Journal of

Clinical Medicine

Article
Long-Term Outcomes after Pelvic Organ Prolapse Repair in
Young Women
Marine Lallemant * , Yasmine Clermont-Hama, Géraldine Giraudet, Chrystèle Rubod, Sophie Delplanque,
Yohan Kerbage and Michel Cosson

Department of Gynecologic Surgery, Jeanne de Flandre University Hospital, 59000 Lille, France
* Correspondence: [email protected]

Abstract: The aim of the study was to describe the long-term outcomes of Pelvis Organ Prolapse
(POP) repair in women under 40 years old. A retrospective chart review of all POP repairs performed
in women ≤40 years old between January 1997 and December 2015 in the Gynecologic Surgery
Department of Lille University Hospital was performed. Inclusion criteria were all women ≤40
years old who underwent a POP repair with a stage ≥2 POP according to the Baden and Walker
classification. The study population was separated into three groups: a sacrohysteropexy group, a
vaginal native tissue repair (NTR) group, and a transvaginal mesh surgery (VMS) group. The primary
outcome was reoperation procedures for a symptomatic recurrent POP. Secondary outcomes were
other complications. During the study period, 43 women ≤ 40 years old who underwent a POP repair
were included and separated into three groups: 28 patients (68%), 8 patients (19%), and 7 patients
(16%) in the sacrohysteropexy, VMS, and NTR groups respectively. The mean followup time was
83 ± 52 months. POP recurrence, reoperated or not, was essentially diagnosed in the VMS group
(87.5%) and the NTR group (50%). POP recurrence repairs were performed for nine patients (21%):
7%, 62.5%, and 25% in the sacrohysteropexy, VMS, and NTR groups, respectively. Global reoperation
Citation: Lallemant, M.; concerned 10 patients (23%) whatever the type of POP surgery, mainly patients from the VMS group
Clermont-Hama, Y.; Giraudet, G.; (75%) and from the NTR group (25%). It occurred in only 7% of patients from the sacrohysteropexy
Rubod, C.; Delplanque, S.; Kerbage, group. Two patients (4%) presented a vaginal exposure of the mesh (in the VMS group). De
Y.; Cosson, M. Long-Term Outcomes novo stress urinary incontinence was encountered by nine patients (21%): 29% and 12.5% in the
after Pelvic Organ Prolapse Repair in sacrohysteropexy and NTR groups, respectively. Despite the risk of recurrence, POP repair should
Young Women. J. Clin. Med. 2022, 11, be proposed to young women in order to restore their quality of life. Vaginal native tissue repair or
6112. https://doi.org/10.3390/ sacrohysteropexy should be performed after explaining to women the advantages and disadvantages
jcm11206112
of each procedure.
Academic Editor: Gautier Chene
Keywords: young women; POP repair; pelvic organ prolapse; recurrence; complications
Received: 25 September 2022
Accepted: 15 October 2022
Published: 17 October 2022

Publisher’s Note: MDPI stays neutral 1. Introduction

with regard to jurisdictional claims in
Pelvic organ prolapse (POP) is a common disease in postmenopausal women. The
published maps and institutional affil-
incidence in the younger population is uncertain because many women suffering from POP
iations.
do not seek a repair. According to Nygaard et al., the prevalence of POP in women under
40 years old is 1.6% [1]. Surgical repair of POP in young women is challenging because
it must preserve the patient’s fertility and sexual functions while obtaining a satisfying
Copyright: © 2022 by the authors.
and durable anatomic result. In the literature, the young age of women is often described
Licensee MDPI, Basel, Switzerland. as a risk factor for POP recurrence [2–4]. However, the long term results of POP repair
This article is an open access article in women under the age of 40 have rarely been studied [5,6]. In addition, there are no
distributed under the terms and recommendations for the management of POP in young women. The aim of the study was
conditions of the Creative Commons to describe the long-term outcomes of POP repair in women under 40 years old.
Attribution (CC BY) license (https://
creativecommons.org/licenses/by/
4.0/).

J. Clin. Med. 2022, 11, 6112. https://doi.org/10.3390/jcm11206112 https://www.mdpi.com/journal/jcm

J. Clin. Med. 2022, 11, 6112 2 of 9

2. Materials and Methods

We conducted a retrospective chart review of all POP repairs performed in women
≤40 years old between January 1997 and December 2015 in the Gynecologic Surgery
Department of Lille University Hospital. The surgical techniques depended on the stage,
the type of the POP, and the patient’s preference.
The inclusion criteria were all women ≤ 40 years old who underwent a POP repair with
a stage ≥ 2 POP according to the Baden and Walker classification (Supplementary Table
S1). POP surgeries were only performed if patients were symptomatic. Exclusion criteria
were patients with a rectal prolapse and patients with missing data (no postoperative visit).
The study population was separated into three groups: a sacrohysteropexy group, a
vaginal native tissue repair (NTR) group consisting mainly of posterior sacrospinofixations
according to Richter or Richardson’s procedures, and a transvaginal mesh surgery (VMS)
group. In this case, the mesh used was made of polypropylene (Prolift® , Pelvic Floor Repair
System; Ethicon Women’s Health and Urology, Somerville, NJ, USA). Regardless the type
of surgery, the surgery was performed under general anesthesia or loco-regional anesthesia.
Postoperative care was standardized across surgeons. In the absence of any complication,
the urinary catheter was removed, and the patient was allowed to ambulate the day after
surgery, unless a laparotomy was performed.
Sacrohysteropexy was performed by laparoscopy or by laparotomy as described by
Wattiez and Cosson [7,8]. Firstly, the pneumoperitoneum was established with a Veress
needle. A 10-mm umbilical trocar was placed for the laparoscope. Two 5-mm right and left
iliac trocars and one 10-mm suprapubic trocar were inserted. The surgeon was placed on
the left side of the patient and the first assistant on the right. The peritoneum overlying the
sacrum was opened and the anterior longitudinal sacral ligament was exposed. Anterior
and/or posterior mesh was used. The vaginal fornices were dissected by mobilizing
the bladder anteriorly and/or the rectum posteriorly, thanks to a curved metal vaginal
manipulator. Anteriorly, dissection reached the bladder trigone, and posteriorly, the levator
ani muscles were exposed. The mesh was sutured to the vaginal wall using absorbable
sutures, with a digital control to avoid transfixing the vagina and to control the level of
dissection. The anterior mesh was inserted through the right broad ligament before reaching
the promontory. One or both tails of the mesh were suspended to the anterior sacral
ligament by two permanent sutures. Meshes were peritonized to avoid the incarceration of
a digestive loop.
The technique of posterior sacrospinofixation according to Richter began with a vaginal
hysterectomy. Then, the posterior vaginal wall was exposed and infiltrated (mix of 30 mL
Xylocaine 1% and 30 mL of isotonic saline). A posterior colpotomy was performed. The
left or right pararectal fossa was dissected. The vagina was attached on one sacrospinous
ligament. Then, the vagina was partially closed. The sacrospinous ligament fixation was
tightened, and the vagina was completely closed. The Richardson procedure used the same
technique but without the vaginal hysterectomy.
The transvaginal mesh repair technique was standardized, as described by Debodi-
nance et al. [9]. An anterior and/or a posterior mesh was applied according to the prolapse
type (anterior POP, posterior POP, or the complete floor) [10]. The anterior mesh was in-
serted between the bladder and the vagina and fixed laterally by four arms passing through
the obturator foramen, near the tendinous arch of the pelvic fascia. The posterior mesh was
placed between the rectum and the vagina with an arm passing through the ischiorectal
fossa and fixed in the sacrospinous ligament. The mesh was made of non-absorbable
monofilament polypropylene (Prolift Pelvic Floor Repair System; Ethicon Women’s Health
and Urology, Somerville, NJ, USA).
Patients were identified from data collected by the Medical Information Systems
Program. Information was extracted from paper and electronic hospital medical records.
Demographic and medical data as well as histories were collected during the preoperative
work-up. A physical examination was performed to determine the pelvic floor disorders.
POP was classified according to the Baden and Walker classification [11]. Significant intra-
J. Clin. Med. 2022, 11, 6112 3 of 9

operative complications (organ injuries or hemorrhage), early postoperative complications

(hemorrhage, infection, or early reoperation before hospital discharge) or late postoperative
complications (reoperation after hospital discharge and before postoperative visit) were
recorded. All patients underwent a physical examination six weeks after surgery. Followup
was performed once a year or more frequently, especially in the case of persistent or new
symptoms related to the POP surgery, a failed surgery, or a recurrent prolapse. POP recur-
rence was defined as a Baden and Walker stage ≥ 2 in at least one vaginal compartment.
Repeat surgeries for POP recurrence were performed based on functional and anatomical
outcomes not on isolated anatomical outcomes.
The primary outcome was reoperation procedures for a symptomatic recurrent POP.
Secondary outcomes were other complications: intraoperative organ trauma (bladder,
bowel, and/or vagina), postoperative complications, such as vaginal hematoma and dys-
pareunia, postoperative POP recurrence (operated on or not), global reoperation and for
mesh complications, and de novo stress urinary incontinence (SUI). Global reoperation
included repeat surgeries for mesh complication or POP recurrence. Complications were
classified according to the Clavien and Dindo classification [12].
According to French regulations, our study was exempted from a favorable opinion of
an ethics committee, since this observational study used anonymized data from a medical
database. In our center, patients were systematically informed that their medical data
could be used for theoretical practice evaluation purposes and explicitly informed of the
possibility of refusal.
Quantitative variables were expressed as mean ± standard deviation and qualitative
variables as number of cases (percentage).

3. Results
Between January 1997 and December 2015, 74 patients ≤40 years old underwent a POP
repair. Among these, 31 patients were excluded: 2 patients suffered from a rectal prolapse,
and 29 patients had missing data (lost to followup). Forty-three patients constituted the
study population (Figure 1): 28 patients (68%), 8 patients (19%), and 7 patients (16%) in the
sacrohysteropexy, VMS, and NTR groups respectively. Demographics, clinical examination,
and surgery management characteristics are described in Table 1. The mean followup
time was 83 ± 52 months. POP recurrence, reoperated or not, was essentially diagnosed
in the VMS group (87.5%) and the NTR group (50%) (Table 2). POP recurrence repairs
were performed for nine patients (21%): 7%, 62.5%, and 25% in the sacrohysteropexy,
VMS, and NTR groups respectively (Figure 2). No intraoperative organ trauma was
registered. Only one patient (in the VMS group) had a vaginal hematoma that was not
reoperated. Postoperative dyspareunia was reported by only two patients (4%): one (4%) in
the sacrohysteropexy group and one (12.5%) in the VMS group. No women reported pain
in the ipsilateral gluteal region. Global reoperation concerned 10 patients (23%) whatever
the type of POP surgery, mainly patients from the VMS group (75%) and from the NTR
group (25%) (Figure 3). It occurred in only 7% of patients from the sacrohysteropexy group.
Two patients (4%) presented a vaginal exposure of the mesh. All were from the VMS group
(25%). Among these, only one underwent a surgical removal of the vaginal prosthetic mesh.
De novo stress urinary incontinence was experienced by nine patients (21%): 29% (8/28)
and 12.5% (1/8) in the sacrohysteropexy and NTR groups, respectively.
J. Clin. J. Clin.2022,
Med. Med.11,
2022, 11, PEER
x FOR 6112 REVIEW 4 of 9 4 of 9

FigureFigure
1. Flow1.chart.
Flow chart.

Table 1. Population characteristics.

Population Characteristics 50 n = 43
Age (years) 87.5
35 ± 4 (28–40)
POP recurrence (reoperated or not) (%)
BMI (kg/m2 ) 11 25.3 ± 5.3 (17.2–42)
Parity 32 2 (0–6)
Length of followup (months) 83 ± 52 (22–226)
POP stage (Baden and Walker classification)
in at least one compartment:
Stage 2 25 12 (28)
Stage ≥ 3 3162.5
(72)
POPof
Type recurrence reoperation (%)
POP repair 7
Sacrohysteropexy 28 (65)
21
Anterior and posterior meshes 27 (96)
Posterior mesh only 1 (4)
Laparoscopic surgery 0 10 20 30 40 50 602770 (96)80 90 100
Laparotomy surgery 1 (4)
Vaginal mesh surgery
NTR VMS Sacrohysteropexy Total8 (19)
Anterior and posterior meshes 3 (37.5)
Posterior mesh only 5 (62.5)
Native
Figure 2. tissue POP
Long-term repair 8 (19)
recurrence after a POP repair in women under 40 years old according to
Posterior
the surgical sacrospinofixation
technique. according
POP: pelvic organ to Richter
prolapse; 1 (14)
VMS: vaginal mesh surgery; NTR: native tissue
Richardson’s procedure 5 (71)
repair by vaginal route.
Posterior colporrhaphy and perineorrhaphy 1 (14)
Concomitant total hysterectomy 16 (37)
Associated SUI surgery 11 (26)
Quantitative variables are expressed as mean ± standard deviation (range) and qualitative variables as number of
cases (percentage). BMI: body mass index; POP: pelvic organ prolapse; SUI: stress urinary surgery.
 J. Clin. Med. 2022, 11, x FOR PEER REVIEW 4 of 9

J. Clin. Med. 2022, 11, 6112 5 of 9

Table 2. Long-term complications according to the Clavien–Dindo classification after a POP repair in
women under 40 years old.

Total Sacrohysteropexy VMS NTR

n = 43 n = 28 n=8 n=8
Intraoperative complications 0
Grade I and II
Vaginal hematoma 1 (2) 0 1 (12.5) 0
Dyspareunia 2 (4) 1 (4%) 1 (12.5) 0
Non-reoperated POP
5 (12) 1 (4%) 2 (25) 2 (25)
recurrence
Mesh exposure 1 (2) 1 (12.5)
Grade III
Global reoperation 10 (23) 2 (7) 6 (75) 2 (25)
POP recurrence reoperation 9 (21) 2 (7) 5 (62.5) 2 (25)
Mesh related reoperation 1 (2) 0 1 (12.5) 0
Grade IV or V 0
Qualitative variables are expressed as number of cases (percentage). POP: pelvic organ prolapse; VMS: vaginal
mesh surgery; NTR: native tissue repair by vaginal route.
Figure 1. Flow chart.

50
87.5
POP recurrence (reoperated or not) (%)
11
32

25
62.5
POP recurrence reoperation (%)
7
21

0 10 20 30 40 50 60 70 80 90 100

NTR VMS Sacrohysteropexy Total

Figure Long-term
Figure 2.2.Long-term POP POP recurrence
recurrence after
after a POP a POP
repair repair
in women in women
under under
40 years old 40 years
according to old according to
the surgical technique. POP: pelvic organ prolapse; VMS: vaginal mesh surgery; NTR: native tissue
the surgical technique. POP: pelvic organ prolapse; VMS: vaginal mesh surgery;
J. Clin. Med. 2022, 11, x FOR PEER REVIEW 5 of 9 NTR: native tissue
repair by vaginal route.
repair by vaginal route.

25

Global reoperation (%) 75

0 10 20 30 40 50 60 70 80

NTR VMS Sacrohysteropexy

Figure 3. Global reoperation rates after a POP repair in women under 40 years old according to the
Figure
surgical3. Global VMS:
technique. reoperation rates
vaginal mesh after aNTR:
surgery; POP repair
native in repair
tissue women underroute.
by vaginal 40 years old according to the
surgical technique. VMS: vaginal mesh surgery; NTR: native tissue repair by vaginal route.
Table 1. Population characteristics.

Population Characteristics n = 43
Age (years) 35 ± 4 (28–40)
BMI (kg/m2) 25.3 ± 5.3 (17.2–42)
Parity 2 (0–6)
Length of followup (months) 83 ± 52 (22–226)
POP stage (Baden and Walker classification)
J. Clin. Med. 2022, 11, 6112 6 of 9

4. Discussion
In our study, women younger than 40 years old underwent the following surgeries
in order of frequency: sacrohysteropexy (64%), vaginal mesh surgery (19%), and vaginal
native tissue repair (16%). There are currently different surgical approaches for primary
POP repair in young women. The first is that primary vaginal native tissue surgery
could be preferred so that mesh repair could be used ulteriorly in case of recurrence.
This approach is supported by Maher et al. who recommend native tissue repair as
the first line of treatment [13]. The second is that given the possible weakness of the
pelvic floor connective tissues and the lower risk of recurrence, sacrohysteropexy could
be performed as a first-line procedure in young women. This concept is supported by
Wagner et al. and Lucot et al. who demonstrated that sacrocolpopexy was associated with
better long-term outcomes [14,15]. In our study, 19% of women underwent vaginal mesh
surgery. Now, the use of synthetic vaginal mesh is no longer recommended since the FDA
ordered manufacturers to stop distributing transvaginal surgical mesh in April 2019 [16].
Alternative surgeries such as pectopexy or lateral ligament suspension were not evaluated
in this study because they were not performed in the first line in our center. According to
Campagna et al.’s literature review, minimally invasive lateral suspension was safe (1% of
grade ≥ 3 complications according to the Clavien–Dindo classification), efficient (90% of
anatomic success in the apical compartment) and feasible [17]. However, there is a lack of
well-designed, randomized, controlled trials assessing these techniques in the literature for
POP repair, especially in young women.
In our study, POP recurrence occurred in 32% of patients and reoperation for POP
recurrence in 21% of patients, regardless of the type of surgery. According to the literature,
the rate of POP recurrence is about 30% in young women globally [2]. Friedman et al. re-
ported a 36% recurrence rate in their meta-analysis [18]. In the study published by Hickman
et al., the retreatment incidence was less than 10.3% [2]. However, their rate was lower than
in the Lowenstein et al. study (26.9%) because of their shorter followup duration and loss
to followup rate [3]. Other studies reported lower rates of recurrence but included a smaller
and older study population and had a shorter followup period [19–21]. Some studies
reported that young age was a risk factor for POP recurrence [22,23]. Vandendriessche
et al. described a higher recurrence rate in young women who underwent a laparoscopic
sacrohysteropexy [23]. Furthermore, some POP recurrences were probably not due to the
surgical approach but rather due to the surgical strategy (i.e., anterior vaginal wall prolapse
after isolated posterior vaginal mesh).
De novo stress urinary incontinence was reported by 21% of women, regardless
of the type of surgery. It mainly occurred in women from the sacrohysteropexy group
(29%). In the literature, it is estimated to range from 16 to 51% after surgical correction of
prolapse [24–27].
POP recurrence (87.5%), reoperation for POP recurrence (62.5%), and global reoper-
ation (75%) occurred often and more frequently in the vaginal mesh surgery group than
in the sacrohysteropexy and native tissue repair groups. The samples size was too small
for statistical comparison. However, even though meshes are no longer sold, these re-
sults confirmed that transvaginal mesh surgery should not be proposed as first-line POP
therapy [28,29].
In our study, POP recurrence occurred in 11% of young women who underwent
a sacrohysteropexy. However, secondary POP repair was performed in only 7% of the
patients in this group. These results are consistent with those of Hickman et al. who studied
POP recurrence in young women who had an abdominal surgery: overall incidence of
recurrence 13.7% and overall retreatment incidence 5.9% [2].
In conclusion, morbidity was lower after sacrohysteropexy or vaginal native tissue
repair. De novo SUI were more frequent in case of sacrohysteropexy. POP recurrence was
slightly more reported in the NTR group. These results indicate that both procedures should
be proposed to women explaining the advantages and disadvantages of each technique.
In our center, we proposed a vaginal native tissue repair to women with a plan to become
J. Clin. Med. 2022, 11, 6112 7 of 9

pregnant. Sacrohysteropexy is frequently chosen in case of POP recurrence or if the woman

has no pregnancy plans.
In our study, two cases of postoperative dyspareunia after vaginal mesh surgery
(one after an abdominal surgery and one after a transvaginal surgery) were reported. This
could be due to a mesh retraction. In the literature, the rates of dyspareunia were higher
than 4% [30]. In Hickman et al.’s study, 31.2% of women reported pain with intercourse [2].
Our study is original in describing the long-term outcomes of POP repair in
women ≤40 years old. The major limitation of this study was its retrospective design
and lack of randomization. The retrospective collection of baseline data generally misesti-
mates adverse events and introduces measurement bias. In addition, statistical comparison
of the three surgical techniques was not possible because of the small sample of patients
included in the followup analysis. Pregnancy and childbirth after primary POP repair were
not specified. This could be a confusion bias. Finally, our study assumed that the surgical
technique was stable over the study period. However, even though the surgeries were
performed in a single reference center over a period of 18 years by an experienced team,
guaranteeing a relative homogeneity of procedures, slight changes in the surgical technique
necessarily occurred progressively.

5. Conclusions
Despite the risk of recurrence, POP repair should be proposed to young women in
order to restore their quality of life. Vaginal native tissue repair or sacrohysteropexy can be
performed after explaining to women the advantages and disadvantages of each procedure.

Supplementary Materials: The following supporting information can be downloaded at: https:
//www.mdpi.com/article/10.3390/jcm11206112/s1, Supplementary Table S1. Baden and Walker
prolapse grading [11].
Author Contributions: Conceptualization, Y.C.-H. and G.G.; Formal analysis, M.L., Y.C.-H., G.G.,
and M.C.; Methodology, Y.C.-H. and G.G.; Supervision, C.R., S.D., Y.K., and M.C.; Validation, M.C.;
Writing—original draft, M.L. and Y.C.-H.; Writing—review and editing, M.C. All authors have read
and agreed to the published version of the manuscript.
Funding: This research received no external funding.
Institutional Review Board Statement: According to French regulations, our study was exempted
from a favorable opinion of an ethics committee, since this observational study used anonymized
data from a medical database.
Informed Consent Statement: Patients were systematically informed that their medical data could
be used for theoretical practice evaluation purposes and explicitly informed of the possibility
of refusal.
Data Availability Statement: The data used to support the findings of this study are available from
the corresponding author upon request.
Conflicts of Interest: Michel Cosson receives honoraria from and reports participation in a speaker’s
bureau or training in operating rooms or on animals for vaginal meshes for Boston Scientific and
AMI companies. The other authors have no conflicts of interest.

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