Reconstructive surgery for vaginal vault prolapse can be performed either transvaginally or transabdominally via open, laparoscopic or robotically assisted approaches. Vaginal apical suspension includes both native tissue repair (i.e., sacrospinous colpopexy, uterosacral ligament suspension, McCall culdoplasty, or iliococcygeus fixation) and mesh augmentation with commercially available kits aimed at concurrent apical and anterior or posterior vaginal wall support. These kits are no longer available in some countries. Transabdominally, sacrocolpopexy for post-hysterectomy vault prolapse is the most commonly performed apical suspension.¹³

Level 1 evidence comparing the success of these two approaches have been reported in various studies. In the 2016 Cochrane review, six randomized trials (n = 583) compared sacrocolpopexy to vaginal prolapse repair for a predominately vault prolapse cohort. These include three trials comparing abdominal sacrocolpopexy to sacrospinous ligament suspension,¹⁴,¹⁵,¹⁶ one trial comparing abdominal sacrocolpopexy to uterosacral ligament suspension,¹⁷ one trial comparing laparoscopic sacrocolpopexy to transvaginal mesh repair,¹⁸ and one comparing abdominal or laparoscopic sacrocolpopexy to uterosacral ligament suspension with mesh augmentation.¹⁹ On meta-analysis, sacrocolpopexy when compared to the vaginal approach with or without mesh was associated with a lower risk of awareness of prolapse, less recurrent prolapse on examination, less reoperation for prolapse, and less postoperative stress incontinence and dyspareunia.¹⁹ Complications of mesh erosion were similar between the groups at 3% to 4%.

Subsequent to the Cochrane publication, Lucot et al.²⁰ reported the outcomes of a large French multicenter randomized trial comparing laparoscopic sacrocolpopexy (n = 130) and transvaginal mesh (n = 129) for those presenting with cystocele with uterus present. They demonstrated no difference between the groups in symptoms of prolapse, reoperation for prolapse, or validated satisfaction or quality-of-life outcomes. However, laparoscopic sacrocolpopexy had higher elevation of point C on examination, a longer total vaginal length, lower risk of reoperation, and dyspareunia compared to the transvaginal mesh group.²⁰

Furthermore, a systematic review by the Society of Gynecologic Surgeons Systematic Review Group evaluated both uterine and vault prolapse with randomized and nonrandomized comparative trials and noncomparative studies comparing sacrocolpopexy to native tissue vaginal repairs. They reported improved anatomical outcomes with sacrocolpopexy with no difference in reoperation rates or postoperative sexual function.²¹

Although sacrocolpopexy clearly provides better anatomical and functional outcomes in randomized controlled trial for vault prolapse, the open procedure is associated with a longer operative time, slower recovery, and increased cost when compared to vaginal approach.¹⁹ The laparoscopic technique has been adopted by many surgeons over the last decade with a reduction in postoperative recovery and blood loss without compromising surgical outcome.²²,²³ One limitation to widespread uptake is the steep learning curve associated with laparoscopic suturing; hence, the robotic approach was developed.²⁴ However, robotic sacrocolpopexy has a longer operative time, more postoperative pain and bleeding,²⁵ slower recovery, and significantly greater cost than the laparoscopic route²⁶ with equivalence in all other outcomes.²⁷ More recently, several units have reported the learning curve to minimizing intraoperative and postoperative complications using the robotic approach to sacrocolpopexy was longer than anticipated and the learning curve was 80 cases.²⁸,²⁹

Vaginal native tissue apical suspension procedures have been compared to mesh augmentation in various randomized trials, with vaginal mesh conferring no additional benefit. In the 2016 Cochrane review, six randomized trials (n = 589) comparing sacrospinous ligament suspension to first generation polypropylene mesh (either monofilament Prolift, Ethicon, or multifilament weave) were combined for meta-analysis. By 3 years, no difference was observed between mesh and nonmesh repair in awareness of prolapse, recurrent prolapse on examination, reoperation for prolapse, or postoperative stress incontinence and dyspareunia.¹⁹ There was a trend toward higher bladder injury in the mesh group (risk ratio 3; 95% confidence interval 0.91 to 9.89) and high mesh erosion rate of 18%, with 9.5% reoperation for mesh exposure.

Since the 2011 U.S. Food and Drug Administration public health notification regarding transvaginal meshes, most first-generation vaginal mesh kits are no longer marketed. Furthermore, between 2016 and 2019, countries such as United Kingdom, Australia, and United States have banned the use of all transvaginal mesh kits outside the context of clinical trials.³⁰ Thus, these results serve as only historic reading for a large portion of clinicians.

To date, only one randomized trial (OPTIMAL trial, n = 374)³¹ has compared the two most commonly performed apical suspension procedures: sacrospinous
ligament and uterosacral ligament suspension. In both groups, post-hysterectomy vault prolapse and uterine prolapse (which were the minority) were included, but all patients underwent a concurrent vaginal hysterectomy if the uterus was present.