How do you decide between sacrocolpopexy and vaginal native tissue repair for apical prolapse in a patient with no prior mesh complications?

Sacrocolpopexy provides better average anatomic durability. In the 2024 ASPIRe randomized trial of posthysterectomy vault prolapse, adjusted 36-month composite failure was 28% after sacrocolpopexy versus 43% after native-tissue repair. Nevertheless, symptom improvement, satisfaction, and decision regret were similar, which is an important reminder that anatomic “failure” does not necessarily equal bothersome recurrence or reoperation.

The benefit may be most relevant in advanced disease. One sta...

I have a discussion with the patient regarding risks, benefits, and alternatives. If they decide on surgery rather than conservative management with a pessary, or if they fail a pessary, I describe both options.

Most patients choose the vaginal approach - 45 minutes, outpatient, no risk of mesh complications, high success rate with low reoperation rate, and it's easy to do concomitant stress incontinence surgery when indicated.

The abdominal approach takes several hours, has a 10% risk of mesh c...

The patient's comorbidities (e.g., ability to withstand Trendelenburg, previous abdominal surgeries, overall health status) are an important contributor, with more comorbid patients likely undergoing vaginal repairs. The other important factor is the desire to preserve coitus. Any vaginal surgery carries the potential to shorten, narrow, or deviate the vagina to some degree, potentially impacting penetrative intercourse. While sacral colpopexy is not immune to impacting vaginal dimensions, it ty...