss, and shorter hospital stay compared to apical prolapse repair involving hysterectomy.
“Advantages include shorter operative time, reduced intraoperative blood loss, and shorter hospital stay compared to apical prolapse repair involving hysterectomy”
From Individualized Prediction of Recurrence Following Uterine-Preserving Pelvic Organ Prolapse Repair Using Internally Validated Machine Learning Models (2026) · cites this paper as [13]
Uterine-preserving procedures during POP repair are a viable surgical option promoted in recent years by both caregivers and patients.
“Uterine-preserving procedures during POP repair are a viable surgical option promoted in recent years by both caregivers and patients.”
From Individualized Prediction of Recurrence Following Uterine-Preserving Pelvic Organ Prolapse Repair Using Internally Validated Machine Learning Models (2026) · cites this paper as [13]
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References 108 · Cited by 254
- Authors
- Meriwether, K. V., Antosh, D. D., Olivera, C. K., Kim-Fine, S., Balk, E. M., Murphy, M., Grimes, C. L., Sleemi, A., Singh, R., Dieter, A. A., Crisp, C. C., & Rahn, D. D.
- Affiliations
- University of Louisville (US)
- Houston Methodist (US)
- New York University (US)
- University of Calgary (CA)
- Brown University (US)
- Institute for Female Pelvic Medicine and Reconstructive Surgery (US)
- Columbia University Irving Medical Center (US)
- University of Florida Health (US)
- University of North Carolina at Chapel Hill (US)
- TriHealth (US)
- The University of Texas Southwestern Medical Center (US)
- Corresponding author
- Meriwether, Kate V.
- ORCID
- Venue
- American Journal of Obstetrics and Gynecology
- Publisher
- Elsevier BV
- Published
- 2018-08
- Volume
- 219
- Issue
- 2
- Pages
- 129-146.e2
- ISSN
- 0002-9378 (ISSN-L)
- OpenAlex
- W2783052634
- Cited by
- 254
- References
- 108
- Citations by year
- 2026: 29 · 2025: 23 · 2024: 32 · 2023: 36 · 2022: 35 · 2021: 37 · 2020: 32 · 2019: 24 · 2018: 5
- FWCI
- 4.06
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- American Journal of Obstetrics and Gynecology (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Health Sciences › Medicine › Rheumatology › Pelvic floor disorders treatments
- Health Sciences › Medicine › Obstetrics and Gynecology › Uterine Myomas and Treatments
- Health Sciences › Medicine › Surgery › Hernia repair and management
- Keywords
- uterine preservation, hysterectomy, pelvic organ prolapse, sacrohysteropexy, sacrocolpopexy, vaginal hysterectomy, prolapse recurrence, mesh exposure, estimated blood loss, operative time, length of hospital stay, postoperative pain, urinary symptoms, quality of life
- MeSH terms
- Female, Humans, Hysterectomy, Hysterectomy, Vaginal, Length of Stay, Postoperative Pain, Pain, Postoperative, Laparoscopy, Quality of Life, Recurrence, Reoperation, Gynecologic Surgical Procedures, Surgical Mesh, Vagina, Blood Loss, Surgical, Treatment Outcome, Practice Guidelines as Topic, Plastic Surgery Procedures, Pelvic Organ Prolapse, Organ Sparing Treatments, Operative Time
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