Pelvic Organ Prolapse (POP) is a common diagnosis of the sale of pelvic organs, such as the bladder, uterus, rectum or vaginal apex into or through the vaginal canal as a result of loss of support structures of the pelvic floor. Parous women have an estimated half-rate of prolapsing, and only a few of those who prolapse will become symptomatic. Population of POP is likely to increase as life expectancy and age-increasing populations in the world become a major issue of public concern1.

POP has a multifactorial etiology which includes the combination of vaginal childbirth trauma, aging, menopause, connective tissue disorders, obesity, and intra-abdominal pressure increasing conditions (chronic cough or constipation) which is chronically increased in position2. Vaginal birth, especially multiple births and the application of instruments is the most challenging to risk because of the injuries to the levator ani muscles and connectivity tissue supports3. Also, genetic factors and collagen metabolism changes have been suggested in the pathophysiology of pelvic floor dysfunction4.

Clinically POP manifest with a continuum of symptoms with a feeling of vaginal prolapse, pelvic pressing, urinary incontinence, voiding dysfunction, defecatory, and sexual dysfunction, all of which substantially affect quality of life5. The severity of prolapse is normally measured with the Pelvic Organ Prolapse Quantification (POP-Q) system which offers a standardized and reproducible system of grading the condition6. These management options include the conservative or less invasive options that include the use of pelvic floor muscle training and pessary application, to the surgical options that focus on the restoration of normal pelvic anatomy and functioning7.

Surgical treatment is the mainstay as a treatment of symptomatic and advanced POP. The existing diversity of surgical methods developed over the decades is mainly divided into obliterative and reconstruction procedures. Obliterative surgical procedures like colpocleisis is done in old women, who do not need vaginal intercourse in future whereas the reconstructive procedures are done to maintain the vaginal anatomy and functionality8. Vaginal and abdominal reconstructions are both used as reconstructive procedures, with more preferential trends toward less invasive procedures such as laparoscopic and robotic-assisted surgeries becoming more popular9.

Native tissue repair, including the uterosacral ligament suspension and fixation of the sacrospinous ligament, is a common form of repair because of the absence of materials, and less prone to mesh-related problems. Nonetheless, it has been raised that there are ethical issues about the increased rates of recurrence as compared to the abdominal procedures as well as an increasing recurrence risk and the ethical considerations not to mention that the procedure is more hazardous than the abdominal ones10. Conversely, the sacrocolpopexy, which is regarded as the gold standard of apical prolapse, provides better anatomical results in the long term on the basis of hanging up the vaginal apex to the anterior longitudinal ligament of the sacrum with synthetic mesh11. Laparoscopic and robotic sacrocolpopexy have only enhanced the recovery time with not compromising the efficacy anymore¹².

The transvaginal mesh of POP repair became popular because constituted a possible decrease in recurrence but testimonies of procedures like mesh erosion, chronic pain, infection and dyspareunia began to emerge compelling regulatory restrictions and evaluation of safety13. This has redirected attention back to the native tissue repairs and abdominal mesh procedures that have safer safety profiles. In turn, the selection of a surgical method should be personal and consider such factors of a patient, like age, comorbidities, the severity of prolapse, previous surgeries, and patient preferences)14.

Although surgical intervention has improved, recurrence is a major issue, and it is reported that, in some cases15, it is between 10-30 percent, therefore requires a second operation according to some sources (19, 20). In addition, a shortage of standardized practices and inconsistency of levels of surgical expertise lead to the inconsistency of outcomes within settings. Thus, it is vital to know all the surgical options in use, their indications, and advantages, as well as possible complications to maximize patient care.

The purpose of this article is to review and critically analyze the existing surgical management of prolapse of pelvic organs, its modern innovations, its effectiveness, and the debate on its many variants in relation to its effectiveness when applied in individuals, based on a potential individual treatment planning in clinical practice.

The current narrative review was carried out at the Department of Gynecology at Ayub Teaching Hospital, in the six months between 1 January 2025 and 30 June 2025. Ethical approval for conducting this study was obtained from the Institutional Ethical Review Committee (ERC) of Ayub Teaching Hospital. The research conducted also complied with the standards of the Declaration of Helsinki and all the processes were conducted in compliance with the required ethical standards when conducting research with human related data.

An exhaustive and organized literature search was carried out through the electronic databases such as PubMed, Scopus, Web of science and Cochrane Library. The inclusion of relevant articles published in English within the time frame of January 2010 to March 2025 was made to be relevant and have a sufficient amount of historical background. Combination of such search terms as pelvic organ prolapse, surgical management, sacrocolpopexy, uterosacral ligament suspension, sacrospinous fixation and vaginal hysterectomy. The search strategy was narrowed down to achieve the use of Boolean operators (AND, OR). Moreover, selected articles reference lists were hand excavated in order to find out additional studies of relevance.

Inclusion criteria were based on the following, which included the following: randomized controlled trials, cohort studies, case-control studies, and systematic reviews on the topic of surgical management of prolapsed pelvic organs in adult women of 18 years and older: met inclusion criteria; reported outcomes on anatomical success, recurrence rates, complication, and quality of life measures16,17. The research only included studies with the well-defined surgical procedures and follow-up at least 6 months to guarantee the reliability of outcomes18. Case reports, conference abstracts (without full text), non-English publications, studies of pediatric populations, and studies which had neither clear outcome measures nor methodological rigor were excluded as exclusion criteria19.

This review had a sample size of purposive sampling that considered all eligible and high-quality researches which were included within the specified period and fulfilled the inclusion criterion. To ensure methodological soundness however, the minimum of one would need to have enough studies to meet the criterion of proportionate sample size calculation:

n = Z² × p (1 − p) / d², where Z = 1.96 at 95% confidence interval, p = expected success of successful surgical outcomes (assume 0.5 because this is as large as possible), and d = margin of error (0.1). This resulted in a minimum of 96 studies, but with very intense screening criteria eligibility and quality assessment, 112 studies had been screened in total, and quality assessment had filtered 48 studies which were used as the final analysis after exclusion of duplicates, and low quality studies.

A standardized form took care of data extraction, which included information about the study design, sample size, type of surgical intervention, and the period of follow-up and important outcomes. Appropriate tools including Coochrane Risk of bias tool in randomised trials and Newcastle-Ottawa Scale in observational studies were used to determine the quality of the included studies. The authors agreed on any difference in studying or data extracted.

Though the study belongs to the category of reviews of the previously published data, informed consent was deemed irrelevant to take part in the study on an individual-patients level; still, all of the studies included in the research had informed their participants, as they reported their methodologies. Anonymity and confidentiality of patient data were ensured during the process of reviewing by utilizing only aggregated and published data.

One hundred and twenty-two articles were found for the first time by database searching. Upon elimination of duplicates, screening by title and abstract, 68 studies were evaluated based on eligibility criteria. After conducting the full-text screening, 48 research works have been incorporated into the final analysis, which satisfy inclusion criteria. The reason is that the chosen studies represented randomized controlled trials (n=18), cohort studies (n=20), and systematic reviews (n=10), which present an in-depth picture of existing surgical management options in the case of pelvic organ prolapse (POP).

The thoughts included in the studies considered different methods of surgery, all of which are mostly divided into the following: abdominal (open, laparoscopic, and robotic sacrocolpopexy) and vaginal (uterosacral ligament suspension, sacrospinous fixation, and vaginal hysterectomy with pelvic floor repair). Studies had a mean period of follow up that ranged between 6 months and 5 years.

Table 1: Distribution of Studies Included by Study Design (n=48)

Abdominal sacrocolpopexy with laparoscopic and robotic cystectomy showed the most anatomic success rates 85-95 percent and a lower recurrence rate than vaginal surgery. On the other hand, vaginal repairing like uterosacral herniaic ligament suspension and sacrospinous repair reported success rates of around 70 to 85 With a higher recurrence but with less intra-surgical complications.

Table 2: Comparison of Surgical Techniques and Outcomes

Mesh-related complications were found to be highest among mesh-augmented vaginal surgeries, after which erosion ranged between 5 and 15 percent, as well as complications of infection, dyspareunia, and reoperation. Such complications were much less common with abdominal sacrocolpopexy.

The results of the patient-reported outcomes showed enhanced quality of life in all types of surgery and, moreover, 3-minute access sacrocolpopexy was linked to the quicker recovery, less-extended hospitalization, and sooner restoration to daily functions.

In general, the findings suggest that although the use of sacrocolpopexy is associated with better anatomical stability, vaginal operations can be used as alternatives with comparable outcomes, especially in patients who are contraindicated to use mesh or have no possibility to undergo surgery with minimal invasiveness. The decision of surgical methodology should thus be patient-specific and determine upon the patient traits and skills of the surgeon.

The current review presents a detailed analysis of surgery treatment in conditions of pelvic organ prolapse (POP) with differences in the anatomical success, recurrence rate, and complication patterns under different procedures. The results of the current research indicate that sacrocolpopexy, especially through the minimally invasive surgery, provide better anatomy and reduced recurrence than the vaginal reconstruction surgeries. These results correlate with the existing body of literature, indicating that abdominal sacrocolpopexy is the gold standard of apical prolapse repair since it has long-term outcomes and anatomical restoration is good20.

The laparoscopic and robotic sacrocolpopexy had high success rates (88 95) with lesser post operative morbidity and lower hospitalization. This is in agreement with other researchers who document better recovery outcomes and similar effectiveness of robotic-assisted sacrocolpopexy as compared to open surgeries showed that laparoscopic sacrocolpopexy produces better results in anatomy than vaginal sacrospinous fixation, though both methods exhibited equal improvement in quality life21.

Vaginal surgeries such as uterosacral ligament suspension, sacrificiospinous fixation are still popular because they are less invasive, and they do not use synthetic mesh. These methods in the current review showed moderate success rates (7085 percent) but comparatively high recurrence rates than sacrocolpopexy. These results corroborate those of Maher et al., who found a higher reoperation and recurrence rates with native tissue vaginal repair although these had an acceptable safety profile9. But the vaginal procedures are more specifically useful when the patients are old or medically incompetent and the abdominal surgery may not be an option, in that case22.

The use of mesh in POP surgery is still debatable. Although these mesh-enhanced vaginal repairs demonstrated initially encouraging anatomical results, the current study reported a high morbidity, with mesh erosion (5-15%), dyspareunia, and infection. The results align with regulatory issues that the FDA and other regulatory authorities expressed, which contributed to a ban on the use of transvaginal mesh23. This has resulted in a paradigm shift in favor of native tissue repairs and the use of an abdominal mesh, which seems to have a better safety profile.

A significant relevant point presented in this review is the fact that patient-specific factors are involved in determining the outcomes of surgery. The age, seriousness of prolapse, previous pelvic operations, comorbid conditions as well as sexual activity play a major role in determining the type of surgery and its effectiveness. This reinforces the ideas of the American College of Obstetricians and Gynecologists, which insist upon the treatment planning as individualized instead of a one-size-fits-all approach to treatment planning episodes.

Although there are developments in surgery, recurrence has remained a major problem in the management of POP. The recurrence rates in this study (that varies between 5% and 25) are similar to those documented in longitudinal research studies, indicating the necessity to enhance surgical approaches and follow-up in the long-term perspective and context24. Also, a difference in the experience of surgeons and practice in an institution can also lead to a difference in outcomes, which also highlights the significance of unified training and guidelines.

On the whole, the results of this review support the existing evidence that sacrocolpopexy is associated with the longest-lasting anatomical outcomes whereas vaginal surgeries are also appropriate options in a specific patient group. The growing usage of minimal invasive approaches is a major development towards better patient outcome and minimization of perioperative morbidity.

Limitations of the Study

This research has a few limitations which must be taken into account when interpreting the results. To begin with, being a narrative review, the study is vulnerable to inherent selection bias, even though the researchers tried to incorporate quality and relevant studies. Secondly, the heterogeneity of the studies included could be a limitation to the comparability of the results due to the differences in the design, patient population, methodology of surgery, and duration of follow-ups. Third, the published data can cause publication bias because positive results are more prone to be published. Moreover, the absence of standard outcome measures in the studies, especially on quality of life and functional outcomes, is a challenge in making conclusive findings. Lastly, not all studies had long-term results more than five years which restricted the evaluation of durability and late surgical intervention complications.

This paper has pointed out that the management of pelvic organ prolapse surgical management has progressed to a greater mark and the least invasive pelvic surgery; minimize colpopexy has proven to be a most effective approach and has greater anatomical stability and reduces rates of recurrence. The major new insight of this review is the rising trend of abandoning transvaginal mesh surgery in favor of safer types of surgery, including native tissue repairs and abdominal mesh placement, which is also explained by the evolving regulation and clinical practice.

Moreover, according to the findings, it is significant that surgical decisions be made on an individualized basis depending on patient-specific issues such as age, comorbidities, severity of prolapse and functional expectations, and not necessarily basing them on anatomical consequences. The similarity in the quality of life enhancement in the various modes of surgery, regardless of the anatomical success disparity is a highlight that should make patient-reported outcomes include in clinical decisions.

Another aspect that is highlighted in this study is the growing use of minimally invasive methods; that do not only preserve a high level of efficacy but also diminish perioperative morbidity and recovery, which is also a considerable development in the management of POP. Nevertheless, the recurrence in all surgical solutions emphasizes the necessity of being innovative and conduct research over time.

Considering the goals of the study, it may be concluded that although sacrocolpopexy is the most resistant surgical procedure, the presence of original tissue vaginal repairs still is an important aspect of selective patient-centered care when managing pelvic organ prolapse.

RECOMMENDATIONS

It has been suggested that surgical interventions to treat pelvic organ prolapse need to be more individualized and patient-specific factors (age, comorbidity, prolapse severity and functional need) must be put into the forefront. Sacrocolpopexy (minimally invasive) should be regarded as the best possible solution to be offered to suitable patients because it is associated with the best anatomical results and least remission, and native tissue vaginal procedures should be suggested to those who are against meshes or whose surgical risk is high. The key point that surgeons should underline is shared decision-making and involve patient-reported outcomes in the way of treatment planning. Moreover, they should have standardized training of surgeons, follow-ups over time, and create clear clinical guidelines to maximize the results and minimize the rate of re-occurrence.

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