Journal of

Clinical Medicine

Review
Summary: 2021 International Consultation on Incontinence
Evidence-Based Surgical Pathway for Pelvic Organ Prolapse
Renaud de Tayrac 1, * , Danielle D. Antosh 2 , Kaven Baessler 3 , Cecilia Cheon 4 , Xavier Deffieux 5 ,
Robert Gutman 6 , Joseph Lee 7 , Charles Nager 8 , Alexis Schizas 9 , Vivian Sung 10 and Christopher Maher 11

1 Service de Gynécologie-Obstétrique, CHU de Nîmes, Université de Montpellier, 34000 Nîmes, France

2 Department of Obstetrics and Gynecology, Houston Methodist Hospital, Houston, TX 77030, USA
3 Pelvic Floor Centre, Franziskus and St. Joseph Hospitals, Budapester Str. 15-19, 10787 Berlin, Germany
4 Urogynaecology Section of Queen Elizabeth Hospital, Hong Kong and Shenzhen Hong Kong University
Hospital, Shenzhen 518009, China
5 Service de Gynécologie-Obstétrique, Hôpital Antoine Béclère, 92140 Clamart, France
6 Urogynecology & Pelvic Reconstructive Surgery, MedStar Washington Hospital Center,
106 Irving St. NW 405 S, Washington, DC 20010, USA
7 St. Vincents Clinic, UNSW University of New South Wales, Sydney, NSW 2010, Australia
8 Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Diego Health,
San Diego, CA 92037, USA
9 General Surgery Department, Guy’s and St. Thomas’ NHS Foundation Trust, Monkton Street,
London SE11 4TX, UK
10 Department of Obstetrics and Gynecology, The Warren Alpert Medical School of Brown University,
Providence, RI 02903, USA
11 Royal Brisbane and Womens Hospital, Urogynaecology University QLD, Herston, QLD 4029, Australia
* Correspondence: renaud.detayrac@chu-nimes.fr

Citation: de Tayrac, R.; Antosh, D.D.; Abstract: (1) Background: There is wide variation in the reported prevalence rates for pelvic organ prolapse
Baessler, K.; Cheon, C.; Deffieux, X.; (POP). There is also wide variation in the rate at which surgical interventions for pelvic organ prolapse
Gutman, R.; Lee, J.; Nager, C.; are performed, as well as the type of interventions undertaken. As part of the International Consultation
Schizas, A.; Sung, V.; et al. Summary:
on Incontinence (ICI), our committee was tasked to produce evidence-based pathways for the surgical
2021 International Consultation on
management of POP, any associated stress urinary incontinence (SUI), and bowel dysfunction. (2) Methods:
Incontinence Evidence-Based
To enable us to generate such evidence, we undertook a thorough search for the POP surgery-related,
Surgical Pathway for Pelvic Organ
English-language scientific literature published up to April 2021. (3) Results: The committee evaluated the
Prolapse. J. Clin. Med. 2022, 11, 6106.
https://doi.org/10.3390/jcm11206106
literature and made recommendations based on the Oxford grading system. (4) Conclusions: This review
serves to provide a summary of the 2021 ICI surgical management of an evidence-based prolapse pathway
Academic Editors: Emilio Sacco and
and outline the evidence used to inform this guidance.
Gautier Chene

Received: 29 August 2022 Keywords: POP; pelvic organ prolapse; guideline; repair; mesh
Accepted: 10 October 2022
Published: 17 October 2022

Publisher’s Note: MDPI stays neutral

1. Introduction
with regard to jurisdictional claims in
published maps and institutional affil- Pelvic organ prolapse (POP) is a common problem reported to affect up to 50% of
iations. parous women, and of these 62% would have undergone a surgical correction for this
problem by the age of 80 [1–3]. Nonetheless, there is wide variation in the reported POP
prevalence rates. Where POP is defined, and graded by symptoms, the prevalence is re-
ported to be 3–6%, compared to 41–50% when based on examination [4–6]. On examination,
Copyright: © 2022 by the authors. anterior compartment prolapse is the most frequently reported site of prolapse and is
Licensee MDPI, Basel, Switzerland. detected twice as often as posterior compartmental defects and three times more com-
This article is an open access article monly than apical prolapse [7,8]. Following hysterectomy, 6–12% of women will develop a
distributed under the terms and
vaginal vault prolapse and in two-thirds of these cases a multi-compartment prolapse is
conditions of the Creative Commons
present [9–11].
Attribution (CC BY) license (https://
There is wide variation in the rate at which surgical interventions for pelvic or-
creativecommons.org/licenses/by/
gan prolapse are performed in the USA (2.6/1000 women) compared to Switzerland
4.0/).

J. Clin. Med. 2022, 11, 6106. https://doi.org/10.3390/jcm11206106 https://www.mdpi.com/journal/jcm

J. Clin. Med. 2022, 11, 6106 2 of 13

(0.5/1000 women) [12]. There is also very significant variation in the type of interventions
undertaken. Such large variations in the rate and types of surgery performed for pelvic
organ prolapse may be explained by a variety of factors including women’s preferences,
cultural and demographic variables, access to healthcare professionals, health professionals’
training, and a lack of a clear consensus regarding the guidelines for the surgical manage-
ment of prolapses. Given the increasing time and resources that will be required for POP
surgery in the future, it is paramount that we perform effective, durable, and cost-effective
interventions with minimal morbidity. Furthermore, the variation in maternity practices,
particularly with regard to operative vaginal delivery rates and types and the demographic
changes such as an aging population, have significant implications for the future planning
of women’s health services. However, this must be balanced against models that evaluate
the impact of decreasing parity and increasing elective caesarean section rates are required
to more accurately predict future rates of POP.
As part of the International Consultation on Incontinence (ICI), our committee was
tasked to produce evidence-based pathways for the surgical management of POP, any
associated stress urinary incontinence (SUI), and bowel dysfunction. To enable us to
generate such evidence, we undertook a thorough search for the POP surgery-related
English-language scientific literature on PubMed, Medline, the Cochrane library, and the
Cochrane database of systematic reviews, published up to April 2021. The committee
evaluated the literature and made recommendations based on the Oxford grading system,
summarized as follows: a Grade A recommendation (GoR A), which usually depends on
consistent randomized controlled trials (RCTs) or systematic reviews of RCTs; a Grade B rec-
ommendation (GoR B), which usually depends on consistent data from poor quality RCTs
or prospective cohort studies or ‘majority evidence’ from RCTs; a Grade C recommendation
(GoR C), which usually depends on retrospective or case series or Delphi-processed expert
opinion; and a Grade D recommendation (GoR D)—‘No recommendation possible’ would
be used where the evidence is inadequate or conflicting. This review serves to provide a
summary of the 2021 ICI surgical management of the evidence-based prolapse pathway
and outline the evidence used to inform this guidance.

2. POP Outcomes’ Assessment

POP is a multidimensional phenomenon, and the “success” of its treatment is often
difficult to define. Historically, most studies focused exclusively on anatomical success
without reporting the outcomes considered more important for women [13]. The Pelvic
Organ Prolapse Quantification system (POPQ), despite its limitations, provides a repro-
ducible and reliable description of the support of the anterior, posterior, and apical vaginal
segments using precise measurements to a fixed reference point [14]. Reoperation for
recurrence after POP surgery is an important measure of a procedure’s efficacy. In order
to provide some clarity for future studies reporting reoperation rates after POP surgery,
ICS/IUGA proposed a standardized definition for the different types of POP surgery [15].
Another important clinical outcome relates to the pre-operative complications of mesh
and native tissue repairs and there are standardized systems for reporting these, which
include the IUGA/ICS classification system for prosthesis/graft complication [16] or the
Clavien–Dindo classification [17]. The reporting of these as individual rather than compos-
ite outcome measures allows for more ready and reliable comparisons in meta-analyses.
In contrast, patient-reported outcomes (PRO) or outcome measures (PROM) are tools
used to measure any aspect of a patient’s health status that comes directly from the patient.
These can be generic and condition-specific. Generic PRO instruments are used to assess
the health-related quality of life (HRQOL) status in a broad range of illnesses or populations
while condition-specific measures are designed to measure the impact of a specific disease.
The evaluation of a patient with a vaginal prolapse requires a comprehensive review of
the full spectrum of pelvic floor symptoms and their impacts on the woman’s quality of
life. A symptom that is almost consistently acknowledged by patients with advanced
POP is the presence of a vaginal bulge that can be seen or felt [6,18,19]. ICS/IUGA also
J. Clin. Med. 2022, 11, 6106 3 of 13

recommend reporting the sexually functional status of all individual participants pre-
and post-intervention [15]. Moreover, assessing the patient’s satisfaction is important yet
complex because the determinants of satisfaction are multifactorial. The patient global
impression of severity (PGI-S) or improvement (PGI-I) is often used as the validated PRO
to measure improvement and satisfaction following prolapse treatment [20].
Based on reviewing the literature relating to POP outcome measures, our committee’s
recommendations are as follows:
• The anatomical outcomes reported should include all POP-Q points and staging utilizing
a traditional definition of success. Assessments should be prospective, and assessors
should be blinded to the surgical intervention performed wherever possible and should
not possess any conflict of interest related to the assessment undertaken (GoR C).
• Prolapse surgery should be defined as primary surgery and repeat surgery sub-
classified as primary surgery of a different site for repeat surgeries, complications
related to surgery, and surgery for non-prolapse-related conditions (GoR C).
• Functional outcomes are best reported using valid, reliable, and responsive symptom
questionnaires and condition-specific HRQOL instruments (GoR C).
• Sexual function is best reported utilizing validated condition-specific HRQOL instru-
ments that assess sexual function or validated sexual function questionnaires such as
the Pelvic Organ Prolapse/Incontinence Sexual Questionnaire (PISQ) or the Female
Sexual Function Index (FSFI). The sexual activity status of all the study participants
should be reported pre-and post-operatively under the following categories: sexually
active without pain, sexually active with pain, or not sexually active (GoR C).

3. Anterior Compartment Surgery

Historically, anterior colporrhaphy (AC) was the standard procedure in the manage-
ment of an anterior compartment prolapse. The importance of paravaginal defects in
anterior compartment prolapses has been highlighted since 1912 [21]. Since then, several
vaginal, abdominal, and laparoscopic procedures have been described. However, no ran-
domized control studies have evaluated these in isolation. Raz et al. (96) popularized the
needle suspension type procedure for cystocele repair and reported success rates in case
series ranging from 90 to 98% [22,23]. Further studies demonstrated a reduction in recur-
rence and reoperation rates when an apical suspension procedure is performed [24–26].
Nevertheless, this message does not seem to be reflected in clinical practice.
Following high reported objective failure and reoperation rates after native tissue
repairs, the last decade has seen both a rapid uptake and subsequent decline in the use of
transvaginal permanent meshes for the management of anterior compartment prolapse.
A Cochrane review, evaluating nearly 2000 women, demonstrated some advantages and
disadvantages to the use of polypropylene mesh in anterior compartment surgery [27].
More recently, the majority of the polypropylene mesh products evaluated in this meta-
analysis have been voluntarily withdrawn by the manufacturers in the face of ongoing
litigation. Pain and dyspareunia were the leading causes of adverse events that triggered the
2011 FDA warnings on the safety of transvaginal meshes [28,29]. Absorbable meshes were
proposed as an attractive option because of the proposed increased strength during the early
healing phase without the long-term complications of a permanent mesh. Nevertheless,
they seem to offer little advantage compared to AC for anterior compartment prolapse [27].
Furthermore, autologous grafts and allografts have been tested to improve the outcomes of
native tissue repair while mitigating the risks associated with synthetic meshes. However,
a meta-analysis of eight trials using various biological grafts demonstrated that they had
similar outcomes to AC regarding prolapse awareness and reoperation [27].
Transvaginal meshes have also been shown to have some advantages in women
with a recurrent anterior prolapse, yet with a similar risk profile to that described for
primary repairs and even higher mesh exposure rates. Although some clinicians believe
that polypropylene mesh still has a role in recurrent prolapse, the number of proponents of
such a policy is declining.
J. Clin. Med. 2022, 11, 6106 4 of 13

Further, with respect to the review of the current evidence, our current committee’s
recommendations for the management of anterior compartment POP are as follows:
• Polypropylene mesh has a superior anatomical outcome compared to a biological
graft (Pelvicol) in the anterior compartment (Feldner, Menefee). However, the mesh
exposure rate was significantly higher in the polypropylene mesh group (GoR A).
• Polypropylene mesh demonstrates improved anatomical and subjective outcomes
compared to AC with no difference in the functional outcomes using validated ques-
tionnaires or a lower reoperation rate for prolapse. The mesh group was also associated
with longer operating times, greater blood loss, and a non-significant tendency towards
higher cystotomy, de novo dyspareunia, and de novo stress urinary incontinence rates
compared to AC. Apical or posterior compartment prolapse was significantly more
common following polypropylene mesh and the mesh exposure rate was 10.4% with
6.3% undergoing surgical correction (GoR B).
• The data for recurrent anterior vaginal wall prolapses show conflicting information
regarding the advantages for polypropylene mesh compared to AC, with relatively
high rates of mesh complication reported in the long-term (GoR C).

4. Surgical Treatment of Uterovaginal Prolapse

Despite the fact that most gynecologists and pelvic-reconstructive surgeons consider
the uterus to be a passive structure in prolapse development, it is frequently removed dur-
ing uterovaginal prolapse surgery. Surveys of women suggest that 40–60% of respondents
in the USA, the Netherlands, Austria/Germany, and Russia would choose uterine preser-
vation assuming equal surgical efficacy [30–33]. In contrast, 66% of female gynecologists
in the Czech Republic, Slovenia, and Slovakia preferred concomitant hysterectomy if they
were to have a POP that required a repair assuming equal outcomes [34].
Due to the limited data regarding the risks associated with subsequent pregnancy and
delivery, surgery should be reserved for those that cannot be managed with a pessary. This
review focuses on women who have completed childbearing and are postmenopausal or
practicing reliable contraception with a particular focus on comparing hysteropexy and
hysterectomy surgical outcomes for the treatment of uterovaginal prolapses. Moreover,
the candidates for uterine conservation should be made aware that if a subsequent hys-
terectomy is required, it could be more technically challenging. Women at increased risk
for endometrial, cervical, or ovarian cancer and those with a personal history of estrogen
receptor-positive breast cancer, especially those taking Tamoxifen, should have their uterus,
cervix, and possibly ovaries removed at the time of the prolapse repair.
Broadly, there are different types of native tissue repairs involving uterine conserva-
tion: LeFort colpocleisis, the Manchester procedure, Sacrospinous hysteropexy (SSHP), and
uterosacral hysteropexy (USHP). Whereas there are two main types of mesh hysteropexy
procedures: SSHP with a graft, previously referred to as vaginal mesh hysteropexy, and
sacrohysteropexy (SHP). Regarding SSHP with a graft, all of the first and second genera-
tion anterior and posterior mesh kits are no longer commercially available. SHP typically
involves the attachment of at least one graft from the cervix and uterus to the anterior
longitudinal ligament near the sacral promontory. This is an abdominal procedure that
can be performed via an open, laparoscopic, or robotic approach. A variety of graft mate-
rials, configurations, and operative techniques have been described, which may explain
the differences in anterior wall recurrences and the development of cervical elongation.
Supracervical hysterectomy and sacrocervicopexy (SCerP) were introduced to obtain the
benefits of SCP and hysterectomy without the risk of mesh exposure. However, the data to
support or refute this claim are still awaited.
In summary, there are numerous options for the primary treatment of uterovaginal
prolapse. The committee’s evidence-based recommendations regarding the management
of uterovaginal prolapse and uterine preservation are as follows:
J. Clin. Med. 2022, 11, 6106 5 of 13

• Hysteropexy is reasonable in women undergoing surgery for uterovaginal prolapse

without contraindications to uterine preservation. However, long-term data are limited
and the need for subsequent hysterectomy is unknown (GoR C).
• When considering relative contra-indications to uterine preservation, an opportunistic
salpingectomy, which cannot be performed during vaginal hysteropexy, should be
included in the shared decision-making process (GoR C).
• Large database studies demonstrated lower reoperation rates for recurrent prolapses
and slightly higher complication rates in the hysterectomy group compared to hys-
teropexy (GoR C).
• Consistent level one and two evidence reveal no differences in outcomes comparing
sacrospinous hysteropexy to vaginal hysterectomy with native tissue prolapse repair,
with the exception of a single smaller RCT showing a higher risk of apical recurrence
for patients with advanced prolapse undergoing hysteropexy (GoR B).
• A partial Colpocleisis is preferred over a vaginal hysterectomy and total colpocleisis
when there is no specific indication for hysterectomy and no interest in preserving
coital function (GoR C).
• The role of the Manchester procedure for the treatment of a mild uterovaginal prolapse
with or without cervical elongation has yet to be determined based on limited, poor
level two and three evidence (GoR D).
• The data are not supportive of transvaginal meshes and hysterectomy for uterine
prolapse. Consistent Level two evidence shows no difference in anatomic success
when comparing a sacrospinous hysteropexy with a mesh graft to a hysterectomy
with a graft; additionally, the mesh exposure rate was significantly higher after a
hysterectomy than hysteropexy (11% vs. 5%) (GoR C).
• Sacrohysteropexy (SHP) has a similar success rate and reoperation for prolapse when
compared to a vaginal hysterectomy and USLS; however, it has lower success rates
than sacrocolpopexy with total or supracervical hysterectomy (GoR C).
• A sacrocolpopexy with a total hysterectomy is not recommended due to a three- to
five-fold higher mesh exposure rate (GoR C).
• A single small study sacrocolpopexy with a supracervical hysterectomy had a lower
anatomic success rate than a sacrocolpopexy with a total hysterectomy (GoR D).
• Level three evidence reveals low rates of unanticipated pathology (1.5%) and endome-
trial cancer (0.3%) with no cases of sarcoma identified during hysterectomies in women
with a low risk of malignancy and dysplasia undergoing prolapse surgery (GoR C).

5. Apical Prolapse Surgery

A loss of apical support is usually present in women with a prolapse that extends be-
yond the hymen [35,36]. There is growing recognition that adequate support for the vaginal
apex is an essential component of a durable surgical repair for women with an advanced
prolapse [37,38]. Apical suspension procedures can be classified into those performed
transvaginally and those performed abdominally. Abdominal procedures, predominantly
sacrocolpopexy, can be performed via laparotomy or using conventional laparoscopic or
robotically assisted-laparoscopic techniques. Transvaginal apical suspension procedures
include both non-mesh (native tissue) procedures and mesh repairs.
Sacrospinous ligament fixation (SSLF) is one of the most popular and widely re-
ported native tissue transvaginal procedures for correcting apical prolapses. Ipsilateral
uterosacral ligament fixation (USLS) suspends the vaginal apex to the proximal remnants
of the uterosacral ligaments using an intraperitoneal surgical approach. This procedure
restores the vagina to a near normal axis, avoiding the greater occurrence of retroflexion as-
sociated with SSLF. Traditionally, sacrocolpopexies have been performed via a laparotomy
(i.e., an abdominal sacrocolpopexy, ASCP) but the use of minimally invasive approaches,
both laparoscopic (LSCP) and robotic (RSCP), has become the norm over the last decade.
Obliterative surgery, such as total or the LeFort partial colpocleisis, can also be used in the
J. Clin. Med. 2022, 11, 6106 6 of 13

management of apical POP, but are usually reserved for women who are elderly, medically
compromised, and no longer sexually active.
In addition to the above synthesis of the evidence, the committee’s conclusions regard-
ing apical prolapse surgery are as follows:
• A single large RCT suggests that USLS and SSLF have similar anatomical, functional,
and adverse event outcomes (GoR B).
• Level one evidence demonstrates transvaginal mesh procedures offer no significant
advantage over vaginal native tissue apical repairs and are associated with mesh
exposures (GoR A).
• Level one evidence suggests that overall sacrocolpopexy is associated with a lower
risk of awareness of prolapse, a recurrent prolapse on examination, repeat surgery
for prolapse, and post-operative SUI and dyspareunia when compared broadly with
vaginal prolapse repairs with and without mesh augmentation (GoR A).
• Level one evidence suggests that ASCP has a higher success rate as compared to
SSLS with fewer occurrences of SUI and post-operative dyspareunia. ASC had a
greater morbidity including regarding operating time, inpatient stay, a slower return
to activities of daily living, and a higher cost (GoR A).
• In a single RCT, ASCP was associated with greater anatomical success, fewer reoper-
ations, and greater post-operative complications than USLS but no difference in the
improvement in symptoms or quality of life was reported (GoR B).
• LSCP is associated with lower levels of blood loss, longer operating times, and shorter
hospital stays than ASCP, with no difference in the objective or subjective cure rates (GoR B).
• Compared to LSCP, RSCP is associated with longer operating times, greater post-
operative pain, and a higher cost with similar rates of anatomic success and complica-
tions (GoR B).
• ASCP performed with polypropylene mesh has superior outcomes to fascia lata (GoR B).
• In a single RCT, LSCP had superior objective and subjective success rates and lower reoperation
rates compared to polypropylene transvaginal mesh for vault prolapses (GoR B).
• Level three evidence suggests McCall culdoplasty, Iliococcygeus fixation, and colpoclei-
sis are relatively safe and effective interventions (GoR C).

6. Surgery for Posterior Vaginal Wall Prolapse

Based on the work of DeLancey [39], the connective tissue support of the vagina can
be divided into three levels: the apical portion of the posterior vagina (level I), supported
primarily by the cardinal-uterosacral ligaments; the mid-section of the vagina (level II),
supported by the endopelvic fascia; and the distal support of the posterior vaginal wall
(level III), which is primarily provided by the perineal body.
The prolapse of the posterior vaginal wall may be secondary to the presence of
rectocele, sigmoidocele, enterocoele, or a combination of these. A posterior vaginal prolapse
can be associated with a bothersome vaginal bulge as well as emotional, sexual, and
defecatory dysfunctions. Its surgical treatment should be primarily driven by the patient’s
symptoms and discomfort. Of note, many patients may present with both defecatory
symptoms as well as a posterior vaginal prolapse leading to the assumption that the
prolapse is causing the problems. However, the data are conflicting regarding the efficacy
of posterior vaginal repair for improving defecatory symptoms and the association is
incompletely understood [40,41]. The types of surgical repair for a posterior vaginal
prolapse include midline plication (native tissue), site-specific techniques (native tissue),
graft/mesh augmentation of the midline or site-specific repairs, transanal repair, ventral
rectopexy, and sacral colpopexy, in which the mesh is extended to the distal portion of the
posterior vaginal wall and/or perineum.
Women with a vaginal prolapse frequently have a coexistent bowel dysfunction including
obstructed defection, constipation, and fecal incontinence. We were unable to identify an
evidence-based pathway for the management of pelvic organ prolapse and associated bowel
symptoms. So, utilizing the wide clinical and academic experience of the committee members
 graft/mesh augmentation of the midline or site-specific repairs, transanal repair, ventral
rectopexy, and sacral colpopexy, in which the mesh is extended to the distal portion of the
posterior vaginal wall and/or perineum.
Women with a vaginal prolapse frequently have a coexistent bowel dysfunction in-
cluding obstructed defection, constipation, and fecal incontinence. We were unable to
J. Clin. Med. 2022, 11, 6106 7 of 13
identify an evidence-based pathway for the management of pelvic organ prolapse and as-
sociated bowel symptoms. So, utilizing the wide clinical and academic experience of the
committee members and the Delphi process, we established clinical guidance for the man-
agement
and of women
the Delphi withwe
process, a vaginal prolapse
established andguidance
clinical associated
forbowel symptoms asofseen
the management womenin with a
Figure 1.
vaginal prolapse and associated bowel symptoms as seen in Figure 1.

Figure 1.
Figure 1. Suggested
Suggestedsurgical
surgicalpathway for for
pathway prolapse repair
prolapse with coexisting
repair bowel symptoms.
with coexisting bowel symptoms.

The current
The currentcommittee’s
committee’s recommendations for the
recommendations forsurgery of the of
the surgery posterior vaginal vaginal
the posterior
wall prolapse are as follows:
wall prolapse are as follows:
•• Level one
Level oneand
andtwo
twoevidence
evidence suggest thatthat
suggest a midline plication
a midline posterior
plication repairrepair
posterior withoutwithout a
a levatorplasty has superior objective outcomes as compared to a site-specific poste-
levatorplasty has superior objective outcomes as compared to a site-specific posterior
rior repair. (GoR B.)
repair (GoR B).
• A higher dyspareunia rate is reported when a levatorplasty is performed. (GoR C.)
•• AThehigher dyspareunia
transvaginal approachrateisissuperior
reported
to when a levatorplasty
the transanal approach is
forperformed (GoR
the repair of a C).
• The transvaginal approach
posterior wall prolapse. (GoR A.) is superior to the transanal approach for the repair of a
posterior wall prolapse (GoR A).
• To date, no study has shown any benefit to a graft or mesh overlay or to the augmen-
tation of a suture repair for a posterior vaginal wall prolapse (GoR B).
• While modified abdominal sacrocolpopexy results have been reported, the data on
how these results would compare to the traditional transvaginal repair of a posterior
vaginal wall prolapse are lacking.
• The data comparing Delorme’s procedure and ventral mesh rectopexy (VMR) for an
external rectal prolapse are conflicting, with a single RCT demonstrating no statistical
difference, while the level 3 data are supportive of VMR performed laparoscopically
or robotically, with low rates of recurrent rectal prolapses and improved rates of fecal
incontinence and constipation (GoR D).
• VMR appears superior to other abdominal rectopexies (posterior mesh rectopexy,
Ripstein, and Orr–Loygue) with different rectal mobilizations to treat ERP in terms of
functional outcome (GoE C).
• LoE 3 supports a ventral rectopexy for an Oxford grade 3–4 internal rectal prolapse.
The data are not conclusive regarding the graft material or route of surgery (GoR C).
• No data demonstrate that a ventral rectopexy with or without a graft attachment to
the posterior vaginal wall is effective for the management of rectocele (GoR D).
• Limited level three evidence suggest that patients with combined rectal and vaginal prolapses
benefit from colorectal surgeons and urogynecologist collaborating closely (GoR C).

7. Surgery for Pelvic Organ Prolapse and Bladder Function

Patients with POP often present with bladder symptoms such as urinary incontinence
or voiding difficulties. Many women with advanced POP do not experience SUI. However,
J. Clin. Med. 2022, 11, 6106 8 of 13

if the prolapse is reduced digitally or with the help of a pessary, sponge holder, or speculum,
SUI may be demonstrated in 10 to 80% [42–45]. This type of SUI, which becomes only obvi-
ous with the prolapse reduced in otherwise continent women, is termed an occult, masked,
or latent SUI. Although different techniques to reduce the prolapse have been described, a
gold-standard has not been established [46,47]. Neither the speculum nor the pessary test
to reduce the prolapse had acceptable positive predictive values to identify women in need
of a concomitant continence procedure. However, women with preoperatively negative
tests for occult SUI are at low risk of developing SUI postoperatively [46,48].
Our review group have evaluated the current evidence relating to women undergoing
prolapse surgery with or without SUI and devised a decision-making flowchart (Figure 2)
together with the following recommendations:
• Continent women who test negative for occult SUI do not require a concurrent pro-
phylactic continence procedure (GoR B).
• In continent women who test negative for occult SUI undergoing sacrocolpopexy, an addi-
tional Burch colposuspension may reduce the occurrence of postoperative SUI (GoR C).
• Anterior mesh repair increases the risk for SUI as compared to anterior repair without
mesh in continent women (GoR B).
• Continent women with occult SUI benefit from POP surgery with concomitant continence
procedures as compared to POP surgery without continence intervention (GoR B).
• In women with POP and SUI, a concomitant continence procedure increases postoper-
ative SUI cure rates (GoR A).
•
J. Clin. Med. 2022, 11, x FOR PEER REVIEW preoperative OAB (40%) resolves in approximately 50% of post-prolapse
A 9 of 14surgeries,
although the impact of a concomitant non- surgical treatment remains unclear (GoR C).
• The rate of de novo OAB varies widely (2–32%) (GoR C).
•• The
The rates
rates of
of urinary
urinaryretention
retentionfollowing
followingPOP
POPsurgery
surgeryvaries
varies from
from 0–34%
0–34% andand
areare nearly
always temporary (GoR C).
nearly always temporary. (GoR C.)
•• Pre-operative
Pre-operativeurinary
urinary retention
retention resolves
resolves in asinmany
as many as of
as 90% 90% of post-prolapse
post-prolapse surger-surgeries
(GoR
ies. C).C.)
(GoR

Figure 2.2.Decision-making
Figure Decision-makingflowchart for women
flowchart undergoing
for women prolapse
undergoing surgerysurgery
prolapse with or without
with or SUI.
without SUI.

8. Pelvic organ Prolapse Surgery and Sexual Function

The prevalence of sexual dysfunction in patients with pelvic organ prolapse (POP)
and other pelvic floor disorders is approximately 64% [49]. Therefore, it is important to
assess the sexual function in patients undergoing reconstructive surgery for a prolapse in
general practice and research trials. According to the IUGA-ICS Joint Report on the Ter-
minology and Assessment of the Sexual Health of Women with Pelvic Floor Disorders,
J. Clin. Med. 2022, 11, 6106 9 of 13

8. Pelvic Organ Prolapse Surgery and Sexual Function

The prevalence of sexual dysfunction in patients with pelvic organ prolapse (POP) and
other pelvic floor disorders is approximately 64% [48]. Therefore, it is important to assess
the sexual function in patients undergoing reconstructive surgery for a prolapse in general
practice and research trials. According to the IUGA-ICS Joint Report on the Terminology
and Assessment of the Sexual Health of Women with Pelvic Floor Disorders, trials should
report both the pre-operative AND post-operative outcomes for sexual activity, dyspareu-
nia, and validated sexual function questionnaire scores [49]. The validated measures for
sexual function in relation to POP surgery have been discussed above. The summary of our
comprehensive review of different types of POP surgery and perioperative sexual function
is as follows:
• While synthetic transvaginal mesh and non-mesh vaginal repairs have similar rates
of de novo and total dyspareunia, the transvaginal mesh repair has a poorer sexual
function as measured by the PISQ when compared to non-mesh repairs (GoR B).
• Synthetic transvaginal meshes have a higher rate of total dyspareunia when compared to
sacrocolpopexy (GoR B).
• When comparing vaginal biologic grafts to vaginal native tissue repairs, there are similar
decreases in postoperative dyspareunia and similar changes in sexual function (GoR B).
• Postoperative sexual activity in patients undergoing POP reconstructive surgery ranges
from 42–65%, while postoperative sexual activity ranges from 32–62% (GoR C).
• The de novo dyspareunia rates for native tissue vaginal repair and sacrocolpopexy
range from 2–8% (GoR C).
• Total dyspareunia rates generally decrease following native tissue repairs and sacro-
colpopexy from 15–30% preoperatively to 8–20% postoperatively (GoR C).
• It is preferable to use validated questionnaires measuring sexual function in women
before and after prolapse surgery. We also recommend reporting sexual activity and
dyspareunia rates de novo, pre-, and post-intervention in all patients (GoR C).

9. Discussion
Despite our robust methodology and thorough review of the literature relating to the
surgical management of POP, we have not identified consistent evidence for the superiority
of a single intervention that has resulted in better outcomes compared to others as assessed
by validated quality of life pelvic floor questionnaires. This suggests that either the inter-
ventions are not significantly different between women or that the questionnaires are not
sensitive enough to detect a change. Notwithstanding this problem, our committee has
developed a treatment algorithm for the surgical management of prolapses (Figure 3).
Similar to the 2017 pathway [50], the 2021 ICI pathway for the surgical management
of prolapse utilizes traffic light-colored arrows to guide treatment options, with a green
line indicating the preferred option, yellow a possible alternative, and red indicating
that further data are required to make a comprehensive assessment and, hence, that this
treatment option is currently not recommended. The decisions that informed the algorithm
are based on the findings in the report and the recommendations summarized above.
Nonetheless, our committee recognizes that the algorithm is a guideline for both patients
and clinicians and that patients’ treatment is best individualized and underpinned by an
open and transparent consultation process and consent.
Our review has also demonstrated that as a group we continue to perform surgeries
with limited evidence to support their safety and efficacy. One example relates to several of
the newer lightweight mesh devices that are currently available. Indeed, these products
require a significant further evaluation prior to being introduced into treatment pathways
for the surgical management of prolapses. A second example relates to the anecdotal
perception that the performance of a sacral colpopexy for uterine prolapse is increasingly
common. The confidence in surgical outcomes relating to sacral colpopexy is largely
derived from post-hysterectomy prolapse data. Interestingly, while there are increasing
data to support the performance of a sacral colpopexy for a post-hysterectomy prolapse,
J. Clin. Med. 2022, 11, 6106 10 of 13
J. Clin. Med. 2022, 11, x FOR PEER REVIEW 11 of 14

the limited early data available in our review suggest that neither sacrohysteropexy nor
the mesh to theorvagina
supracervical are recommended
total hysterectomy and (GoR
sacralC). Furthermore,
colpopexy a concomitant
are superior total hys-
to a variety of
terectomy seems to be associated with an increased risk of mesh exposure (GoR
vaginally based interventions. Hence, the current evidence-based algorithm points towards C). Fi-
nally, our based
vaginally groupnative
also recommends that the for
tissue interventions type and commercial
primary name ofand
uterine prolapses mesh used is
reserving
clearly recorded and that peritoneal closure is recommended
sacral colpopexy for post-hysterectomy and recurrent prolapses. to cover the meshes.

Figure 3.
Figure ICI 2021
3. ICI 2021 pathways
pathways for
for surgical
surgical treatment
treatment of
of POP.
POP.

Many countries have prohibited access to vaginal meshes. However, in countries where
Finally, there is wide variation and lack of consistency regarding non-procedure-re-
transvaginal meshes are still available, patients should be made aware that a mesh is consid-
lated causes for recurrence; these include patients’ characteristics, a high versus low vol-
ered a permanent implant and that it might not be possible to completely remove it or reverse
ume surgeons, and the role of a physiotherapist. Based on our review, there is current
its complications despite multiple operations. Patients should be informed that transvaginal
evidence to suggest that the rate of recurrence is associated with the patient’s age < 60
meshes have a higher reoperation rate than native tissue vaginal repairs (CoR A). Therefore,
years, POP stages of 3–4, and low volume surgeons. In contrast, a poor levator strength
and perioperative physiotherapist do not seem to increase or protect against recurrence,
J. Clin. Med. 2022, 11, 6106 11 of 13

patients must be informed of conservative and alternative surgical techniques. If a synthetic

mesh is placed by the vaginal route, it is recommended that a macroporous polypropylene
monofilament mesh is used while the use of a polyester mesh is not recommended (GoR B).
Moreover, it is our expert opinion that a non-absorbable synthetic mesh should not be inserted
into the rectovaginal septum when a rectal injury occurs.
Regarding sacrocolpopexy, the use of silicone-coated polyester, porcine dermis, fascia
lata, and polytetrafluoroethylene meshes are not currently recommended. Our review
demonstrated that a laparoscopic approach, polyester (without silicone coating) or monofil-
ament polypropylene meshes, and the use of delayed absorbable sutures for securing the
mesh to the vagina are recommended (GoR C). Furthermore, a concomitant total hysterec-
tomy seems to be associated with an increased risk of mesh exposure (GoR C). Finally,
our group also recommends that the type and commercial name of mesh used is clearly
recorded and that peritoneal closure is recommended to cover the meshes.
Finally, there is wide variation and lack of consistency regarding non-procedure-
related causes for recurrence; these include patients’ characteristics, a high versus low
volume surgeons, and the role of a physiotherapist. Based on our review, there is current
evidence to suggest that the rate of recurrence is associated with the patient’s age < 60 years,
POP stages of 3–4, and low volume surgeons. In contrast, a poor levator strength and
perioperative physiotherapist do not seem to increase or protect against recurrence, respec-
tively. Whereas the evidence for the role of levator defects and enlarged levator hiatus in
POP recurrence is conflicting [51–56].

Author Contributions: Conceptualization, R.d.T. and C.M.; methodology, C.M.; validation, R.d.T.,
D.D.A., K.B., C.C., X.D., R.G., J.L., C.N., A.S., V.S. and C.M.; formal analysis, R.d.T., D.D.A., K.B., C.C.,
X.D., R.G., J.L., C.N., A.S., V.S. and C.M.; investigation, R.d.T., D.D.A., K.B., C.C., X.D., R.G., J.L., C.N.,
A.S., V.S. and C.M.; resources, R.d.T., D.D.A., K.B., C.C., X.D., R.G., J.L., C.N., A.S., V.S. and C.M.;
data curation, R.d.T., D.D.A., K.B., C.C., X.D., R.G., J.L., C.N., A.S., V.S. and C.M.; writing—original
draft preparation, R.d.T.; writing—review and editing, R.d.T., D.D.A., K.B., C.C., X.D., R.G., J.L., C.N.,
A.S., V.S. and C.M.; visualization, C.M.; supervision, C.M.; project administration, C.M. All authors
have read and agreed to the published version of the manuscript.
Funding: This research received no external funding.
Institutional Review Board Statement: Not applicable.
Informed Consent Statement: Not applicable.
Data Availability Statement: The literature searches and review data is available in the full guideline
and upon request from the corresponding author.
Conflicts of Interest: The authors declare no conflict of interest.

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