Introduction

Pelvic floor dysfunction (PFD) is a common disease among middle-aged and elderly women. The lifetime risk of undergoing surgery for pelvic floor diseases is 11% to 20%. With the aggravation of the aging population, pelvic floor dysfunctional diseases have increasingly attracted people’s attention1,2. The main manifestations of pelvic floor dysfunction are the prolapse of the uterus and vaginal wall and in severe cases it may lead to dysfunctions in urination and defecation, pelvic pain, and sexual dysfunction3,4,5. Its main pathogenesis is the relaxation of the pelvic floor muscles and the decrease in muscle tension, making it unable to support the pelvic organs. Based on the structural changes, it further causes functional disorders6.Currently, there are various treatment methods for pelvic floor dysfunction, including pelvic floor function training, physical therapy, surgical treatment, and so on. Among them, surgical treatment is the most effective approach for uterine and vaginal wall prolapse7,8,9. However, with the advancement of medical technology, there are an increasing number of surgical approaches. Nevertheless, postoperative recurrence remains a rather thorny problem10.

In the past, the typical surgical methods for pelvic floor disorders were transvaginal hysterectomy along with anterior and posterior colporrhaphy. Nevertheless, with the progress in medical technology, laparoscopic-assisted surgeries have notably simplified the operation process11,12.Presently, to decrease the likelihood of postoperative recurrence, various types of meshes have gradually found their way into clinical practice, opening up new avenues for surgical treatment13.The widely used polypropylene mesh has also brought about a number of adverse reactions14.At present, the use of new-generation polypropylene mesh in the surgical treatment of uterine prolapse is becoming more and more common. It is mainly used in lateral abdominal wall suspension surgeries, whether the uterus is preserved or not15. However, there is still a lack of sufficient clinical data to support whether it has advantages over traditional uterine prolapse surgeries that do not preserve the uterus in terms of surgical outcome, postoperative recovery, and postoperative recurrence. This research intends to compare the pros and cons of laparoscopic total hysterectomy + bilateral salpingectomy/oophorectomy + lateral abdominal wall suspension + posterior colporrhaphy with traditional surgeries (laparoscopic-assisted vaginal hysterectomy + bilateral salpingectomy/oophorectomy + posterior colporrhaphy or vaginal hysterectomy + anterior and posterior colporrhaphy) for patients with uterine and vaginal wall prolapse, so as to offer a reference for clinical treatment.

Methods

Participants

We retrospectively reviewed the 112 patients who underwent surgeries without preserving the uterus due to uterine and vaginal wall prolapse in the Department of Gynecology of the second hospital of Tianjin Medical University from January 2022 to December 2023. According to different surgical methods, they were divided into the Study group: laparoscopic total hysterectomy + bilateral salpingectomy/bilateral oophorectomy + lateral abdominal wall suspension + posterior colporrhaphy; Control Group 1: laparoscopic-assisted vaginal total hysterectomy + bilateral salpingectomy/bilateral oophorectomy + anterior and posterior colporrhaphy; Control Group 2: vaginal total hysterectomy + anterior and posterior colporrhaphy. All patients had no history of pelvic surgery and other chronic diseases. A total of 33 patients were included in the Study group, 49 patients in Control Group 1, and 30 patients in Control Group 2. This study followed relevant ethical guidelines and regulations.

Surgical methods

Study group surgical procedure

The repair mesh used in the surgery is Titanized mesh implants, which is composed of a single-strand polypropylene and a titanium compound layer. A thin layer of fibrous tissue will grow into the mesh, and its cells will grow through the mesh pores, allowing the mesh to be enveloped by human tissues. Meanwhile, the mesh can maintain its softness and a certain degree of mobility. It has been confirmed that it has better histocompatibility16.

Patients were placed in the lithotomy position. After achieving satisfactory general anesthesia, laparoscopic total hysterectomy with bilateral salpingectomy/oophorectomy was performed using standard techniques. Excised tissues were extracted transvaginally, and vaginal vault closure was completed. The bladder apex was sutured to the anterior abdominal wall for suspension. A bowel retractor was used to elevate the vaginal vault, followed by meticulous dissection of the anterior and posterior vaginal walls. A pre-shaped T4 mesh was trimmed externally and inserted into the peritoneal cavity, then secured to the vaginal walls and vault using non-absorbable sutures. A 5 mm skin incision was made 4 cm superior and 3 cm lateral to each anterior superior iliac spine. A laparoscopic needle driver penetrated the subcutaneous tissue without breaching the peritoneum, passed obliquely beneath the round ligament, and exited the abdominal wall. The mesh was clamped and exteriorized (Fig. 1). After suspension, the anterior vaginal wall was elevated sufficiently without additional repair, and posterior colporrhaphy was thereafter performed.

Fig. 1
figure 1

Schematic diagram of lateral abdominal wall suspension (Photos taken during the operation). (a) The shape of the mesh after trimming. (b) After fully dissecting the bladder from the anterior vaginal wall, the mesh is laid flat on the anterior vaginal wall, folded back to the posterior vaginal wall after covering the vaginal stump. (c) The bilateral sides of the mesh are pulled through the extraperitoneal pathway of the lateral abdominal wall to the subcutaneous tissue 3 cm superior and 4 cm lateral to the anterior superior iliac spine, and sutured and embedded in the peritoneum with absorbable sutures.

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Control group 1 procedure

Laparoscopic total hysterectomy with bilateral salpingectomy/oophorectomy and anterior/posterior colporrhaphy were performed. Patient positioning and anesthesia protocols mirrored those of the Study group. Following uterine and adnexal resection, anterior/posterior colporrhaphy was conducted according to preoperative evaluations.

Control group 2 procedure

Vaginal hysterectomy with optional bilateral salpingectomy/oophorectomy and anterior/posterior colporrhaphy were performed. Same surgical and anesthesia protocols as the Study group were used.

Statistical indicators

Patient age, pelvic organ prolapse (POP-Q) staging, stress incontinence, the duration of the operation, the amount of blood loss during the operation, the length of time the urinary catheter was kept after the operation (in hours), the incidence of urinary tract infections after the operation, the number of days spent in the hospital and complications ≥ Clavien-Dindo Grade 3 were statistically analyzed across all groups. Complications ≥ Clavien-Dindo Grade 3 incluse severe complications such as ureteral injury, bladder injury, and intestinal injury, which require further surgical intervention. In addition, the follow-up data of the patients 1 year after the operation were reviewed to evaluate the recurrence situation and the treatment results.In the evaluation of postoperative stress urinary incontinence (SUI), all patients were considered to have SUI regardless of their postoperative severity grade. During postoperative follow-up, the vaginal wall was assessed using the Pelvic Organ Prolapse Quantification (POP-Q) system, and vaginal wall prolapse with a degree of ≥ Stage 1 was defined as recurrence.

Statistical analysis

Data analysis was performed using SPSS 27 software. For continuous variables that conformed to a normal distribution, such as age and the number of hospital stay days, an independent samples t-test was employed to compare the differences between the two groups. For ordinal variables, including the staging of uterine prolapse, anterior vaginal wall prolapse, and posterior vaginal wall prolapse, the Mann–Whitney U test was utilized. In cases of comparisons involving small sample sizes and low expected frequencies, Fisher’s exact test was applied. A P value less than 0.05 was considered to indicate a statistically significant difference.

Results

Comparison of basic characteristics of patients

There was no significant difference in age between the patients in the Study group and those in Control Group 1 (P > 0.05). However, there were significant differences in the severity of pelvic organ prolapse. The conditions of uterine prolapse, anterior vaginal wall prolapse, and posterior vaginal wall prolapse in the Study group were all more severe than those in Control Group 1 (P < 0.01). The specific data are shown in Table 1. There was no significant difference in the occurrence of SUI between the two groups(P > 0.05).

Table 1 Comparison of basic characteristics between study group and control group 1 patients.
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There was no significant difference in age between the patients in the Study group and those in Control Group 2 (P > 0.05). However, significant differences existed in the severity of pelvic organ prolapse. The degrees of uterine prolapse, anterior vaginal wall prolapse, and posterior vaginal wall prolapse in the Study group were all more severe than those in Control Group 2 (P < 0.01). The specific data are presented in Table 2. There was no significant difference in the occurrence of SUI between the two groups (P > 0.05).

Table 2 Comparison of basic characteristics between study group and control group 2 patients.
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Comparison of surgical related indicators among patients

The patients in the Study group had a shorter hospital stay (P =  < 0.01), a shorter duration of postoperative urinary catheterization (P = 0.01), and less intraoperative blood loss (P = 0.01) compared with those in Control Group 1. However, the operation time of the Study group was longer (P = 0.01). There were no significant differences in the incidence of postoperative urinary tract infections and vaginal bleeding between the two groups (P > 0.05). No complications of Clavien-Dindo Grade ≥ 3 happen in two groups. The data was shown in Table.3.

Table 3 Comparison of surgical related indicators between study group and control group 1 patients.
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There was no significant difference in the number of hospital stay days between the patients in the Study group and those in Control Group 2 (P > 0.05). The intraoperative blood loss and the number of days with the urinary catheter in place for the patients in the Study group were superior to those in Control Group 2 (P < 0.01), while the operation time of the Study group was significantly longer than that of Control Group 2 (P < 0.01). There were no significant differences in the incidence of postoperative urinary tract infections, postoperative vaginal bleeding between the two groups (P > 0.05). Meanwhile, no surgical complications of Clavien-Dindo Grade 3 or higher occurred in two groups. The specific data are shown in Table 4.

Table 4 Comparison of surgical related indicators between study group and control group 2 patients.
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Recurrence in different groups 1 year after operation

There was no marked difference in the occurrence of stress incontinence among patients in each group 1 year after the operation. Nevertheless, in the first control group, 5 patients developed anterior vaginal wall prolapse 1 year after the operation, with a higher incidence than that in the study group(P < 0.05). Moreover, there was no significant difference in the occurrence of vaginal wall prolapse between the control group 2 and the study group. The specific data are shown in Table 5.

Table 5 Recurrence in different groups 1 year after operation.
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Discussion

In the surgical treatment of patients with uterine and vaginal wall prolapse, the primary objectives are to alleviate symptoms, restore anatomical structure, and preserve organ function. The selection of surgical approach plays a critical role in patient outcomes and long-term prognosis17,18.Pelvic floor dysfunction surgeries are associated with high recurrence rates, but mesh repair has been shown to significantly delay recurrence compared to traditional procedures19,20.With advancements in biomaterial technology, novel composite materials such as titanium-reinforced polypropylene mesh have been introduced into clinical practice. These materials demonstrate improved histocompatibility, stable physical properties, and reduced inflammatory responses, thereby minimizing surgical complications21,22.

This study retrospectively analyzed clinical data of patients with non-uterus-sparing uterine and vaginal wall prolapse, comparing outcomes between different groups: those undergoing lateral abdominal wall suspension with mesh implantation versus traditional surgical approaches (laparoscopically assisted vaginal hysterectomy with bilateral salpingectomy/ oophorectomy + posterior colporrhaphy, or vaginal hysterectomy + anterior/posterior colporrhaphy). Demographic analysis revealed no significant differences in age among the Study group, Control group 1, and Control group 2, confirming balanced baseline characteristics. Notably, patients undergoing lateral abdominal wall suspension had more severe uterine and vaginal wall prolapse, as this procedure was preferentially selected for cases with higher prolapse grades. Despite this selection bias, subsequent analyses demonstrated superior outcomes in multiple domains for patients treated with lateral abdominal wall suspension compared to traditional surgical methods.

In the subsequent analysis, we further evaluated intergroup differences in surgical parameters. The lateral abdominal wall suspension group demonstrated significantly longer operative time compared to both laparoscopic-assisted vaginal hysterectomy and vaginal hysterectomy groups. This discrepancy can be attributed to the technically demanding nature of the procedure, which requires meticulous dissection of anterior/posterior vaginal walls, laparoscopic mesh suture fixation, and complete extraperitoneal mesh embedding to prevent exposure23,24. Despite the extended operative duration, no significant increase in intraoperative blood loss was observed in the lateral abdominal wall suspension group; conversely, a statistically significant reduction in blood loss was documented. Potential mechanisms include improved visualization afforded by pelvic floor muscle relaxation reducing operative complexity, and minimized anterior vaginal wall manipulation directly decreasing vascular trauma—though this hypothesis remains unreported in current literature. Notably, lateral abdominal wall suspension achieved significant vaginal apex elevation without requiring additional anterior colporrhaphy, thereby reducing urethral injury risk and shortening catheterization duration, which was corroborated by our data analysis. Postoperative care for prolonged catheterization cases included daily perineal cleansing and topical levofloxacin application to urethral orifices, effectively mitigating urinary tract infection risks. Although mesh fixation involving multiple suture points theoretically could reduce vaginal bleeding, no postoperative vaginal hemorrhage occurred in the Study group, whereas 6 cases of minor vaginal bleeding were observed in Control group 1 (without statistical significance due to limited sample size).In clinical practice, urethral suspension is commonly performed to improve symptoms in patients with pelvic floor dysfunction primarily characterized by stress urinary incontinence (SUI). In contrast, the patients included in this study who underwent lateral abdominal wall suspension predominantly presented with pelvic organ prolapse (POP), with a low preoperative incidence of concomitant SUI (only 5/33, 15.15%). Although lateral abdominal wall suspension may transiently increase the risk of SUI in the short term, no cases of SUI were observed at 10 days postoperatively. Additionally, over a 1-year follow-up period, no SUI developed as tissue repair and urination function recovered. These results may be partially attributed to the small sample size.

Procedural selection prioritized recurrence prevention. One-year follow-up demonstrated 0% recurrence in the lateral abdominal wall suspension group, compared to 5 cases of mild posterior vaginal wall prolapse in Control group 1, underscoring the recurrence prevention advantage of this technique25. While no statistically significant difference existed between the Study group and Control group 2, 2 recurrences observed in Control group 2 suggest potential differences may emerge with extended follow-up.

Conclusion

This study compared the outcomes of different surgical approaches for uterine prolapse and found that patients undergoing concurrent lateral abdominal wall suspension during laparoscopic surgery had significantly longer operative times but demonstrated significantly shorter catheterization duration and reduced intraoperative blood loss. No statistically significant differences were observed between groups in postoperative complications such as vaginal hemorrhage, urinary tract infections or other serious complications(Clavien-Dindo Grade ≥ 3). However, patients receiving lateral abdominal wall suspension showed a significant reduction in postoperative recurrence rates.Different surgical approaches have distinct characteristics. Clinicians should consider individual patient factors including the type of pelvic organ prolapse, primary symptoms, severity of prolapse, age, and general health status for comprehensive consideration to select the most appropriate procedure, aiming to optimize surgical outcomes and patient quality of life. Future studies with larger sample sizes and longer follow-up periods are warranted to further validate the long-term efficacy and safety profiles of these surgical techniques.