SOGC CLINICAL PRACTICE GUIDELINE

It is the Society of Obstetricians and Gynaecologists of Canada (SOGC) policy to review the content 5 years after publication, at which
time the document may be revised to reflect new evidence or the document may be archived.

No. 413, April 2021

Guideline No. 413: Surgical Management of

Apical Pelvic Organ Prolapse in Women
(En français : Traitement chirurgical du prolapsus g
enital apical chez les femmes)
The English document is the original version. In the event of any discrepancy between the English and French content, the English version prevails.

This clinical practice guideline was prepared by the authors and
overseen by the SOGC Urogynaecology Committee. It was
approved by the SOGC Guideline Management and Oversight
Committee and the SOGC Board of Directors.
Authors
Roxana Geoffrion, MD, Vancouver, BC

al, QC
Maryse Larouche, MD, Montre
SOGC Urogynaecology Committee (2019): Aisling Clancy,
Laura Didomizio, Sine
ad Dufour, Roxana Geoffrion, Dobrochna
Globerman, Maryse Larouche, Marie-Claude Lemieux, Ola
Malabarey, Dante Pascali (co-chair), Jens-Erik Walter, David
Wilkie (co-chair), and Maria Wu
Disclosures: Statements were received from all authors. No
relationships or activities that could involve a conflict of interest
J Obstet Gynaecol Can 2021;43(4):511−523
https://doi.org/10.1016/j.jogc.2021.02.001
© 2021 The Society of Obstetricians and Gynaecologists of Canada/La
Société des obstétriciens et gynécologues du Canada. Published by
Elsevier Inc.
were declared. All authors have indicated that they meet the
journal’s requirements for authorship.
Acknowledgements: The authors would like to acknowledge and
thank special contributor Mr. Eric Belzile, Montre
al, QC, for
statistical support and meta-analysis, and Dr. Mina Majd, Ottawa,
ON, for literature search support. Statistical support was funded
by the St. Mary’s Hospital Foundation, Montre
al, QC.
Keywords: surgical mesh; suspensions; uterine prolapse; pelvic
pain; urinary bladder; decision making, shared
Corresponding author: Maryse Larouche,
ml.larouche@mcgill.ca
KEY MESSAGES
1. There are many surgical techniques to manage symptomatic
uterine or vault prolapse.
2. For sexually active patients seeking surgical correction of
symptomatic vaginal apical prolapse (uterine or vault), a
reconstructive method of apical suspension should be offered
at the same time as other repairs.
3. For patients seeking surgical correction of symptomatic
vaginal apical prolapse (uterine or vault) who are no longer
sexually active, an obliterative method of repair should be
offered as an alternative to reconstructive options.

This document reflects emerging clinical and scientific advances as of the publication date and is subject to change. The information is not meant
to dictate an exclusive course of treatment or procedure. Institutions are free to amend the recommendations. The SOGC suggests, however,
that they adequately document any such amendments.
Informed consent: Everyone has the right and responsibility to make informed decisions about their care together with their health care
providers. In order to facilitate this, the SOGC recommends that health care providers provide patients with information and support that is
evidence-based, culturally appropriate, and personalized.
Language and inclusivity: This document uses gendered language in order to facilitate plain language writing but is meant to be inclusive of all
individuals, including those who do not identify as a woman/female. The SOGC recognizes and respects the rights of all people for whom the
information in this document may apply, including but not limited to transgender, non-binary, and intersex people. The SOGC encourages
healthcare providers to engage in respectful conversation with their patients about their gender identity and preferred gender pronouns and to
apply these guidelines in a way that is sensitive to each person’s needs.
Copyright: The contents of this document, in whole or in part, cannot be reproduced in any form without prior written permission of the publisher
of the Journal of Obstetrics and Gynaecology Canada.

APRIL JOGC AVRIL 2021  511

SOGC CLINICAL PRACTICE GUIDELINE
4. Objective and subjective outcomes of various procedures
often differ, and an exploration of patient expectations is
essential before every prolapse operation.
5. Patients should be counselled that there are limited existing
data, including poor evidence regarding outcomes of pain and
sexual function, and lack of data on the long-term durability of
all surgical options.
6. Pelvic pain and sexuality after apical prolapse procedures
need to be further explored through rigorous comparative
research.
7. Abdominal sacrocolpopexy, although superior in some
objective outcomes, is similar to vaginal ligament suspensions
for subjective outcomes in the short to medium term and
carries a higher risk of mesh exposure over the long term.
8. Although hysteropexy is an option for surgical correction of
symptomatic vaginal apical prolapse, existing data are of low
quality; more comparative research is needed before this
procedure can be widely adopted in routine clinical practice.
Abstract
Objective: To compare success and complication rates of apical
suspension procedures for the surgical management of
symptomatic uterine or vaginal vault prolapse.
Target population: Women with symptomatic uterine or vaginal vault
prolapse seeking surgical correction.
Options: Interventions included abdominal apical reconstructive
repairs (sacrocolpopexy, sacrohysteropexy, or uterosacral
hysteropexy) via open, laparoscopic, or robotic approaches; vaginal
apical reconstructive repairs (vault suspensions or hysteropexy,
sacrospinous, uterosacral, iliococcygeus, McCall’s, or Manchester
types); and vaginal obliterative procedures (with or without uterus in
situ). Individual procedures or broad categories of procedures were
compared: (1) vaginal versus abdominal routes for reconstruction,
(2) abdominal procedures for reconstruction, (3) vaginal procedures
for reconstruction, (4) hysterectomy and suspension versus
hysteropexy for reconstruction, and (5) reconstructive versus
obliterative options.
Outcomes: The Urogynaecology Committee selected outcomes of
interest: objective failure (obtained via validated pelvic organ
prolapse [POP] quantification systems and defined as overall
objective failure as well as failure rate by compartment); subjective
failure (recurrence of bulge symptoms determined subjectively, with
or without use of a validated questionnaire); reoperation for POP
recurrence; complications of postoperative lower urinary tract
symptoms (de novo or postoperative stress urinary incontinence;
reoperation for persistent, recurrent, or de novo stress urinary
incontinence; urge urinary incontinence; and voiding dysfunction);
perioperatively recognized urinary tract injury (bladder or ureter);
other complications (mesh exposure, defined as mesh being visible
and exposed in the vagina, and non-sexual pelvic pain); and sexual
function (de novo dyspareunia and sexual function score according
to a validated questionnaire).
Benefits, harms, and costs: This guideline will benefit patients
seeking surgical correction of apical POP by improving counselling
on surgical treatment options and possible outcomes. It will also
benefit surgical providers by improving their knowledge of various
surgical approaches. Data presented could be used to develop
frameworks and tools for shared decision-making.
Evidence: We searched Medline, the Cochrane Central Register of
Controlled Trials (CENTRAL), and Embase from 2002 to 2019. The
512  APRIL JOGC AVRIL 2021
search included multiple terms for apical POP surgical procedures,
approaches, and complications. We excluded POP repairs using
transvaginal mesh and studies that compared procedures without
apical suspension. We included randomized controlled trials and
prospective or retrospective comparative studies. We limited
language of publication to English and French and accessibility to
full text. A systematic review and meta-analysis was performed.
Validation methods: The authors rated the quality of evidence and
strength of recommendations using the Grading of
Recommendations Assessment, Development, and Evaluation
(GRADE) approach. See online Appendix A (Tables A1 for
definitions and A2 for interpretations of strong and weak
recommendations).
Intended users: Gynaecologists, urologists, urogynaecologists, and
other health care providers who assess, counsel, and care for
women with POP.
SUMMARY STATEMENTS: All statements refer to correction of apical
vaginal prolapse in the short and medium term (up to 5 years),
except when otherwise specified.
1. Vaginal suture suspension to various pelvic ligaments was inferior
to abdominal sacrocolpopexy (any route) with synthetic mesh for
the outcomes of
 overall objective failure (moderate)
 objective apical failure (moderate)
2. Vaginal suture suspension to various pelvic ligaments was similar
to abdominal sacrocolpopexy (any route) with synthetic mesh for
the outcomes of
 objective anterior failure (moderate)
 objective posterior failure (moderate)
 subjective awareness of pelvic organ prolapse recurrence
(moderate)
 reoperation for pelvic organ prolapse recurrence (moderate)
 intraoperative bladder and ureteric injuries (low)
 postoperative lower urinary tract symptoms (low)
3. Vaginal suture suspension to various pelvic ligaments was not
associated with a risk of mesh exposure compared with abdominal
sacrocolpopexy (any route) with synthetic mesh, which is associ-
ated with a 2.7% to 3.4% risk of mesh exposure (moderate).
4. Open abdominal sacrocolpopexy was inferior to minimally invasive
(laparoscopic or robotic) sacrocolpopexy for the outcomes of
 overall objective failure (low)
 objective posterior failure (low)
5. Open abdominal sacrocolpopexy was similar to minimally invasive
(laparoscopic or robotic) sacrocolpopexy for the outcomes of
 objective anterior failure (low)
 subjective awareness of pelvic organ prolapse recurrence
(moderate)
 reoperation for pelvic organ prolapse recurrence (moderate)
 intraoperative bladder injuries (moderate)
 reoperation for stress urinary incontinence (low)
 mesh exposure (moderate)
6. Various minimally invasive sacrocolpopexy approaches (laparo-
scopic or robotic) showed similar risk of
 Guideline No. 413: Surgical Management of Apical Pelvic Organ Prolapse in Women
 subjective awareness of pelvic organ prolapse recurrence (very
low)
 intraoperative bladder injury (moderate)
 postoperative stress urinary incontinence (very low)
 mesh exposure (moderate)
7. There are insufficient data comparing urge urinary incontinence
and voiding dysfunction risk after open abdominal and minimally
invasive sacrocolpopexy and among various approaches to mini-
mally invasive sacrocolpopexy (very low).
8. Uterosacral ligament suspension and sacrospinous fixation
showed similar risk of
 objective failure rates (overall and by compartment) (moderate)
 subjective awareness of pelvic organ prolapse recurrence
(moderate)
 reoperation for pelvic organ prolapse recurrence (moderate)
 intraoperative bladder injury (moderate)
 reoperation for stress urinary incontinence (moderate)
9. Uterosacral ligament suspension compared with sacrospinous fix-
ation showed a higher risk of
 intraoperative ureteric injury (moderate)
10. Hysterectomy and suspension versus hysteropexy (by any route)
were similar for the outcomes of
 overall objective failure (low)
 objective anterior failure (low)
 objective apical failure (low)
 subjective awareness of pelvic organ prolapse recurrence (low)
 reoperation for pelvic organ prolapse recurrence (low)
 lower urinary tract symptoms (low)
 intraoperative bladder or ureteric injury (low)
11. Hysterectomy and suspension compared with hysteropexy (by any
route) were inferior for the outcome of
 objective posterior failure (low)
12. Hysterectomy and sacrocolpopexy compared with sacrohystero-
pexy (abdominal, laparoscopic, or robotic) showed a higher risk of
 mesh exposure (low)
13. Vaginal hysterectomy with suspension and vaginal hysteropexy
showed similar risk of
 objective failure (overall and by compartment) (low)
 risk of reoperation for pelvic organ prolapse recurrence (very
low)
 intraoperative ureteric injury (very low)
14. In the short-term (1-year) correction of advanced apical vaginal
prolapse (stage 3 or 4), vaginal suture suspension to various pelvic
ligaments is similar to colpocleisis for the outcomes of overall
objective failure, intraoperative urinary tract injury, and condition-
specific improvement in quality of life (very low).
15. Uterosacral ligament suspension compared with sacrospinous fix-
ation showed a lower risk of
 short-term/transient buttock pain (low)
16. Current data are inconclusive for the outcomes of persistent pelvic
pain or postoperative sexual function, including de novo dyspareu-
nia, when comparing vaginal with abdominal apical suspensions,
open with minimally invasive apical suspensions, various vaginal
apical suspensions, and hysterectomy and suspension with hyster-
opexy (very low).
RECOMMENDATIONS:
1. Women seeking surgical correction of apical pelvic organ prolapse
should be counselled about the higher risk of objective failure but
similar rate of (1) subjective failure, (2) reoperation for pelvic organ
prolapse recurrence, and (3) complications after vaginal suture sus-
pensions compared with abdominal sacrocolpopexy (any
approach). This is balanced against the ongoing risk of mesh expo-
sure after sacrocolpopexy, possibly requiring reintervention (condi-
tional, moderate).
2. Appropriately trained surgeons should favour minimally invasive lap-
aroscopic or robotic approaches to sacrocolpopexy (if surgical
equipment is available) over open sacrocolpopexy, considering the
improved overall objective outcomes and similar subjective out-
comes in the short and medium term (conditional, low).
3. Both vaginal uterosacral ligament suspension and sacrospinous fix-
ation can be offered to women with apical pelvic organ prolapse,
based on surgeon and patient preference; they appear to have simi-
lar objective and subjective outcomes at up to 5 years, apart from an
increased risk of intraoperative ureteric injury with uterosacral liga-
ment suspension and a higher risk of short-term/transient buttock
pain after sacrospinous fixation (strong, moderate).
4. Various hysteropexy routes and techniques can be offered as an
alternative to hysterectomy and suspension for women with apical
pelvic organ prolapse who wish to conserve their uterus; they are
associated with similar objective and subjective outcomes in the first
5 years (conditional, low).
5. Colpocleisis should be discussed as a treatment option for women
who do not wish to be sexually active in the future, despite the pau-
city of comparative evidence; it appears to be a successful proce-
dure with few reported complications (strong, low).
6. Women undergoing surgery for symptomatic apical pelvic organ
prolapse should receive counselling about the lack of comparative
data on postoperative pelvic pain and sexual function for various
procedures. Overall, the risk of postoperative pelvic pain appears to
be low, and sexual function seems to improve among sexually active
women with pelvic organ prolapse who undergo reconstructive sur-
gery (conditional, very low).
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SOGC CLINICAL PRACTICE GUIDELINE
INTRODUCTION
omen’s reproductive organs maintain their anatomic
W position in the pelvis through an intricate network
of support structures, including connective tissues, liga-
ments, and muscles. Pelvic organ prolapse (POP) results
when 1 or more of these support structures are compro-
mised as a result of childbirth, aging, and/or increased
intra-abdominal pressure. As a result, the vagina descends
and normal pelvic function may be lost to a variable extent.
Routine gynaecological examination can detect a vaginal
bulge in approximately 50% of patients. However, POP is
only symptomatic in 3% to 6% of women,1 with the most
common symptom being a sensation of vaginal bulging.2
POP is 1 of several pelvic floor disorders. These often
coexist, and their symptoms overlap. As a consequence,
clinical assessment for POP also includes screening for uri-
nary, vaginal, or bowel dysfunction, including sexual dys-
function and pain. Although POP treatments can
occasionally correct other pelvic symptoms, they may also
exacerbate them. For example, stress urinary incontinence
can be unmasked after surgery for POP. Other pelvic floor
disorders and possible effects on them warrant discussion
with patients seeking care for POP.
First-line management of POP includes conservative
options such as pelvic floor physiotherapy and pessaries.
When conservative treatments fail or are not acceptable to
individual patients, surgical treatments are available to cor-
rect POP. Of all POP symptoms, vaginal bulging is the
most amenable to correction by surgery. Epidemiological
studies place the lifetime incidence of surgery for POP
within a range of 12.6% to 19%, with up to 30% of those
undergoing surgery requiring subsequent procedures for
recurrence.3-6
POP surgical procedures are broadly categorized as recon-
structive or obliterative.7 Reconstructive pelvic surgery is
usually performed when women wish to maintain a func-
tional vagina. While surgical procedures for anterior and
posterior vaginal wall prolapse have been fairly standard,
those for apical POP have varied considerably, based on
patient preference and comorbidities, surgeon experience,
and evolving technologies. Reconstruction for apical POP
can be performed vaginally or abdominally, with or without
preserving the uterus.7 Obliterative surgery for apical POP
includes total colpocleisis (for vaginal vault prolapse fol-
lowing hysterectomy) and LeFort colpocleisis (for uterine
prolapse, with uterine preservation). Such obliterative sur-
gery is typically performed in women with severe POP
and significant medical comorbidities who are no longer
sexually active.
514  APRIL JOGC AVRIL 2021
Hysterectomy alone is not an adequate treatment for uter-
ine prolapse.7 In a prospective comparative trial of vaginal
hysterectomy alone versus vaginal hysterectomy with sac-
rospinous fixation for severe uterine prolapse, at 1 year of
follow-up, vaginal vault prolapse recurred significantly
more frequently in patients who underwent vaginal hyster-
ectomy alone (20% vs. 3.1%; P = 0.035).8 Suspending the
vaginal vault during hysterectomy for uterine prolapse is
accepted practice in many urban teaching centres and uro-
gynaecological practices. However, overall, apical support
procedures are still performed only in a minority (37.1%)
of hysterectomies performed for a main indication of
POP.9
Apical resuspension can be accomplished vaginally or
abdominally, with vaginal procedures most commonly
involving suspension to pelvic ligaments (uterosacral or
sacrospinous) and abdominal approaches most commonly
involving sacrocolpopexy (open, laparoscopic, or robotic).7
This clinical practice guideline provides recommendations
for selection of apical support procedures based on objec-
tive and subjective outcomes and discusses selected com-
plications in women seeking surgery for symptomatic
POP.
Reconstructive Surgery for Pelvic Organ Prolapse
We compared results of broad categories of interventions.
Previous hysterectomy, concomitant hysterectomy, and
hysteropexy are all included in this guideline.
Vaginal Versus Abdominal Procedures
We included the following vaginal procedures: uterosacral
ligament suspension, sacrospinous fixation, McCall culdo-
plasty, and iliococcygeus suspension. The majority of vagi-
nal suspensions described in comparative studies were
uterosacral and sacrospinous. We included the following
abdominal procedures: open, laparoscopic, and robotic
sacrocolpopexy. Our search also yielded a small number of
studies of laparoscopic pectopexy and laparoscopic or
robotic uterosacral ligament suspension. However, only
sacrocolpopexies were included in the meta-analysis and
summary of results, owing to the difficulty in comparing
these different procedures (Table 1).10-27 Sacrocolpopexy
is associated with a risk of mesh exposure of 2.7% to 3.4%
in the short to medium term; this can be asymptomatic or
can cause vaginal bleeding, discharge, pain, dyspareunia, or
discomfort for a sexual partner.28,29 Long-term studies of
sacrocolpopexy show that the risk of developing mesh
exposure continues for up to 7 years after the surgery.30
Symptomatic mesh exposures can be treated with vaginal
estrogen, but they may require surgical reintervention to
excise the exposed mesh. A more detailed description of
 Table 1. Vaginal procedures compared with sacrocolpopexy
Characteristics Descriptive analysis Meta-analysis
No. Length of Vaginal procedures Sacrocolpopexy
follow-up, y Pooled RR
Outcomes Studies RCTs Median (range) na Nb Rate, % na Nb Rate, % (95% CI) I2 , % c
Objective failure
Overall 7 1 2 (0.8−5.0) 85 553 15.4 87 1080 8.1 1.82 (1.22−2.74)d 36
e d
Apical 9 3 2.3 (1.0−4.5) 36 547 6.6 10 561 1.8 2.70 (1.33−5.50) 11
Anterior 8 3 2.7 (1−5) 73 453 16.1 43 448 9.6 1.92 (0.97−3.82) 66
Posterior 7 3 2.5 (1−5) 26 424 6.1 15 373 4.0 1.7 (0.86−3.35) 7
Subjective failure
Reoperation for POP recurrence 13 4 2.5 (1−5) 241 2993 8.1 114 1746 6.5 1.34 (0.70−2.56 63
Awareness of POP recurrence 7 2 3 (1−5) 96 634 15.1 86 462 18.6 0.78 (0.53−1.15) 29

Guideline No. 413: Surgical Management of Apical Pelvic Organ Prolapse in Women
Lower urinary tract symptoms
SUI (de novo or postoperative) 4 1 2 (1.3−4.9) 62 275 22.5 82 373 22.0 0.93 (0.42−2.02) 64
Reoperation for SUI 4 1 2.4 (2−3) 5 211 2.4 10 191 5.2 0.65 (0.22−1.88) 15
Urge urinary incontinence 3 1 2.8 (2.0−4.9) 72 185 38.9 75 226 33.2 1.10 (0.65−1.85) 34
Voiding dysfunction 2 1 2.4 (2.0−2.8) 2 73 2.7 4 79 5.1 0.56 (0.10−3.16) 0
Urinary tract injury
Bladder 12e 2 N/A 87 2932 3.0 37 1790 2.1 1.22 (0.82−1.82) 0
Ureteric 7f 1 N/A 49 2539 1.9 11 1352 0.8 1.89 (1.00−3.57) 0
Complications
Mesh exposure 12g 4 2.5 (1−5) 0 728 0.0 21 792 2.7 0.21 (0.08−0.54)d 0
Non-sexual pelvic pain 1 0 2 (—) 8 95 8.4 13 113 11.5 N/A −
Sexual function
De novo dyspareunia 1 1 1 (—) 3 17 17.6 2 19 10.5 N/A −
a
n: total number of events (all studies).
b
N: total sample size (all studies).
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I : Higgin’s statistic represents the percentage of total variation across studies and is used to assess heterogeneity. An I2 value of 0% indicates no observed heterogeneity; values of 25%, 50%, and 75% correspond to “low,”
c 2

“moderate,” and “high” levels of heterogeneity, respectively.29 When substantial heterogeneity was not observed (I2 <25%), the pooled RR calculated based on the fixed effects model was reported; the “inverse variance
method” was used in the fixed effects model. When substantial heterogeneity was observed (I2 ≥25%), the pooled RR calculated based on the random effects model was reported (DerSimonian and Laird method).29
d
Significant RR.
e
One study were removed from the meta-analysis because no event occurred in either group.
f
Three studies were removed from the meta-analysis because no event occurred in either group.
g
Two studies were removed from the meta-analysis because no event occurred in either group.N/A: not applicable; POP: pelvic organ prolapse; RCT: randomized controlled trial; RR: relative risk; SUI: stress urinary
incontinence.

515
SOGC CLINICAL PRACTICE GUIDELINE
the management of mesh complications can be found in
the SOGC “Guideline No. 351: Transvaginal Mesh Proce-
dures for Pelvic Organ Prolapse”;29 the management of
mesh exposure is similar whether the mesh was placed
transvaginally or during sacrocolpopexy.29 A systematic
review of the surgical management of mesh complications
following sacrocolpopexy was not performed for the cur-
rent guideline because it was outside the predetermined
scope.
SUMMARY STATEMENTS 1, 2, AND 3
RECOMMENDATION 1
Abdominal Procedures
Different sacrocolpopexy approaches were compared,
including open, laparoscopic, and robotic sacrocolpopexy
(Table 2).25, 31-44
SUMMARY STATEMENTS 4, 5, 6, and 7
RECOMMENDATION 2
Vaginal Procedures
The majority of included studies compared uterosacral liga-
ment suspension with sacrospinous fixation (Table 3).25,45-51
SUMMARY STATEMENTS 8 and 9
RECOMMENDATION 3
Hysterectomy and Suspension Versus Hysteropexy
Procedures
Some women may prefer to retain their uterus during pro-
lapse repair surgery. However, hysteropexy procedures are
not indicated for women with significant risk factors for
endometrial or cervical cancer or for those with undiag-
nosed abnormal or postmenopausal bleeding. Women con-
sidering hysteropexy should be made aware that a
hysterectomy may be required in the future for these con-
ditions. All routes for hysterectomy and suspension versus
hysteropexy were compared in this analysis
(Table 4).25,26,45,48,49,51-58 Types of procedures included
vaginal or laparoscopic ligament suspensions, as well as
sacrocolpopexies or sacrohysteropexies. Included studies
often compared different approaches in either arm (e.g.,
sacrospinous hysteropexy vs. vaginal hysterectomy with
uterosacral ligament suspension), limiting the analysis of
more specific comparisons.
516  APRIL JOGC AVRIL 2021
SUMMARY STATEMENTS 10, 11, 12, and 13
RECOMMENDATION 4
Reconstructive Versus Obliterative Surgery
We did not identify any studies comparing obliterative pro-
cedures with and without uterine preservation or random-
ized trials comparing reconstructive with obliterative
vaginal surgery. One prospective comparative study com-
pared the 1-year outcomes in 40 women undergoing vagi-
nal apical suspensions (uterosacral, iliococcygeus, and
McCall’s) with the outcomes in 30 women undergoing col-
pocleisis (total, partial, and LeFort).59 Patients had stage 3
or 4 POP at baseline. The anatomical outcome of recur-
rent POP beyond the hymen was similar (5% reconstruc-
tive vs. 0% obliterative; P = 0.53). There was 1
intraoperative bladder injury in the group undergoing
reconstructive surgery and none in the group undergoing
obliterative surgery. Both treatment groups showed signifi-
cant improvement in POP, urinary, and colorectal scales of
quality-of-life questionnaires for this condition (Pelvic
Floor Distress Inventory and Pelvic Floor Impact Ques-
tionnaire), and there was no difference between groups.59
SUMMARY STATEMENT 14
RECOMMENDATION 5
Outcomes of Pain and Sexual Function
Few comparative studies consistently reported pain out-
comes. When studies reported pain, they rarely graded the
severity of the pain or assessed its impact on quality of life.
In addition, most reported pain outcomes were short-term
(up to 6 weeks postoperatively) because most pain resolved
spontaneously. Only 4 studies reported reoperation
for pain.15,40,48 Few comparative studies consistently
reported sexual function and/or scores on validated sex-
ual-function questionnaires. Studies mainly provided the
number of sexually active patients pre- and postoperatively
or presented only postoperative data without baseline
information.
Vaginal Versus Abdominal Procedures
After abdominal sacrocolpopexy with synthetic mesh, pel-
vic pain was reported in up to 11.5% of cases (13 of 113)11
and de novo dyspareunia in up to 10.5% (2 of 19).13 After
abdominal suture suspensions, pelvic pain was reported in
3.8% to 9.1% of cases (combined N = 48).60,61 After vagi-
nal suture suspensions, pelvic pain was reported in 0% to
14.6% of cases (combined N = 233)11,60,61 and de novo
dyspareunia in up to 17.6% (3 of 17).13 Reoperations for
 Table 2. Minimally invasive sacrocolpopexy compared with abdominal sacrocolpopexy
Characteristics Descriptive analysis Meta-analysis
No. Length of Minimally invasive sacrocolpopexy Abdominal sacrocolpopexy
follow-up, y Pooled RR
Outcomes Studies RCTs Median (range) na Nb Rate, % na Nb Rate, % (95% CI) I2 , % c
Objective failure
Overall 4 1 1 (1.0−2.5) 84 682 12.3 168 959 17.5 0.59 (0.47−0.75)d 0
Apical 3 2 2.9 (1.0−3.7) 0 112 0.0 0 117 0.0 N/A —
Anterior 2 1 3.6 (3.5−3.7) 16 83 19.3 4 88 4.5 4.03 (0.72−22.71) 47
Posterior 3 1 3.5 (1.0−3.7) 59 618 9.5 110 677 16.2 0.59 (0.44−0.80)d 0
Subjective failure
Reoperation for POP recurrence 5e 2 1.8 (0.8−5.0) 12 242 5.0 9 463 1.9 2.19 (0.89−5.35) 0
Awareness of POP recurrence 4e 2 1.8 (1.0−3.5) 12 231 5.2 21 450 4.7 1.01 (0.38−2.67) 43

Guideline No. 413: Surgical Management of Apical Pelvic Organ Prolapse in Women
Lower urinary tract symptoms
SUI (de novo or postoperative) 1 1 1 (—) 5 31 16.1 4 29 13.8 N/A —
Reoperation for SUI 2 2 1 (1.0−1.0) 3 59 5.1 4 61 6.6 0.84 (0.21−3.31) 0
Urge urinary incontinence 1 1 1 (—) 2 31 6.5 3 29 10.3 N/A —
Voiding dysfunction 1 0 2.5 (—) 0 54 0.0 9 57 15.8 N/A —
Urinary tract injury
Bladder 5 2 N/A 18 765 2.4 26 1015 2.6 1.44 (0.45−4.57) 38
Ureteric 2e 0 N/A 0 561 0.0 2 616 0.3 N/A —
Complications
Mesh exposure 8f 1 1 (0.8−3.7) 26 892 2.9 39 1150 3.4 1 (0.59−1.69) 0
Non-sexual pelvic pain 1 1 1 (—) 8 31 25.8 13 29 44.8 N/A —
Sexual function
De novo dyspareunia 0 — — — — — — — — — —
a
n: total number of events (all studies).
b
N: total sample size (all studies).
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I : Higgin’s statistic represents the percentage of total variation across studies and is used to assess heterogeneity. An I2 value of 0% indicates no observed heterogeneity; values of 25%, 50%, and 75% correspond to “low,”
c 2

“moderate,” and “high” levels of heterogeneity, respectively.29 When substantial heterogeneity was not observed (I2 <25%), the pooled RR calculated based on the fixed effects model was reported; the “inverse variance
method” was used in the fixed effects model. When substantial heterogeneity was observed (I2 ≥25%), the pooled RR calculated based on the random effects model was reported (DerSimonian and Laird method).29
d
Significant RR.
e
One study was removed from the meta-analysis because no event occurred in either group.
f
Three studies were removed from the meta-analysis because no event occurred in either group.N/A: not applicable; POP: pelvic organ prolapse; RCT: randomized controlled trial; RR: relative risk; SUI: stress urinary
incontinence.

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Table 3. Uterosacral ligament suspension compared with sacrospinous fixation

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Characteristics Descriptive analysis Meta-analysis

No. Length of Uterosacral ligament suspension Sacrospinous fixation
follow-up, y Pooled RR
Outcomes Studies RCTs Median (range) na Nb Rate, % n N Rate, % ( 95% CI) I2 , % c
Objective failure
Overall 2 2 5 (5−5) 119 235 50.6 126 236 53.4 0.96 (0.74−1.23) 49
Apical 3 3 1 (1−2) 9 266 3.4 13 288 4.5 0.58 (0.10−3.46) 64
Anterior 3 3 1 (1−2) 76 287 26.5 78 289 27.0 1.02 (0.80−1.31) 0
Posterior 3 3 1 (1−2) 30 287 10.5 16 289 5.5 1.71 (0.68−4.30) 56
Subjective failure
Reoperation for POP recurrence 5 4 3.6 (1−5) 465 4806 9.7 230 2305 10.0 0.98 (0.49−2.00) 87
Awareness of POP recurrence 1 1 5 (—) 56 133 42.1 64 134 47.8 N/A —
Lower urinary tract symptoms
SUI (de novo or postoperative) 0 — — — — — — — — — —
Reoperation for SUI 2 1 3.5 (2−5) 13 263 4.9 8 257 3.1 1.53 (0.63−3.70) 2
Urge urinary incontinence 0 — — — — — — — — — —
Voiding dysfunction 0 — — — — — — — — — —
Urinary tract injury
Bladder 3d 2 N/A 29 729 4.0 52 1863 2.8 2.04 (0.57−7.27) 26
Ureteric 3 2 N/A 27 729 3.7 27 1863 1.4 2.46 (1.41−4.31)e 0
Complication
Mesh exposure N/A — — — — — — — — — —
Non-sexual pelvic pain 2 2 1.5 (1−2) 8 278 2.9 27 274 9.9 0.22 (0.03−1.78) 57
Sexual function
De novo dyspareunia 0 — — — — — — — — N/A —
a
n: total number of events (all studies).
b
N: total sample size (all studies).
I : Higgin’s statistic represents the percentage of total variation across studies and is used to assess heterogeneity. An I2 value of 0% indicates no observed heterogeneity; values of 25%, 50%, and 75% correspond to “low,”
c 2

“moderate,” and “high” levels of heterogeneity, respectively.29 When substantial heterogeneity was not observed (I2 <25%), the pooled RR calculated based on the fixed effects model was reported; the “inverse variance
method” was used in the fixed effects model. When substantial heterogeneity was observed (I2 ≥25%), the pooled RR calculated based on the random effects model was reported (DerSimonian and Laird method).29
d
One study was removed from the meta-analysis because no event occurred in either group.
e
Significant RR.N/A: not applicable; POP: pelvic organ prolapse; RCT: randomized controlled trial; RR: relative risk; SUI: stress urinary incontinence.
 Table 4. Hysterectomy and suspension compared with hysteropexy (any route)
Characteristics Descriptive analysis Meta-analysis
No. Length of Hysterectomy and suspension Hysteropexy
follow-up, y Pooled RR
Outcomes Studies RCTs Median (range) na Nb Rate, % na Nb Rate, % (95% CI) I2 , % c
Objective failure
Overall 5 1 2.5 (1−5) 107 330 32.4 108 284 38.0 0.85 (0.57−1.27) 57
d
Apical 9 3 2.1 (1−5) 24 485 4.9 41 506 8.1 0.63 (0.30−1.31) 35
Anterior 8 3 2.1 (1−5) 85 401 21.2 109 455 24.0 0.94 (0.75−1.18) 9
d e
Posterior 8 3 2.1 (1−5) 42 401 9.5 21 455 4.4 2.18 (1.32−3.60) 0
Subjective failure
Reoperation for POP recurrence 12d 4 2 (1−5) 455 4741 9.6 153 1018 15.0 0.66 (0.43−1.01) 44
Awareness of POP recurrence 4 1 1.9 (1.0−4.3) 13 216 6.0 31 188 16.5 0.52 (0.17−1.59) 48

Guideline No. 413: Surgical Management of Apical Pelvic Organ Prolapse in Women
Lower urinary tract symptoms
SUI (de novo or postoperative) 2 0 8.8 (4.3−13.3) 8 111 7.2 11 98 11.2 0.66 (0.29−1.53) 0
Reoperation for SUI 3 1 4.3 (1−5) 10 221 4.5 8 180 4.4 0.97 (0.19−5.05) 57
Urge urinary incontinence 2 0 8.8 (4.3−13.3) 17 111 15.3 24 98 24.5 0.63 (0.37−1.07) 0
Voiding dysfunction 3 0 4.3 (2.8−13.3) 9 159 5.7 14 159 8.8 0.58 (0.25−1.31) 0
Urinary tract injury
Bladder 5f 0 N/A 5 294 1.7 0 305 0.0 4.43 (0.54−36.46) 0
Ureteric 5f 1 N/A 3 373 0.8 0 365 0.0 4.14 (0.47−36.90) 0
Complications
Mesh exposure 5d 2 2.2 (1.0−4.3) 6 171 3.5 2 208 1.0 2.74 (0.21−35.28) 56
Non-sexual pelvic pain 3 1 2.75 (1.0−2.8) 4 187 2.1 13 229 5.7 0.62 (0.07−5.27) 57
Sexual function
De novo dyspareunia 0 — — — — — — — — — —
a
n: total number of events (all studies).
b
N: total sample size (all studies).
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I : Higgin’s statistic represents the percentage of total variation across studies and is used to assess heterogeneity. An I2 value of 0% indicates no observed heterogeneity; values of 25%, 50%, and 75% correspond to “low,”
c 2

“moderate,” and “high” levels of heterogeneity, respectively.29 When substantial heterogeneity was not observed (I2 <25%), the pooled RR calculated based on the fixed effects model was reported; the “inverse variance
method” was used in the fixed effects model. When substantial heterogeneity was observed (I2 ≥25%), the pooled RR calculated based on the random effects model was reported (DerSimonian and Laird method).29
d
Two were studies removed from the meta-analysis because no event occurred in either group.
e
Significant RR.
f
Three studies were removed from the meta-analysis because no event occurred in either group.POP: pelvic organ prolapse; RCT: randomized controlled trial; RR: relative risk; SUI: stress urinary incontinence.

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SOGC CLINICAL PRACTICE GUIDELINE
pelvic pain were rare for both abdominal and vaginal pro-
lapse repairs (range 0%−2.8%; combined N = 396).15,40,48
Only 1 study compared pre- and postoperative sexual
function; similar improvements in sexual-function scores
were reported after uterosacral ligament suspension and
abdominal sacrocolpopexy.18
Abdominal Procedures
After open versus laparoscopic abdominal sacrocolpopexy
with synthetic mesh, 44.8% versus 25.8% of patients had
pelvic pain during the follow-up period (N = 60).32 Only
3.2% versus 10.3% complained about pain (whereas the
other cases were picked up from questionnaires); those
women had preoperative pelvic pain that was exacerbated
by the surgery. No further explanation for the high rate of
pelvic pain was given in this study.32 Reoperations for pel-
vic pain were very rarely reported (1.8% vs. 0% for open
vs. minimally invasive sacrohysteropexy, respectively;
N = 111).40 Generally, sexual function was reported as
similarly improved among the various sacrocolpopexy
approaches,33,37 sacrocolpopexy with total versus subtotal
hysterectomy,62 and sacrocolpopexy with and without uter-
ine conservation.57
Vaginal Procedures
In 1 randomized controlled trial (RCT) of sacrospinous
hysteropexy versus vaginal hysterectomy and uterosacral
ligament suspension, buttock pain incidence was 8.7% ver-
sus 0%, respectively (n = 208), with 1 patient (1%) needing
reoperation after sacrospinous hysteropexy.48 Another
RCT found a higher risk of intervention for neurologic
pain (12.4% vs. 6.9%; P = 0.049) and a higher rate of per-
sistent neurologic pain at 4−6 weeks postoperatively (4.3%
vs. 0.5%) after hysterectomy with vaginal sacrospinous fix-
ation versus uterosacral ligament suspension.46 Generally,
sexual function was reported as similarly improved follow-
ing various vaginal apical suspension procedures.48,63
Hysterectomy and Suspension Versus Hysteropexy
Procedures
Risk of pelvic pain was reported in 2.1% (4 of 187) cases
after hysterectomy and suspension versus 5.7% (13 of 229)
cases after hysteropexy.48,55,57 One patient had to undergo
reoperation for pain after sacrospinous hysteropexy.48
Three studies reported both pre- and postoperative sexual-
function scores and found similar improvements in scores
in both groups.48,57,64
SUMMARY STATEMENTS 15 and 16
RECOMMENDATION 6
520  APRIL JOGC AVRIL 2021
In addition to the main procedures compared in this docu-
ment, other procedures were included in the systematic
review and meta-analysis, where relevant results may be
found.65
STRENGTHS AND LIMITATIONS
Our systematic review included comparative studies of sur-
gical procedures to manage apical POP. Following a rigor-
ous methodology, experts in urogynaecology reviewed the
available literature. They used a 15-year timeline that coin-
cides with the widespread adoption of standard POP stag-
ing and the use of patient-reported quality-of-life
outcomes in this area of research. However, our review
was limited to searching outcomes predetermined by the
SOGC’s Urogynaecology Committee. Other outcomes
could have been considered, such as patient regret with
procedure choice or gastrointestinal complications. These
infrequent but possible complications were not addressed
in this review owing to prioritization of outcomes assessed.
A systematic review that included non-comparative studies
found an increased risk of ileus or small bowel obstruction
after sacrocolpopexy compared with native tissue vaginal
apical suspensions (2.7% vs. 0.2%; P < 0.01; N = 1294)
but overall found no strong evidence of a difference
between the 2 approaches in the rate of adverse events or
reoperation.66 In our review, there were minimal or no
data reported for 2 of the included outcomes, pelvic pain
and sexual function. No clear conclusions could be drawn
regarding de novo chronic pelvic pain, given the paucity of
data on persistent pain (beyond 6 weeks postoperatively).
We were unable to make recommendations based on spe-
cific patient factors because of limitations in the current lit-
erature and the methodology used to develop this
guideline. In clinical practice, surgeons must interpret these
data in the context of each patient’s specific risk factors for
recurrence and complications, as well as the patient’s surgi-
cal goals.
There was immense variation in types of surgical proce-
dures and significant bias in patient selection for these pro-
cedures, which was driven by surgeon experience or
preference, availability of resources or surgical materials,
and patient choice. As with all surgical studies, some of the
detected differences in outcomes may represent differences
in surgical skill or technique rather than differences in the
procedures themselves. Minimally invasive techniques are
typically associated with a faster recovery or different types
of complications. Therefore, our finding of different suc-
cess rates for open versus minimally invasive sacrocolpo-
pexy was unexpected, because the procedure itself should
be the same, regardless of approach. This finding may
 Guideline No. 413: Surgical Management of Apical Pelvic Organ Prolapse in Women
reflect differences in surgical skill or patient selection.
Some procedures, such as sacrocolpopexy, were more
prominently represented in the literature, whereas others,
such as obliterative procedures, were minimally examined
in comparative research. Within individual procedures,
there was great variation in suture types, suturing instru-
ments, and suture attachment location. Uterosacral liga-
ment suspensions had the widest variation in surgical
technique. Few RCTs were found, and grading of out-
comes was generally low to moderate, owing to small num-
bers of patients, the possibility of bias, short- to medium-
term duration of follow-up, and differences in the out-
comes described.
CONCLUSION
Surgeons counselling women on operative options for
POP should be aware that there are similar subjective out-
comes in the short and medium term for a variety of surgi-
cal options, but there are some differences in objective
failure for different procedures. Sacrocolpopexy, by any
approach, shows lower rates of objective overall failure
than vaginal suspension. There is limited literature regard-
ing long-term outcomes, postoperative urinary function,
pelvic pain, and sexual function. The success rates of pelvic
reconstructive surgical procedures are variable, and com-
parative evidence for these procedures is low to moderate.
Consequently, conservative strategies should be considered
over surgical interventions for first-line treatment. Further
well-designed studies comparing surgical procedures would
be of benefit.
GUIDELINE TOOLKIT
SOGC members can visit the Guideline Resource Kit web-
page on sogc.org to find complementary tools and resour-
ces and to participate in accredited continuing professional
development activities.
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SOGC CLINICAL PRACTICE GUIDELINE

APPENDIX A

Tables A1 and A2

Table A1. Key to Grading of Recommendations, Assessment, Development and Evaluation Quality of Evidence
Grade Definition
Strength of recommendation
Strong High level of confidence that the desirable effects outweigh the undesirable effects (strong recommendation for) or
the undesirable effects outweigh the desirable effects (strong recommendation against)
Conditional a Desirable effects probably outweigh the undesirable effects (weak recommendation for) or the undesirable effects
probably outweigh the desirable effects (weak recommendation against)
Quality of evidence
High High level of confidence that the true effect lies close to that of the estimate of the effect
Moderate Moderate confidence in the effect estimate:
The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially
different
Low Limited confidence in the effect estimate:
The true effect may be substantially different from the estimate of the effect
Very low Very little confidence in the effect estimate:
The true effect is likely to be substantially different from the estimate of effect
a
Do not interpret conditional recommendations to mean weak evidence or uncertainty of the recommendation.Adapted from GRADE Handbook (2013), Table 5.1.

Table A2. Implications of Strong and Conditional recommendations, by guideline user

Strong Recommendation Conditional (Weak) Recommendation
 “We recommend that. . .”  “We suggest. . .”
Perspective  “We recommend to not. . .”  “We suggest to not. . .”

Authors The net desirable effects of a course of action outweigh
the effects of the alternative course of action.
Patients Most individuals in the situation would want the recom-
mended course of action, while only a small propor-
tion would not.
Clinicians Most individuals should receive the course of action.
Adherence to this recommendation according to the
guideline could be used as a quality criterion or per-
formance indicator.
Policymakers The recommendation can be adapted as policy in most
settings.
Adapted from GRADE Handbook (2013), Table 6.1.
It is less clear whether the net desirable consequences
of a strategy outweigh the alternative strategy.
The majority of individuals in the situation would want
the suggested course of action, but many would not.
Recognize that patient choices will vary by individual
and that clinicians must help patients arrive at a care
decision consistent with the patient’s values and
preferences.
The recommendation can serve as a starting point for
debate with the involvement of many stakeholders.

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