Original Article

Sexual Function after Minimally Invasive Total Hysterectomy and

Sacrocolpopexy
Elizabeth J. Geller, MD, C. Emi Bretschneider, MD, Jennifer M. Wu, MD, MPH,
Kim Kenton, MD, and Catherine A. Matthews, MD
From the Department of Obstetrics and Gynecology, Division of Female Pelvic Medicine and Reconstructive Surgery, University of North Carolina at
Chapel Hill, Chapel Hill (Drs. Geller and Wu), Department of Obstetrics and Gynecology, Division of Female Pelvic Medicine and Reconstructive Surgery,
Northwestern University, Evanston, Illinois (Drs. Bretschneider and Kenton), Department of Obstetrics and Gynecology, Division of Female Pelvic Medicine
and Reconstructive Surgery, Wake Forest Baptist Hospital, Winston-Salem (Dr. Matthews), North Carolina, and Department of Urology, Wake Forest
Baptist Hospital, Winston-Salem (Dr. Matthews), North Carolina

ABSTRACT Study Objective: To evaluate sexual function in women undergoing minimally invasive total hysterectomy and sacrocolpo-
pexy (TLH + SCP) with a lightweight polypropylene Y-mesh 1 year after surgery.
Design: This was a planned secondary analysis of a 5-site randomized trial comparing permanent (2-0 Gore-Tex; W. L.
Gore & Associates, Inc., Newark, DE) vs absorbable suture (2-0 polydioxanone suture) for vaginal attachment of a Y-mesh
(Upsylon; Boston Scientific Corporation, Natick, MA) graft during TLH + SCP.
Setting: Multicenter trial at 5 study sites (4 academic and 1 community). The study sites were: (1) University of North Caro-
lina at Chapel Hill, Chapel Hill, NC; (2) Wake Forest Baptist Hospital, Winston-Salem, NC; (3) Northwestern University,
Evanston, IL; (4) Georgia Regents University, Augusta, GA; and (5) Atlantic Health Medical Group, Morristown, NJ.
Patients: Women previously enrolled in an original study undergoing TLH + SCP.
Interventions: Quality-of-life questionnaires and physical examination.
Measurements and Main Results: The primary objective was to assess changes in sexual function at 1 year after surgery
as measured by the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire, International Urogynecological
Association−Revised. The secondary objective was to assess the factors associated with postoperative sexual activity and
dyspareunia. Of the 200 participants enrolled, 182 (92.8%) completed follow-up: n = 95/99 Gore-Tex and n = 87/101 poly-
dioxanone suture. The mean age was 60 § 10 years; body mass index was 27 § 5 kg/m2; 78% were menopausal and 56%
sexually active before surgery. At 1 year after surgery, 63% were sexually active: 93% of the sexually active women preop-
eratively remained so at 1 year, and 24% reported new sexual activity at 1 year (p <.001). Sexual function at 1 year showed
marked improvement in activity, quality, and arousal/orgasm compared with baseline Pelvic Organ Prolapse/Urinary Incon-
tinence Sexual Questionnaire scores. Dyspareunia rates decreased from 22% preoperatively to 16.5% at 1 year (p = .65).
Women who were sexually active at 1 year were younger (56.8 § 9.6 years vs 65.4 § 9.2 years, p <.001), more likely to be
premenopausal (31.6% vs 7.4%, p = .001), and less likely to undergo bilateral salpingo-oophorectomy (53.3% vs 78.9%,
p <.001).
Conclusion: Women undergoing TLH + SCP with a lightweight mesh graft report increased rates of sexual activity,
improved sexual quality and arousal/orgasm, and lower rates of dyspareunia at 1 year after surgery. Journal of Minimally
Invasive Gynecology (2021) 00, 1−7. © 2021 AAGL. All rights reserved.
Keywords: Prolapse; Dyspareunia; Mesh

Catherine A. Matthews and Kim Kenton are consultants for Boston Scien-
tific Corporation and expert witnesses for defense for Johnson & Johnson.
This work was supported by an unrestricted research grant from Boston
Scientific Corporation. The other authors declare that they have no conflict
of interest.
This work was presented at the American Urogynecology Society Annual
Scientific Meeting, October XX, 2020.
Corresponding author: Elizabeth J. Geller, MD, Department of Obstetrics
and Gynecology, University of California, CB 7570, Old Clinic, Chapel
Hill, NC 27599-7570.
E-mail: egeller@med.unc.edu
Submitted November 18, 2020, Revised January 15, 2021, Accepted for pub-
lication January 23, 2021.
Available at www.sciencedirect.com and www.jmig.org

1553-4650/$ — see front matter © 2021 AAGL. All rights reserved.

https://doi.org/10.1016/j.jmig.2021.01.021
2 Journal of Minimally Invasive Gynecology. Vol 00, No 00, 00 2021
Sexual function is an important component of quality of
life and can be affected by pelvic organ prolapse (POP) and
the resultant surgical interventions [1]. In a study evaluating
patient perceptions of adverse outcomes after surgery,
women rated a lack of improvement in sexual function after
surgery as akin to chronic pain or an intensive care unit
admission [2]. Because the estimated lifetime risk of under-
going surgery for prolapse or incontinence is 11% to 19%
[3] and because the rate of pelvic floor disorders continues
to rise, the need for durable surgical repairs without an
adverse impact on sexual function has become critical.
Abdominal sacrocolpopexy (SCP) is considered to be the
most durable operation for advanced POP [4−6] and is
offered as a primary surgical option for uterovaginal pro-
lapse to improve longer-term surgical outcomes [7].
Although SCP has been associated with lower rates of dys-
pareunia than native tissue vaginal repair of vaginal vault
prolapse [8], sexual outcomes after SCP with concomitant
total hysterectomy (TLH) are unknown. Higher rates of
mesh exposure related to performance of colpotomy may
influence the incidence of dyspareunia and sexual dysfunc-
tion [9]. United States Food and Drug Administration
actions relating to mesh prolapse repairs have heightened
awareness and concerns over prolapse repair and risks of
adverse outcomes such as dyspareunia [10].
A systematic review by the Society of Gynecologic Sur-
geons of mesh-specific complications for transvaginal mesh
criticized the lack of validated measures in most studies,
which typically only reported pain, to assess global sexual
function [11]. Although mesh complication rates are lower
with transabdominal pelvic mesh compared with transvagi-
nal mesh, the same standards for comprehensive reporting
of patient-centered outcomes such as sexual function are
needed.
It is not fully understood what impact minimally inva-
sive TLH + SCP may have on sexual function. This infor-
mation is necessary for preoperative surgical counseling.
Therefore, our primary objective of this secondary analysis
was to assess changes in sexual function from baseline to 1
year after minimally invasive SCP. Our secondary objective
was to assess the clinical factors associated with sexual
function at 1 year after surgery, including sexual activity,
sexual quality, and dyspareunia.
Materials and Methods
This was a planned secondary analysis of a 5-site random-
ized trial comparing permanent (2-0 Gore-Tex; W. L. Gore
& Associates, Inc., Newark, DE) vs absorbable suture (2-0
polydioxanone suture [PDS]) for vaginal attachment of a Y-
mesh (Upsylon; Boston Scientific Corporation, Natick, MA)
graft during TLH + SCP. The original study took place
between April 2015 and May 2019, and the methodology of
the primary study was previously published [12]. Institutional
review board approval was obtained at each clinical site.
Randomization to permanent 2-0 Gore-Tex vs delayed-
absorbable 2-0 PDS suture took place in the operating room
before mesh graft attachment. The participants and research
staff were blinded to the treatment assignment, and blinding
was maintained through the 1-year follow-up visit.
Baseline demographic information was collected,
including past medical and surgical history and medica-
tions, and a physical examination, including pelvic exami-
nation and POP quantification (POP-Q) examination, was
performed. The participants completed the Pelvic Organ
Prolapse/Incontinence Sexual Questionnaire, International
Urogynecological Association−Revised (PISQ-IR) [13].
The PISQ-IR is a validated tool that was developed by an
International Urogynecological Association panel of
experts to enhance the original PISQ, specifically the ability
to also assess sexual function outcomes in women who are
not sexually active with a partner. Sexual activity was based
on the response to question 1 on the PISQ-IR, which asks
whether the respondent is sexually active or not. Dyspareu-
nia was directly assessed with question 11 on the PISQ-IR,
which asks, “How often do you feel pain during sexual
intercourse?” A response of “Sometimes” or higher
(“Usually,” “Always”) was considered positive.
All participants underwent TLH with or without bilat-
eral salpingo-oophorectomy (BSO) (at the discretion of
the patient and surgeon) before laparoscopic SCP, with
or without robotic assistance. All hysterectomies were
performed for the indication of prolapse. Surgeon prefer-
ence determined the method of vaginal cuff closure and
included interrupted vs continuous sutures using barbed,
monofilament, or braided absorbable suture material.
Upsylon mesh was used for SCP. Upsylon is a pre-
formed type I polypropylene Y-mesh that is lightweight
(25 g/m2), with a pore size of 2.8 mm2 and surface area
ratio of 1.11. Optional additional procedures included
any full-length midurethral sling for treatment or pre-
vention of stress incontinence that was placed through a
separate vaginal incision, retropubic urethropexy, and
distal posterior colporrhaphy per surgeon discretion. All
intraoperative study variables, including intraoperative
complications, were recorded in real time. Postoperative
complications were categorized using the Clavien-Dindo
surgical complication grading scale [14].
Sexual function as well as symptomatic and anatomic
improvement of POP were evaluated at 6 weeks and 1 year
after surgery with the PISQ-IR, pelvic examination, and
POP-Q. A blinded examiner completed the pelvic examina-
tion and POP-Q. Any SCP mesh that was visible in the
vagina was reported as a mesh exposure. Permanent suture
material that was visible in the vagina beyond 12 weeks
was reported as a suture exposure.
Means and standard deviations or counts and percen-
tages were computed for univariate analyses using continu-
ous and categorical data, respectively. The t test, chi-square
test, or Fisher exact test were used for bivariate analyses. A
p-value ≤.05 was considered statistically significant. All
analyses were performed using version 27 IBM SPSS
Geller et al. Sexual Function after Minimally Invasive TLH and SCP 3

(Armonk, NY). The primary objective was to assess
changes in sexual function at 1 year after surgery. The sec-
ondary objective was to assess the factors associated with
the quality of sexual activity and changes in dyspareunia at
1 year after surgery.
Results
Of the 200 participants enrolled in the original study,
182 (92.8%) completed 1 year follow-up (n = 95/99 Gore-
Tex, n = 87/101 PDS). There were no baseline differences
between the 2 groups (Table 1). The mean age was 60 §
10 years, and most were Caucasian, overweight, postmeno-
pausal, nonsmokers, privately insured, with low morbidity,
and not likely to have had prior prolapse or incontinence
surgery. Median preoperative POP-Q showed stage III ante-
rior prolapse (Ba 2, IQR 0.9−4), stage II posterior prolapse
(Bp −1, IQR −2 to 0.1), and stage II apical prolapse (C 0,
IQR −3 to 3). There were also no differences in surgical
characteristics and concomitant procedures between the
groups. Overall, 75.5% of the cases were performed with
robotic assistance, with no differences in concomitant pro-
cedures, surgical times, learner involvement, estimated
blood loss, length of stay, postoperative retention, or com-
plications between the Gore-Tex and PDS groups.
Our primary outcome was change in sexual function at 1
year after surgery. We found that, at baseline, 56% of the
women were sexually active, with no differences between
the Gore-Tex and PDS groups. At 1 year after surgery, the
rate of sexually active women increased to 63%, with no
difference between the suture groups (p = .09). Of the
women who were sexually active at baseline, 93%
remained sexually active at 1 year. Of those who were not
sexually active at baseline, 24% were sexually active at 1
year (p <.001). The incidence of de novo dyspareunia was
8.2%.

Table 1
Baseline demographics

Characteristics Permanent suture, N = 99 Delayed-absorbable suture, N = 101 p-value

Age, yrs, mean § SD 59.7 § 10.7 59.0 § 10.2 .60
Hispanic ethnicity 14 (14.1) 11 (10.9) .49
Race
White 91 (91.9) 90 (89.1) .59
African American 7 (7.1) 8 (7.9)
Other 1 (1.0) 3 (3.0)
BMI, kg/m2, mean § SD 27.5 § 5.0 27.5 § 4.7 .91
Parity, median (IQR) 2 (2−3) 2 (2−3) .59
POP-Q stage
Stage 0 or I 0 0 .27
Stage II 27 (27.3) 28 (27.7)
Stage III 57 (57.6) 65 (64.4)
Stage IV 15 (15.2) 8 (7.9)
Baseline sexually active 55 (55.6) 55 (54.5) .78
Baseline dyspareunia 24 (24.2) 21 (20.8) .62
Charlson comorbidity index, median (range) 0 (0−6) 0 (0−3) .79
Menopausal status
Pre- or perimenopausal 24 (24.2) 24 (23.8) .64
Postmenopausal, no hormones 60 (60.6) 57 (56.4)
Postmenopausal, vaginal estrogen 12 (12.1) 13 (12.9)
Postmenopausal, oral hormones 3 (3.0) 7 (6.9)
Smoking status
Never 64 (64.6) 73 (72.3) .39
Prior smoker 33 (33.3) 25 (24.8)
Current smoker 2 (2.0) 3 (3.0)
Prior vaginal prolapse surgery with mesh 1 (1.0) 1 (1.0) 1.0*
Prior vaginal surgery without mesh 2 (2.1) 4 (4.0) .68*
Prior abdominal POP surgery with mesh 0 0
Prior abdominal POP surgery without mesh 1 (1.0) 0 .50*
Prior Burch urethropexy 0 1 (1.0) 1.0
Prior sling 2 (2.0) 2 (2.0) 1.0
Prior bulking agent 0 0 1.0*

BMI = body mass index; IQR = interquartile range; POP-Q = pelvic organ prolapse quantification; SD = standard deviation.
Data are presented as n § SD or number (%).
* Fisher exact test (otherwise t test or chi-square test).
4 Journal of Minimally Invasive Gynecology. Vol 00, No 00, 00 2021

Table 2
Characteristics associated with sexual activity 1 year after surgery

Characteristics Sexually active at 1 yr Not sexually active at 1 yr p-value

after surgery, N = 114 after surgery, N = 68
Age, yrs, mean § SD 56.8 § 9.6 65.4 § 9.2 <.001
Race
White 105 (92.1) 59 (86.8) .42*
African American 7 (6.1) 8 (11.8)
Other 2 (1.8) 1 (1.5)
Smoking status
Never 82 (71.9) 47 (69.1) .56*
Prior smoker 30 (26.3) 21 (30.9)
Current smoker 2 (1.8) 0 (0)
Baseline menopausal status
Pre- or perimenopausal 36 (31.6) 5 (7.4) .001
Postmenopausal 78 (68.4) 63 (92.6)
No hormones 58 (50.9) 53 (77.9)
Vaginal estrogen 14 (12.3) 8 (11.8)
Oral hormones 6 (5.3) 2 (2.9)
Baseline sexually active 94 (83.2) 7 (10.4) <.001
Baseline dyspareunia 39 (34.2) 1 (1.5) .15*
Baseline generalized pain 16 (14.0) 13 (19.1) .41
Route of surgery
Robotic 83 (72.8) 54 (79.4) .38
Laparoscopic 31 (27.2) 14 (20.6)
Concomitant BSO 58 (50.9) 53 (77.9) <.001
SCP suture type
Gore-Tex 53 (46.5) 41 (60.3) .09
PDS 61 (53.5) 27 (39.7)
Cuff suture type
Barbed 76 (66.7) 57 (83.8) .05*
Vicryl 10 (8.8) 4 (5.9)
PDS 23 (20.2) 7 (10.3)
Other 5 (4.4) 0 (0)
Cuff suture technique
Interrupted 51 (44.7) 13 (19.1) .001
Continuous 63 (55.3) 55 (80.9)
POP-Q stage at 1 year
0 30 (26.5) 24 (35.3)
I 56 (49.6) 34 (37.8)
II 24 (21.2) 9 (27.3)
III 3 (2.7) 1 (1.5) .43*
IV 0 (0) 0 (0)
Any mesh or suture exposure at 1 year 8 (7.0) 4 5.(9.0) .51*

BSO = bilateral salpingo-oophorectomy; PDS = polydioxanone suture; POP-Q = pelvic organ prolapse quantification; SCP = sacrocolpopexy; SD = standard deviation.
Data are presented as n § SD or number (%).
* Fisher exact test (otherwise t test or chi-square test).

Our secondary outcomes included the factors associated
with sexual function and dyspareunia at 1 year after surgery
(Table 2). We found that the women who were sexually
active 1 year after surgery were younger (56.8 § 9.6 years
vs 65.4 § 9.2 years, p <.001), more likely to be premeno-
pausal (31.6% vs 7.4%, p = .001), more likely to be sexually
active before surgery, and less likely to undergo BSO
(53.3% vs 78.9%, p <.001). There were no differences in
race, smoking status, baseline dyspareunia, or baseline gen-
eralized pain between the women who were sexually active
and those who were not at 1 year after surgery. There was a
difference seen in vaginal cuff suture type and technique.
The women who were sexually active at 1 year after surgery
were more likely to have a barbed, continuous suture for
cuff closure. Sexual activity at 1 year postoperatively was
not associated with robotic route, concomitant anterior or
posterior repair, perineorrhaphy, or mesh sling. Mesh or
suture exposure was also not associated with sexual activity
or dyspareunia. In addition, there was no difference in 1
year POP-Q stage between women who were sexually
Geller et al. Sexual Function after Minimally Invasive TLH and SCP
Table 3
Sexual function on the basis of PISQ-IR scores before and 1 year after surgery
PISQ domain scores Sexually active at baseline
Condition-specific impact on sexual activity 66.3 § 28.4
Condition-specific impact on sexual quality 88.4 § 15.2
Global rating of sexual quality 61.7 § 28.1
Sexual desire 52.3 § 18.5
Sexual arousal/orgasm 60.6 § 15.8
Sexual partner−related impact 85.6 § 17.8
PISQ-IR = Pelvic Organ Prolapse/Incontinence Sexual Questionnaire, International Urogynecological Association−Revised.
Analysis only includes women who were sexually active at baseline and 1-year follow-up.
Data are presented as n § standard deviation.
All analyses performed with paired t test.
active and those who were not, with most of the women at
stage 0 or I in both groups. There was no difference in base-
line or 1-year total vaginal length between those who were
sexually active and those who were not at 1 year.
We also assessed sexual function and quality of sexual
activity using responses to the PISQ-IR. Among the women
who were sexually active, sexual function showed a marked
improvement in both sexual activity and sexual quality at 1
year after surgery compared with baseline (Table 3). The
areas of improvement in sexual function included the
impact of prolapse on sexual activity, the impact of pro-
lapse on sexual quality, the global rating of sexual quality,
and sexual arousal/orgasm. There were no differences seen
in sexual desire or partner-related impact (PR) compared
with baseline. For non−sexually active women, there were
also improvements in sexual function on the basis of the
PISQ-IR scores at 1 year after surgery compared with base-
line, including the impact of prolapse on sexual activity,
impact of prolapse on sexual quality, global rating of sexual
quality, and PR scores (all p <.05).
Among the women who were sexually active at 1 year after
surgery, the rates of dyspareunia decreased from 22% preoper-
atively to 15% at 1 year (p = .65), with no difference between
the Gore-Tex and PDS groups (Table 4). In bivariate analyses,
dyspareunia at 1 year was associated with laparoscopic route
compared with robotic route; interrupted vaginal cuff closure
technique compared with continuous; and vaginal cuff suture
closure material: “other” suture types had increased risk com-
pared with barbed suture, polyglactin, and polydioxanone.
However, in a regression model, route of surgery and cuff
suture type and technique did not remain significantly associ-
ated with dyspareunia. Dyspareunia at 1 year was not associ-
ated with race, smoking status, menopausal status, pre- or
postoperative POP-Q or total vaginal length, preoperative sex-
ual activity, preoperative dyspareunia, preoperative generalized
pain, concomitant procedures for POP or urinary incontinence,
or mesh/permanent suture exposure. In terms of sexual func-
tion, dyspareunia at 1 year was inversely associated with sexual
arousal/orgasm on the PISQ-IR (p <.001), indicating less sex-
ual arousal/orgasm in women who reported dyspareunia.
5
Sexually active at 1 year after surgery p-value
92.5 § 16.8 <.001
95.5 § 9.8 <.001
75.5 § 27.3 <.001
53.0 § 17.2 .68
65.1 § 16.1 .02
86.6 § 14.7 .56
Discussion
Women undergoing minimally invasive TLH + SCP with a
lightweight Y-mesh material reported significant improvement
in sexual function at 1 year after surgery, with increased rates
of sexual activity, improved sexual quality and arousal/orgasm,
and lower rates of dyspareunia compared with before surgery.
Despite mesh exposure reported in 6% of the overall cohort
[12], there was no association between mesh exposure and any
sexual function parameter.
Certain characteristics, including younger age, pre-
menopausal status, and baseline sexual activity, were
associated with being sexually active at 1 year after mini-
mally invasive TLH + SCP. We may be reassured by the
fact that neither baseline generalized pain nor concomi-
tant mesh sling were associated with dyspareunia at 1
year after surgery because these are reported risk factors
for transvaginally placed mesh [15]. In addition, there
was no difference in sexual desire or PR, which is helpful
because it shows that women continue to have sexual
desire even if they are not sexually active and that PR is
not affected by this surgery.
Surgical correction of POP seems to have a positive
impact on sexual activity and dyspareunia, regardless of
surgical technique. The Pelvic Floor Disorders Network
recently published a secondary analysis of 4 trials of dif-
ferent methods of POP repair to assess sexual activity
and dyspareunia, 1 of which was the Colpopexy and Uri-
nary Reduction Efforts trial that included women under-
going abdominal SCP [1]. Overall, dyspareunia resolved
in 3 out of 4 women, with no difference between women
who had native tissue vs mesh-augmented repairs. Simi-
larly, Rogers et al [16] assessed sexual function after
surgery for stress urinary incontinence and/or POP using
a variety of surgical interventions as a secondary analy-
sis. At 3 to 6 months after surgery, they report findings
similar to ours, specifically improved sexual function on
the basis of the PISQ scores. However, the study popula-
tion was a heterogenous surgical group, including hyster-
ectomy, various types of prolapse repair, incontinence
6 Journal of Minimally Invasive Gynecology. Vol 00, No 00, 00 2021

Table 4
Characteristics associated with dyspareunia 1 year after surgery

Characteristics Dyspareunia at 1 year No dyspareunia at 1 year p-value

after surgery, N = 30 after surgery, n = 80
Age, yrs, mean § SD 58.0 § 8.4 56.1 § 10.1 .37
Race
White 27 (90.0) 74 (92.5) .43*
African American 3 (10.0) 4 (5.0)
Other 0 (0) 2 (2.5)
Smoking status
Never 21 (70.0) 60 (75.0) .64*
Prior smoker 9 (30.0) 18 (22.5)
Current smoker 0 (0) 2 (2.5)
Menopausal status
Pre- or perimenopausal 6 (20.0) 30 (37.5) .26*
Postmenopausal 24 (80.0) 50 (62.5)
No hormones 19 (63.3) 36 (45.0)
Vaginal estrogen 4 (13.3) 9 (11.3)
Oral hormones 1 (3.3) 5 (6.3)
Baseline sexually active 28 (93.3) 65 (82.3) .23*
Baseline dyspareunia 13 (46.4) 26 (40.0) .65*
Baseline generalized pain 4 (13.3) 11 (13.9) .99*
Generalized pain at 1 year 5 (16.7) 6 (7.5) .17*
Route of surgery
Robotic 17 (56.7) 64 (81.0) .01
Laparoscopic 13 (43.3) 15 (19.0)
Concomitant BSO 16 (53.3) 40 (50.0) .83
SCP suture type
Gore-Tex 19 (63.3) 34 (42.5) .06
PDS 11 (37.7) 46 (57.5)
Cuff suture type
Barbed 17 (56.7) 57 (71.3) .03*
Vicryl 1 (3.3) 9 (11.3)
PDS 9 (30.0) 13 (16.3)
Other 3 (10.0) 1 (1.3)
Cuff suture technique
Interrupted 18 (60.0) 30 (37.5) .05
Continuous 12 (40.0) 50 (62.5)
POP-Q stage at 1 year
0 9 (30.0) .07*
I 17 (56.7) 21 (26.9)
II 2 (6.7) 36 (46.2)
III 2 (6.7) 20 (25.6)
IV 0 (0) 1 (1.3)
Any mesh or suture exposure at 1 year 1 (3.3) 5 (6.4) .99*

BSO = bilateral salpingo-oophorectomy; PDS = polydioxanone suture; POP-Q = pelvic organ prolapse quantification; SCP = sacrocolpopexy; SD = standard deviation.
Analysis only includes sexually active women because dyspareunia only applies to this group.
Data are presented as n § SD or number (%).
* Fisher exact test (otherwise t test or chi-square test).

repair and/or BSO. Handa et al [17] reported sexual
function 1 year after abdominal SCP and Burch urethro-
pexy as a secondary analysis of the Colpopexy and Uri-
nary Reduction Efforts trial. Using the PISQ
questionnaire, they found results similar to ours; specifi-
cally an increase in sexual activity and a decrease in
dyspareunia. There was no difference in dyspareunia on
the basis of concomitant Burch colposuspension, which
is similar to our finding for vaginal mesh sling.
Similarly, they found no difference in sexual desire after
surgery.
Two smaller, noncomparative trials of abdominal and
robot-assisted SCP have provided information about specific
components of sexual function. Kuhn et al [18] reported an
improvement in sexual desire, arousal, lubrication, satisfac-
tion, and pain at 2 years after surgery compared with baseline.
They found no difference in orgasm. Similarly, Geller et al
[19] noted an improvement 3 months after robotic SCP on the
Geller et al. Sexual Function after Minimally Invasive TLH and SCP
basis of the PISQ-12 total score. Finally, a retrospective
cohort study of 51 women (23 robotic SCP vs 28 abdominal
SCP) also found results similar to ours, with both groups dem-
onstrating good sexual function at 44 months after surgery on
the basis of the total PISQ-12 scores, with no difference
between the groups [20].
The limitations of the study include the fact that it is a
secondary analysis and therefore not powered for the mea-
sured outcomes. However, our study comprises a large,
homogeneous cohort of women undergoing the same inter-
vention with a lightweight mesh material, and there were
several statistically significant relationships found for both
sexual activity and dyspareunia. Another limitation is the
lack of standardization of vaginal cuff closure technique
and suture type, which could impact sexual function. How-
ever, this heterogeneity improves generalizability and
allowed us to evaluate differences in the rates of sexual
activity and dyspareunia for these factors. Lack of racial
diversity is another limitation. In addition, we do not have
information on the reasons for avoiding sexual activity
before surgery, which may include body image perception,
fear of harm from the prolapse, history of pain with inter-
course, and other reasons. Another relative limitation is the
follow-up period of 1 year. The aim is to continue to follow
the participants and report on future results.
The strengths of the study include the use of direct and
objective measurements of sexual activity, sexual quality, and
dyspareunia on the basis of direct participant report on vali-
dated quality-of-life questionnaires. Many studies in the past
have used the presence of sexual activity as a proxy for good
sexual function and lack of dyspareunia, which can be very
misleading. Other strengths of the study include the large size
of our study population, which allows for measurement of
more rare outcomes such as dyspareunia; prospective design;
and the use of validated, standardized quality-of-life question-
naires that measure real-time sexual activity, sexual function,
and dyspareunia, and thus reduce recall bias. In addition, 1-
year data provide moderate-term follow-up data.
Although our findings of improved sexual function and
decreased dyspareunia at 1 year are reassuring, longer-term
follow-up is needed to better understand these outcomes.
We plan to continue to follow the study participants over
the next several years and report on longer-term outcomes
of pelvic floor and sexual function.
In conclusion, women undergoing minimally invasive
TLH + SCP with a lightweight Y-mesh graft report
increased sexual activity, improved sexual quality, and less
dyspareunia at 1 year after surgery. There were also several
predictive clinical factors associated with both sexual activ-
ity and dyspareunia at 1 year after surgery. These findings
may help providers in counseling women regarding proce-
dure choice for the repair of POP and concomitant proce-
dures, specifically with regard to expectations for sexual
function after surgery.
7
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