Epidemiology and Overview

Estimates suggest that by 2050, approximately half of all women will experience some degree of pelvic organ prolapse, and roughly 13% will undergo surgical intervention during their lifetime.¹ This prevalent condition—defined as the descent of pelvic organs such as the bladder, uterus, cervix, or rectum into or beyond the vaginal canal—represents a substantial health care burden, with annual costs in the United States estimated at 1.52 billion dollars.²

Historically, hysterectomy was routinely performed as part of prolapse repair, irrespective of underlying uterine pathology. Contemporary practice, however, has shifted away from routine hysterectomy, reflecting evolving evidence and patient-centered priorities. Beyond recurrence rates and anatomic outcomes, determinants influencing surgical decision-making include patient preference, comorbidities, pelvic anatomy, fertility intentions, and surgeon expertise.

Evolving Trends Toward Uterine Preservation

The recent shift toward uterine preservation during prolapse surgery (UPPS), described in Table 1, has been driven by both patient advocacy and evolving societal perspectives on reproductive health. Many women ascribe symbolic and emotional significance to uterine retention, even in the absence of fertility desires.³ In addition, uterine-preserving procedures maintain the option for future childbearing, which is increasingly valued as part of individualized prolapse management.

Table 1. Uterine-Preserving Prolapse Surgeries

Cultural and historical factors also shape these preferences. Historically marginalized patient populations may express greater mistrust toward invasive medical interventions and particular apprehension regarding the sterilizing implications of hysterectomy. Furthermore, heightened public awareness of transvaginal mesh litigation and media coverage of related complications have amplified hesitancy toward pelvic reconstructive surgery in general. Consequently, many patients express preference for surgical approaches perceived as less invasive or morbid, contributing to a decline in concomitant hysterectomy at the time of primary pelvic organ prolapse repair.

A growing body of evidence further supports uterine preservation with concern related to potential systemic effects of hysterectomy, even when the ovaries are conserved. Hysterectomy has been associated with an earlier onset of menopause and increased risk of comorbidities linked to estrogen deficiency. In a prospective cohort study of 257 women undergoing hysterectomy without oophorectomy, 20.6% experienced menopause within 5 years compared with only 7.3% in age-matched controls with intact uteri.⁴ Beyond this accelerated decline in ovarian function, women who underwent hysterectomy with ovarian preservation demonstrated higher rates of cognitive decline and dementia⁵ and an elevated risk of cardiovascular disease, particularly when hysterectomy was performed at younger ages.⁶ These findings suggest that disruption of uterine-ovarian vascular communication may induce a state of relative estrogen deficiency, leading to adverse systemic consequences despite ovarian conservation.

Comparative Outcomes: Uterine-Preserving Vs Hysterectomy-Based Approaches

Evidence consistently supports the noninferiority of UPPS compared with hysterectomy-based repairs.

In the LAVA trial, van IJsselmuiden et al found similar success between laparoscopic sacrohysteropexy and sacrospinous hysteropexy (83% vs 78%), with shorter operative times and less blood loss for uterine preservation.⁷ Aserlind⁸ and Hickman⁹ et al reported high anatomic success rates (92%-94%) and low reoperation rates (2%-6%) after transvaginal hysteropexy. Campagna et al found equivalent outcomes between laparoscopic sacral hysteropexy and sacrocolpopexy with supracervical hysterectomy (94% vs 96%).¹⁰ The Save-U trial 5-year outcomes analysis revealed overall anatomical failure occurred in 45% of participants after sacrospinous hysteropexy vs 50% after vaginal hysterectomy with uterosacral ligament suspension, with surgical failure of the apical compartment with bothersome bulge symptoms or repeat surgery in 1% vs 7.8%, indicating comparable long-term anatomical outcomes but fewer apical recurrences after hysteropexy.¹¹

A meta-analysis by Meriwether et al confirmed comparable recurrence and reoperation rates, with shorter operative times and reduced blood loss for UPPS.¹² Meanwhile, Nager³ and Aserlind⁸ et al demonstrated that apical suspension outcomes remain strong across approaches, with slightly lower recurrence following sacrocolpopexy.

Overall, these findings confirm that uterine-preserving surgery provides durable anatomic results and potential perioperative advantages in appropriately selected patients.

Clinical Indications and Benefits of Concomitant Hysterectomy

Despite the growing preference for uterine preservation, hysterectomy remains indicated for select patients, summarized in Table 2. Absolute contraindications to uterine-sparing procedures include known or suspected uterine or cervical malignancy and postmenopausal or unexplained abnormal uterine bleeding that has not been fully evaluated. Relative indications include high-risk hereditary cancer syndromes, recurrent cervical dysplasia, or postmenopausal bleeding with inconclusive evaluation.

Table 2. Contraindications for Uterine Preservation at Time of Prolapse Surgery

From a patient-centered perspective, hysterectomy may offer psychological reassurance for individuals with heightened anxiety about cancer risk or a strong family history of uterine malignancy. Beyond oncologic considerations, hysterectomy can also address benign conditions such as abnormal uterine bleeding, adenomyosis, endometriosis, fibroids, or endometrial polyps—each of which may substantially impact quality of life.²

From a surgical standpoint, hysterectomy can simplify apical suspension by allowing direct visualization and tension-free placement of grafts or sutures at the vaginal apex or cervical stump. This may streamline operative planning and reduce anatomical variability inherent in uterine-preserving techniques. Some surgeons, particularly those less experienced with UPPS, may prefer hysterectomy for its familiarity, reproducibility, and standardized outcomes.

Conclusion

Although hysterectomy is no longer universally performed during prolapse repair, its role remains nuanced and patient specific. Optimal management requires a comprehensive individualized approach that integrates clinical evidence, anatomical factors, comorbidities, and patient values.

Uterine-preserving procedures provide comparable anatomical and functional outcomes for appropriately selected candidates and align with a broader movement toward patient autonomy and minimally invasive care. However, hysterectomy continues to have an important place in cases of malignancy risk, coexisting uterine pathology, or when technical factors favor removal.

Ultimately, the decision to remove or preserve the uterus should be grounded in shared decision-making, balancing evidence-based outcomes with patient perspectives, cultural context, and the surgeon’s expertise. This patient-centered framework ensures that prolapse repair strategies remain both scientifically sound and aligned with women’s individualized goals for reproductive and pelvic health.

Disclosure: Artificial intelligence (ChatGPT, OpenAI) was employed to support editorial refinement and reference formatting during article preparation. No part of the scientific content, data analysis, or conclusions was generated by AI. All authors are solely responsible for the manuscript’s intellectual content.

Conflicts of Interest: The authors have no conflicts of interest to disclose.