Comparing Long-Term Efficacy and Safety of Native Tissue Hysteropexy Versus Hysterectomy for Apical Pelvic Organ Prolapse

Highlight

• Native tissue hysteropexy preserves the uterus but is associated with a higher long-term risk of prolapse retreatment than hysterectomy.
• Hysteropexy demonstrates a modestly lower incidence of short-term postoperative complications such as urinary retention and urinary tract infections.
• The study provides robust long-term follow-up data with a median of over 8 years for treatment outcomes, aiding clinical decision-making in pelvic organ prolapse management.

Study Background

Pelvic organ prolapse (POP) is a common condition affecting women, characterized by the descent of pelvic organs due to weakening of supportive tissues. Apical prolapse, involving uterine or vaginal vault descent, significantly impacts quality of life by causing symptoms such as pelvic pressure, urinary dysfunction, and impaired sexual function. Surgical intervention is often required when conservative measures fail.

Traditional surgical treatment includes hysterectomy combined with apical suspension procedures like uterosacral ligament suspension or sacrospinous ligament fixation. However, uterine-preserving procedures, such as native tissue hysteropexy, have gained traction for women desiring to retain their uterus due to personal, cultural, or reproductive considerations. Despite increasing use, there is limited long-term comparative data on the efficacy and safety of hysteropexy versus hysterectomy with apical suspension.

Study Design

This retrospective cohort study encompassed women undergoing native tissue apical prolapse repair between November 1, 2005, and November 1, 2025, across U.S. healthcare organizations participating in the TriNetX research network. Patients were categorized into two groups based on surgical approach: uterine-preserving hysteropexy and hysterectomy, both combined with apical suspension (uterus supported by uterosacral ligament suspension or sacrospinous ligament fixation).

Propensity score matching balanced key demographic, clinical, and procedural variables to reduce confounding bias. Short-term postoperative complications were assessed within 30 days postoperatively. Long-term outcomes were analyzed in patients operated before November 1, 2015, with a median follow-up exceeding 8 years.

The primary endpoint was prolapse retreatment, defined as reoperation or pessary use initiated 30 days or more after the index surgery. Cox proportional hazards models evaluated time-to-event data, providing hazard ratios (HRs) and 95% confidence intervals (CIs) to quantify comparative risks between groups.

Key Findings

Long-term Outcomes

The final analysis included 2,499 women in the hysterectomy group and 876 in the hysteropexy group, with median follow-ups of 9.1 years and 8.7 years, respectively. Among women undergoing hysteropexy, a 2.9% rate of subsequent hysterectomy was observed during long-term follow-up, reflecting the potential need for later hysterectomy intervention.

Results demonstrated a statistically significant higher risk of prolapse reoperation in the hysteropexy group compared with hysterectomy (11.1% vs. 6.5%; HR 1.77, 95% CI 1.27–2.45). Similarly, the overall prolapse retreatment rate—comprising both reoperation and pessary use—was elevated in the hysteropexy cohort (15.0% vs. 9.6%; HR 1.63, 95% CI 1.24–2.14). This indicates that preserving the uterus leads to a modestly greater risk of recurrent or persistent prolapse requiring additional management.

Short-term Outcomes

In contrast, hysteropexy patients experienced fewer short-term postoperative complications. Specifically, urinary retention occurred in 8.5% of hysteropexy cases versus 10.9% in the hysterectomy group (HR 0.78, 95% CI 0.70–0.87). Urinary tract infections were also less frequent in the hysteropexy cohort (6.5% vs. 8.2%; HR 0.79, 95% CI 0.70–0.90). These findings suggest some early postoperative safety advantages with uterine preservation.

Clinical Implications and Safety Considerations

These data offer critical insights for clinicians counseling patients on surgical options for apical POP. Although hysteropexy spares the uterus, patient selection must consider the elevated probability of retreatment. Early benefits in recovery and complication reduction must be balanced against long-term durability.

Expert Commentary

While this large retrospective analysis leverages real-world clinical data with substantial follow-up, limitations include potential residual confounding despite propensity matching, and lack of patient-reported outcome measures such as symptom relief and quality of life metrics, which are vital in prolapse management. Furthermore, the study’s reliance on a U.S.-based healthcare database may limit generalizability to other populations.

Current guidelines emphasize individualized decision-making, factoring patient preferences, uterine pathology, and surgical expertise. The modest increase in retreatment risk following hysteropexy aligns with previous smaller studies displaying variable durability but better short-term safety profiles.

Conclusion

This comprehensive longitudinal study highlights that native tissue hysteropexy offers an effective uterine-sparing surgical option for apical pelvic organ prolapse, accompanied by fewer early postoperative complications. However, it carries a modestly increased long-term risk of prolapse retreatment compared with hysterectomy with apical suspension.

Clinicians should integrate these findings into shared decision-making discussions, balancing the benefits of uterine preservation against the likelihood of future interventions. Further prospective randomized studies incorporating patient-centered outcomes and quality of life assessments are needed to optimize surgical strategies for pelvic organ prolapse.

Funding and ClinicalTrials.gov

No funding or clinical trial registration information was reported in the original study.

References

1. Akavian I, Reuveni-Salzman A, Zilberman T, Nitzan I, Shveiky D, Chill HH. Long-Term Outcomes After Native Tissue Hysteropexy Compared With Hysterectomy for Treatment of Pelvic Organ Prolapse. Obstet Gynecol. 2026 Jul 9. PMID: 42424621.

2. Maher C, Feiner B, Baessler K, Glazener CM. Surgical management of pelvic organ prolapse in women. Cochrane Database Syst Rev. 2013 Apr 30;(4):CD004014.

3. Maher C, et al. Surgery for women with apical vaginal prolapse. Cochrane Database Syst Rev. 2016 Nov 7;11(11):CD012376.