Single-port laparoscopic lateral suspension with total versus subtotal hysterectomy for pelvic organ prolapse: a prospective comparative study

Abstract

Background

Laparoscopic lateral suspension (LLS) is an effective mesh-based repair for pelvic organ prolapse (POP), but the optimal concomitant hysterectomy strategy — total (TH) versus subtotal (STH) — remains undefined. We compared anatomic outcomes, patient-reported outcomes, and complication profiles of LLS combined with TH (LLSHR) versus LLS combined with STH (LLSHE) in a prospective cohort of women who made an informed choice between the two procedures.

Methods

In this prospective comparative study conducted at Chengdu Integrated TCM & Western Medicine Hospital between October 2021 and October 2024, 82 women with symptomatic POP-Q stage II or III uterovaginal prolapse were counseled regarding both hysterectomy options and self-selected into the LLSHR group (n = 41) or the LLSHE group (n = 41). The study was approved by the institutional review board (IRB 2021.XJS.019) and retrospectively registered in the Chinese Clinical Trial Registry (ChiCTR2600118158). Primary outcomes were POP-Q point C and PISQ-12 score at 12 months. Secondary outcomes included POP-Q points Ba and Bp, PFDI-20, PFIQ-7, operative parameters, and mesh-related complications through 24 months.

Results

All 82 participants completed surgery as planned. At 12 months, point C was significantly more negative in the LLSHE group than in the LLSHR group (− 5.1 ± 0.5 cm vs. −4.5 ± 0.6 cm; P < 0.001), indicating superior apical support with cervical preservation. The PISQ-12 score at 12 months was significantly higher (better) in the LLSHE group (37.5 [IQR 33.0–42.5] vs. 31.0 [27.0–34.0]; P < 0.001). PFDI-20 and PFIQ-7 improved substantially in both groups with no between-group difference at any time point (all P > 0.05). At 24 months, point C remained significantly more negative in the LLSHE group (− 4.8 ± 0.5 vs. −4.4 ± 0.6; P = 0.004), and the PISQ-12 advantage of LLSHE persisted (37.0 [34.0–43.0] vs. 31.5 [26.8–39.0]; P = 0.005). Mesh exposure was observed in 3 patients (9.4%) in the LLSHR group and none in the LLSHE group (P = 0.226). Operative time was significantly shorter in the LLSHE group (149.0 [143.0–165.0] min vs. 171.0 [150.0–186.0] min; P = 0.002).

Conclusions

In women undergoing LLS for POP, STH was associated with superior apical support and better sexual function at both 12 and 24 months, with shorter operative time and a numerically lower rate of mesh exposure compared with TH. Given the non-randomized design, these findings should be interpreted as hypothesis-generating. Prospective randomized trials are warranted to confirm these associations. Trial registration: ChiCTR2600118158; registered February 2, 2026, retrospectively registered.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12905-026-04515-x.

Introduction

Pelvic organ prolapse (POP) is a highly prevalent condition affecting an estimated 25–50% of parous women and up to 40% of women aged 50 years or older, representing one of the leading indications for gynecologic surgery worldwide [1, 2]. The condition impairs urinary, bowel, and sexual function and substantially reduces health-related quality of life [3]. The lifetime risk of undergoing at least one surgical intervention for POP is approximately 12–19% [4]. While native-tissue repairs carry acceptable anatomic recurrence rates, mesh augmentation offers durable apical support in appropriately selected patients [5]. Among the available mesh-based techniques, laparoscopic lateral suspension (LLS) — which anchors a polypropylene mesh bilaterally to the anterior abdominal wall rather than to the sacral promontory — has gained traction as a technically versatile and reproducible alternative to laparoscopic sacrocolpopexy, particularly in settings where promontory fixation is challenging or undesirable [6–8]. Recent systematic reviews and meta-analyses have demonstrated comparable anatomic success rates and fewer intraoperative complications with LLS versus sacrocolpopexy, alongside a substantially shorter operative time [9, 10].

LLS is routinely combined with hysterectomy when uterine prolapse is present, yet the choice between total hysterectomy (TH) and subtotal (supracervical) hysterectomy (STH) in this context remains a subject of debate. Proponents of STH argue that cervical preservation maintains the integrity of the cardinal and uterosacral ligament complex, protects the pelvic autonomic nerve supply to the bladder and rectum, and may safeguard sexual function by preserving cervical sensation and natural vaginal axis [11–13]. Conversely, TH eliminates the need for ongoing cervical cancer surveillance and removes any residual prolapse risk attributable to cervical descent. In the sacrocolpopexy literature, subtotal hysterectomy has been associated with improved apical positioning and lower mesh exposure rates compared with total hysterectomy [14, 15], but equivalent evidence specific to LLS is sparse. A single recent retrospective study by Coskun et al. reported no anatomic difference between uterus-preserving and hysterectomy-combined LLS, but did not directly compare STH with TH within the hysterectomy subgroup [16].

We conducted a prospective comparative study to evaluate LLS with TH (LLSHR) against LLS with STH (LLSHE) in women who chose between the two approaches after standardized counseling. We compared anatomic correction per POP-Q [17], patient-reported outcomes, operative parameters, and mesh-related complications through 24 months of follow-up.

Methods

Study design and patient population

This prospective comparative study was conducted at Chengdu Integrated TCM & Western Medicine Hospital. Women presenting with symptomatic stage II or III apical POP between October 2021 and October 2024 were assessed for eligibility. The study protocol was approved by the institutional review board (IRB 2021.XJS.019), and all participants provided written informed consent prior to enrollment. The study was conducted in accordance with Good Clinical Practice guidelines and the Declaration of Helsinki. This trial was retrospectively registered in the Chinese Clinical Trial Registry under the registration number ChiCTR2600118158 (February 2, 2026). Registration was delayed because institutional registration procedures at our center were not standardized for non-commercial comparative observational studies at the time of the study’s initiation in 2021; the delay does not reflect any post-hoc modification of outcomes or analysis plans, which were pre-specified in the IRB protocol (IRB 2021.XJS.019) prior to enrollment. This study was reported in accordance with the CONSORT 2010 guidelines for reporting clinical trials and, where applicable, the TREND (Transparent Reporting of Evaluations with Nonrandomized Designs) extension for non-randomized studies. A completed CONSORT checklist is provided as Additional File 1.

Inclusion criteria were: age 45–80 years; symptomatic POP with predominant apical descent (POP-Q stage II or III uterine prolapse); desire for surgical correction; and willingness to undergo hysterectomy. Exclusion criteria included: contraindication to laparoscopic surgery; desire for uterine preservation; abnormal cervical cytology or history of cervical dysplasia; active pelvic infection; and inability to comply with follow-up protocols.

All eligible patients were counseled by the treating surgeon regarding the anatomic rationale, anticipated benefits, and potential risks of each hysterectomy type in the context of LLS. Specifically, patients choosing STH were informed of the requirement for lifelong annual cervical cytologic surveillance and the theoretical risk of cervical stump pathology. Patients choosing TH were informed of the potential for vaginal vault healing and its relationship to mesh exposure risk. Following this standardized shared decision-making process, patients who chose subtotal hysterectomy formed the LLSHE group and those who chose total hysterectomy formed the LLSHR group. All patients agreed to prospective follow-up at 1, 6, 12, and 24 months postoperatively.

Interventions

All procedures were performed single-port laparoscopically by one experienced gynecologic surgeon (> 50 LLS procedures) at the same institution, using a standardized operative protocol to minimize surgeon-related variability. The LLS technique employed a cross-shaped polypropylene mesh anchored bilaterally to the anterior abdominal wall at the level of the anterior superior iliac spine [18]. In the LLSHR group, total laparoscopic hysterectomy was performed before mesh placement, and the central mesh arm was sutured to the vaginal vault. In the LLSHE group, laparoscopic supracervical hysterectomy was performed (uterine corpus removed via morcellation within a containment bag), and the central mesh arm was sutured to the cervical stump. Concomitant Burch colposuspension, posterior colporrhaphy, or perineal repair was performed at the surgeon’s discretion for coexisting pelvic floor disorders. Annual cervical cytology surveillance was mandated for all LLSHE participants.

Outcomes

The primary outcomes were (1) POP-Q point C position at 12 months, as the principal anatomic measure of apical support, and (2) the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12) total score at 12 months, as the principal patient-reported measure of sexual function (higher scores indicate better function; range 0–48) [19]. Pre-specified secondary outcomes included POP-Q points Ba and Bp at 1, 6, 12, and 24 months; the Pelvic Floor Distress Inventory–20 (PFDI-20; range 0–300, lower = better) [20]; the Pelvic Floor Impact Questionnaire–7 (PFIQ-7; range 0–300, lower = better) [20]; operative time; estimated blood loss; length of hospital stay; intraoperative complications; and mesh-related adverse events through 24 months.

Follow-up

Participants were evaluated at 1, 6, 12, and 24 months postoperatively. Each visit included a standardized pelvic examination with POP-Q assessment performed by a gynecologist blinded to group assignment, and completion of the three PRO questionnaires by the participant. Participants who did not attend scheduled visits were contacted by telephone to determine their status and to encourage clinic attendance. Follow-up completion rates were 100% at 1 month, 94.0% at 6 months (39/41 LLSHR; 38/41 LLSHE), 87.8% at 12 months (36/41 each), and 79.3% at 24 months (32/41 LLSHR; 33/41 LLSHE).

Statistical analysis

No a priori sample size calculation was performed, as this study was designed as a prospective observational registry rather than a pre-planned RCT. A post-hoc power calculation indicated that the observed sample size (41 per group) provided 81% power to detect a between-group difference of 0.8 cm in POP-Q point C (SD 1.0 cm, two-sided α = 0.05). Continuous variables are reported as mean ± standard deviation (SD) or median with interquartile range (IQR) according to results of Shapiro–Wilk normality testing. Between-group comparisons used the independent-samples t-test or Mann–Whitney U test for continuous variables and the chi-square test or Fisher’s exact test for categorical variables. To account for the non-randomized design and potential confounding by baseline covariates, inverse probability of treatment weighting (IPTW) was applied to primary outcome analyses. Propensity scores were estimated using logistic regression with age, BMI, menopausal status, POP-Q apical stage, preoperative SUI prevalence, PFDI-20, PFIQ-7, and PISQ-12 as covariates. Covariate balance after IPTW was assessed using standardized mean differences (SMDs); all SMDs were < 0.10 after weighting, indicating adequate balance across all measured confounders. IPTW-weighted analyses were applied to both primary endpoints (point C at 12 months; PISQ-12 at 12 months). Unadjusted analyses were used for secondary and safety endpoints. Longitudinal changes in POP-Q and PRO outcomes were evaluated using mixed-effects models for repeated measures (MMRM) with group, time, and group×time interaction as fixed effects and participant as the random effect; IPTW weights were incorporated into the MMRM for the primary outcomes. Given the exploratory and hypothesis-generating nature of this study, no correction for multiple comparisons was applied to secondary outcomes; findings for secondary endpoints should therefore be interpreted with appropriate caution. All tests were two-sided; P < 0.05 was considered statistically significant. All analyses were performed using SPSS version 27.0 (SPSS Inc., Chicago, IL, USA).

Results

Enrollment and baseline characteristics

Between October 2021 and October 2024, 82 women with symptomatic POP-Q stage II or III uterovaginal prolapse were enrolled at Chengdu Integrated TCM & Western Medicine Hospital (Fig. 1 — study flow diagram). Following standardized counseling, 41 patients chose LLSHR and 41 chose LLSHE. The two groups were well balanced at baseline (Table 1). Mean age was 57.2 ± 8.9 years in the LLSHR group and 54.0 ± 7.0 years in the LLSHE group (P = 0.094). Body-mass index (BMI), menopausal status, parity, and POP-Q stage distribution were similar between groups (all P > 0.05). Preoperative PRO scores were equivalent: median PFDI-20 was 87.0 (IQR 79.0–92.0) in LLSHR vs. 85.0 (76.0–89.0) in LLSHE (P = 0.574); median PFIQ-7 was 65.0 (51.0–80.0) vs. 67.0 (54.0–74.0) (P = 0.941); and median PISQ-12 was 27.0 (23.0–31.0) vs. 28.0 (23.0–30.0) (P = 0.798). Preoperative stress urinary incontinence was present in 12 women (29.3%) in the LLSHR group and 18 (43.9%) in the LLSHE group (P = 0.252). Propensity score analysis confirmed adequate covariate balance between groups after IPTW adjustment, supporting the comparability of the two cohorts for primary outcome analyses.

Fig. 1.

Study flow diagram. Enrollment, group allocation (by patient-informed choice), follow-up, and analysis of the 82 participants. LLSHR = laparoscopic lateral suspension with total hysterectomy; LLSHE = laparoscopic lateral suspension with subtotal (supracervical) hysterectomy

Table 1.

Baseline demographic and clinical characteristics

Variable	Total Hysterectomy (n = 41)	Subtotal Hysterectomy (n = 41)	P value
Age (years), mean ± SD	57.2 ± 8.9	54.0 ± 7.0	0.094
BMI (kg/m²), mean ± SD	24.5 ± 2.5	23.9 ± 3.5	0.270
Menopausal status, n (%)	35 (85.4%)	31 (75.6%)	0.403
Parity, mean ± SD	1.5 ± 0.6	1.8 ± 0.8	0.091
POP-Q stage (uterine prolapse)	Stage 2: 21 (51.2%); Stage 3: 20 (48.8%)	Stage 2: 14 (34.1%); Stage 3: 27 (65.9%)	0.180
POP-Q stage (anterior wall)	Stage 2: 21 (51.2%); Stage 3: 20 (48.8%)	Stage 2: 21 (51.2%); Stage 3: 20 (48.8%)	1.000
POP-Q stage (posterior wall)	Stage 1: 21 (51.2%); Stage 2: 20 (48.8%)	Stage 1: 23 (56.1%); Stage 2: 18 (43.9%)	0.825
Preoperative POP-Q measurements, mean ± SD
Ba (cm)	2.5 ± 1.0	2.5 ± 1.2	0.783
C (cm)	2.5 ± 0.9	2.4 ± 1.0	0.668
TVL (cm)	6.5 ± 0.5	6.4 ± 0.5	0.509
Bp (cm)	1.0 ± 1.1	1.1 ± 1.0	0.555
Preoperative SUI, n (%)	12 (29.3%)	18 (43.9%)	0.252
Preoperative PROs, median (IQR)
PFDI-20	87.0 (79.0–92.0)	85.0 (76.0–89.0)	0.574
PFIQ-7	65.0 (51.0–80.0)	67.0 (54.0–74.0)	0.941
PISQ-12	27.0 (23.0–31.0)	28.0 (23.0–30.0)	0.798

Data are mean ± SD, median (IQR), or n (%). P values are from independent-samples t-test, Mann–Whitney U test, or Fisher’s exact test, as appropriate

BMI body mass index, IQR interquartile range, POP-Q Pelvic Organ Prolapse Quantification, PRO patient-reported outcome, PFDI-20 Pelvic Floor Distress Inventory–20, PFIQ-7 Pelvic Floor Impact Questionnaire–7, PISQ-12 Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire–12, SUI stress urinary incontinence, TH total hysterectomy (LLSHR), STH subtotal hysterectomy (LLSHE)

Operative outcomes

All 82 participants underwent the procedure consistent with their stated preference; no patient changed their treatment choice after enrollment (Table 2). Operative time was significantly shorter in the LLSHE group (median 149.0 [IQR 143.0–165.0] min vs. 171.0 [150.0–186.0] min; P = 0.002). Estimated blood loss (111.0 [84.0–147.0] mL vs. 117.0 [98.0–146.0] mL; P = 0.756), transfusion rate (0% in both groups), and length of hospital stay (7.1 ± 0.8 vs. 7.0 ± 0.9 days; P = 0.440) did not differ significantly. Concomitant Burch colposuspension was performed in 4 (9.8%) and 6 (14.6%) participants in the LLSHR and LLSHE groups, respectively (P = 0.736). Posterior colporrhaphy was performed more frequently in the LLSHR group (24.4% vs. 9.8%), although the difference did not reach statistical significance (P = 0.142). Intraoperative complications occurred in 2 participants (4.9%) in the LLSHR group and none in the LLSHE group (P = 0.474).

Table 2.

Operative and perioperative outcomes

Variable	Total Hysterectomy (n = 41)	Subtotal Hysterectomy (n = 41)	P value
Operative time (min), median (IQR)	171.0 (150.0–186.0)	149.0 (143.0–165.0)	0.002
Blood loss (mL), median (IQR)	111.0 (84.0–147.0)	117.0 (98.0–146.0)	0.756
Blood transfusion, n (%)	0 (0.0%)	0 (0.0%)	> 0.999
Length of stay (days), mean ± SD	7.1 ± 0.8	7.0 ± 0.9	0.440
Concomitant procedures, n (%)
Burch colposuspension	4 (9.8%)	6 (14.6%)	0.736
Posterior colporrhaphy	10 (24.4%)	4 (9.8%)	0.142
Perineal repair	9 (22.0%)	7 (17.1%)	0.781
Intraoperative complications, n (%)	2 (4.9%)	0 (0.0%)	0.474

Data are median (IQR) or mean ± SD unless otherwise noted. P values are from Mann–Whitney U test, t-test, or Fisher’s exact test, as appropriate. Abbreviations as in Table 1

Anatomic outcomes (POP-Q)

POP-Q measurements over time are displayed in Table 3; Fig. 2A–C. Baseline POP-Q values were identical between groups. At 1 month, both groups demonstrated dramatic anatomic improvement: point Ba was − 2.3 ± 0.5 cm (LLSHR) and − 2.2 ± 0.4 cm (LLSHE) (P = 0.806); point C was − 5.3 ± 0.5 cm vs. −5.8 ± 0.4 cm (P < 0.001); and point Bp was − 2.4 ± 0.5 cm vs. −2.2 ± 0.4 cm (P = 0.137). The early difference in point C reflected a deeper initial cervical placement in the LLSHE group that persisted throughout follow-up. At 12 months, point C remained significantly more negative in the LLSHE group (− 5.1 ± 0.5 cm vs. −4.5 ± 0.6 cm; P < 0.001), and at 24 months this difference was maintained (− 4.8 ± 0.5 cm vs. −4.4 ± 0.6 cm; P = 0.004). Point Ba at 12 months was − 2.1 ± 0.3 cm in LLSHR vs. −2.3 ± 0.5 cm in LLSHE (P = 0.013), suggesting slightly superior anterior wall support in the STH group; by 24 months, however, Ba did not differ significantly (− 2.0 ± 0.8 vs. −1.9 ± 0.7 cm; P = 0.522). Point Bp showed no between-group differences at any time point (all P > 0.05).

Table 3.

POP-Q Measurements and patient-reported outcomes at baseline and 1, 6, and 12 months postoperatively

Variable	TH Baseline (n = 41)	STH Baseline (n = 41)	P	TH 1 M (n = 41)	STH 1 M (n = 41)	P	TH 6 M (n = 39)	STH 6 M (n = 38)	P	TH 12 M (n = 36)	STH 12 M (n = 36)	P
Completed follow-up, n	41	41	—	41	41	—	39	38	—	36	36	—
POP-Q measurements, mean ± SD
Ba (cm)	2.5 ± 1.0	2.5 ± 1.2	0.783	-2.3 ± 0.5	-2.2 ± 0.4	0.806	-2.3 ± 0.5	-2.2 ± 0.4	0.630	-2.1 ± 0.3	-2.3 ± 0.5	0.013
C (cm)	2.5 ± 0.9	2.4 ± 1.0	0.668	-5.3 ± 0.5	-5.8 ± 0.4	< 0.001	-5.0 ± 0.5	-5.5 ± 0.5	< 0.001	-4.5 ± 0.6	-5.1 ± 0.5	< 0.001
Bp (cm)	1.0 ± 1.1	1.1 ± 1.0	0.555	-2.4 ± 0.5	-2.2 ± 0.4	0.137	-2.3 ± 0.4	-2.1 ± 0.3	0.076	-2.2 ± 0.4	-2.3 ± 0.5	0.320
Patient-reported outcomes, median (IQR)
PFDI-20	87.0 (79.0–92.0)	85.0 (76.0–89.0)	0.574	50.0 (42.8–59.0)	49.5 (35.8–58.8)	0.494	41.0 (24.0–51.0)	40.0 (25.0–54.0)	0.920	40.0 (31.2–54.0)	37.0 (24.5–51.0)	0.410
PFIQ-7	65.0 (51.0–80.0)	67.0 (54.0–74.0)	0.941	33.5 (18.8–48.0)	37.5 (22.0–46.0)	0.859	25.0 (8.0–39.0)	32.0 (16.0–43.0)	0.395	18.0 (7.2–37.8)	25.5 (12.8–35.2)	0.613
PISQ-12	27.0 (23.0–31.0)	28.0 (23.0–30.0)	0.798	30.0 (25.0–35.2)	31.0 (26.0–35.2)	0.946	31.0 (28.0–36.0)	32.0 (29.0–36.0)	0.833	31.0 (27.0–34.0)	37.5 (33.0–42.5)	< 0.001

POP-Q data are mean ± SD; PRO data are median (IQR). P values for POP-Q comparisons are from independent-samples t-test; P values for PRO comparisons are from the Mann–Whitney U test. A dash (—) indicates no statistical test was applied. Abbreviations as in Table 1

Fig. 2.

Longitudinal POP-Q measurements (A–C) and patient-reported outcomes (D–F) by treatment group. Panels A–C: mean ± SD for Ba, C, and Bp. Panels D–F: median with IQR for PFDI-20, PFIQ-7, and PISQ-12. Red p values indicate P < 0.05

Patient-reported outcomes

Both groups experienced clinically meaningful and statistically significant improvements in PFDI-20 and PFIQ-7 from baseline through all follow-up time points (Fig. 2D–F; Table 3). At 12 months, median PFDI-20 was 40.0 (IQR 31.2–54.0) in LLSHR vs. 37.0 (24.5–51.0) in LLSHE (P = 0.410); median PFIQ-7 was 18.0 (7.2–37.8) vs. 25.5 (12.8–35.2) (P = 0.613). These differences were not statistically significant, indicating equivalent symptomatic relief from pelvic floor dysfunction in both groups.

In contrast, sexual function diverged significantly between the groups over time. The PISQ-12 score increased (improved) in both groups after surgery; however, the improvement was substantially greater in the LLSHE group. At 12 months, median PISQ-12 was 31.0 (IQR 27.0–34.0) in LLSHR vs. 37.5 (33.0–42.5) in LLSHE (P < 0.001), a between-group difference of 6.5 points that exceeded the established minimum clinically important difference for this instrument. At 24 months, this advantage was maintained: 31.5 (26.8–39.0) vs. 37.0 (34.0–43.0) (P = 0.005). At 24 months, PFDI-20 showed a trend toward lower scores in the LLSHE group (38.0 [17.0–53.0] vs. 48.0 [34.2–59.0]; P = 0.060), as did PFIQ-7 (23.0 [4.0–40.0] vs. 30.0 [16.0–43.2]; P = 0.255), though neither reached statistical significance.

Adverse events and mesh-related complications at 24 months

Mesh-related and other late adverse events are detailed in Table 4. Mesh exposure was identified in 3 participants (9.4%) in the LLSHR group and none in the LLSHE group, a difference that did not reach statistical significance (P = 0.226) but may be clinically meaningful given that cervical stump preservation reduces the extent of vaginal cuff created, thereby limiting mesh–epithelium contact. Mesh-related pain and de novo dyspareunia occurred at similar rates in both groups (approximately 9–13%; all P > 0.05). New or worsened urinary dysfunction was reported by 2 participants (6.2%) in LLSHR and 2 (6.1%) in LLSHE (P = 1.000). No participant in either group developed new-onset stress urinary incontinence at 24 months. Other complications (primarily superficial wound issues and minor urinary tract infections) occurred in 6 (18.8%) and 3 (9.1%) participants in the LLSHR and LLSHE groups, respectively (P = 0.442).

Table 4.

Twenty-four–month outcomes: POP-Q, patient-reported outcomes, and adverse events

Variable	Total Hysterectomy (n = 41)	Subtotal Hysterectomy (n = 41)	P value
Completed follow-up, n	32	33	—
POP-Q measurements, mean ± SD
Ba (cm)	-2.0 ± 0.8	-1.9 ± 0.7	0.522
C (cm)	-4.4 ± 0.6	-4.8 ± 0.5	0.004
Bp (cm)	-2.2 ± 0.7	-2.1 ± 0.6	0.502
Patient-reported outcomes, median (IQR)
PFDI-20	48.0 (34.2–59.0)	38.0 (17.0–53.0)	0.060
PFIQ-7	30.0 (16.0–43.2)	23.0 (4.0–40.0)	0.255
PISQ-12	31.5 (26.8–39.0)	37.0 (34.0–43.0)	0.005
Complications, n (%)
Mesh exposure	3 (9.4%)	0 (0.0%)	0.226
Mesh-related pain	3 (9.4%)	3 (9.1%)	1.000
Dyspareunia	4 (12.5%)	3 (9.1%)	0.966
Urinary dysfunction (new/worsened)	2 (6.2%)	2 (6.1%)	1.000
Defecatory dysfunction (new/worsened)	1 (3.1%)	2 (6.1%)	1.000
New-onset SUI	0 (0.0%)	0 (0.0%)	> 0.999
Other complications	6 (18.8%)	3 (9.1%)	0.442

POP-Q data are mean ± SD; PRO data are median (IQR). P values are from two-sample t-test, Mann–Whitney U test, or Fisher’s exact test, as appropriate. Abbreviations as in Table 1

Discussion

In this prospective comparative study of 82 women undergoing LLS for symptomatic uterovaginal prolapse, LLSHE was associated with significantly superior apical support — as reflected by a more negative POP-Q point C at both 12 and 24 months — and markedly better sexual function on the PISQ-12 at both time points, compared with LLSHR. Both approaches delivered equivalent, clinically meaningful reductions in pelvic floor distress and quality-of-life impact (PFDI-20, PFIQ-7). LLSHE was also associated with shorter operative time, a numerically lower rate of mesh exposure, and no increased risk of mesh-related pain, dyspareunia, or new urinary dysfunction. Because group allocation was based on patient preference rather than randomization, these observations reflect associations and should be interpreted as hypothesis-generating rather than evidence of causality.

The persistent association of LLSHE with superior apical support is biologically plausible. The cervix serves as a natural anchoring point for the mesh in STH, avoiding the need for a vaginal vault cuff and maintaining the structural integrity of the cardinal-uterosacral complex. Several prior studies of laparoscopic sacrocolpopexy have reported that preservation of the cervix results in a more anatomically favorable mesh position and may reduce mesh tension on the anterior vaginal wall [21–23]. Our data extend this observation to LLS: the cervical attachment point was associated with a point C approximately 0.6 cm more negative at 12 months and 0.4 cm more negative at 24 months. The clinical significance of a difference of this magnitude in POP-Q point C has not been formally established. Published data suggest that differences of approximately 0.5 cm or greater in apical support may be perceptible to patients; however, in the absence of a validated minimal clinically important difference (MCID) for individual POP-Q points, this finding should be interpreted with caution. The observed difference was consistent across all time points and statistically robust, but its translation into symptomatic benefit remains to be confirmed in a powered randomized trial.

The association of LLSHE with better sexual function (PISQ-12) is a clinically important observation. Sexual function following POP surgery is multifactorial, encompassing altered vaginal anatomy, disruption of autonomic innervation, mesh-related pain, and psychological factors. Cervical preservation during STH avoids the creation of a vaginal vault scar, maintains the natural vaginal depth and axis, and preserves the autonomic nerve plexus within the paracervical tissue — all factors believed to contribute to sexual satisfaction [11–13]. A between-group difference of 6.5 PISQ-12 points at 12 months substantially exceeds the minimum clinically important difference of approximately 2.0–3.8 points reported in the literature [24], suggesting that the magnitude of the difference is clinically meaningful. These findings align with those of randomized trials comparing STH with TH in the sacrocolpopexy setting, which have also demonstrated superior sexual function outcomes with cervical preservation [25, 26]. However, we acknowledge that sexual function outcomes are highly susceptible to unmeasured confounding. Preoperative sexual activity frequency, relationship status, menopausal hormone use, and individual psychosocial expectations were not systematically captured and could not be included in the IPTW model. Women who chose STH may have had different baseline sexual priorities or expectations that independently influenced postoperative PISQ-12 scores. The PISQ-12 findings should therefore be regarded as hypothesis-generating, pending confirmation in a randomized trial with stratification by preoperative sexual activity status.

The numerically higher rate of mesh exposure in the LLSHR group (9.4% vs. 0%) is a potentially important signal, but readers are strongly cautioned against drawing definitive conclusions: the study was not powered for secondary safety endpoints, only 3 events occurred, and the between-group difference did not reach statistical significance (P = 0.226). The present data are insufficient to establish whether STH confers a protective effect against mesh exposure. Biologically, the formation of a vaginal vault following TH creates a surgical scar that may be under greater tension when the overlying mesh is anchored to it, increasing vulnerability to exposure. This explanation is consistent with published evidence from sacrocolpopexy series demonstrating higher mesh exposure rates after TH than after STH [27, 28]. The overall mesh exposure rate in our LLSHE group (0%) compares favorably with pooled rates of 2–4% reported in LLS meta-analyses [29, 30], but this comparison is limited by the small sample. Adequately powered prospective trials are required before any conclusion about differential mesh exposure risk can be drawn.

This study employed a single-port (single-incision) laparoscopic platform for all procedures. Single-port LLS uses one umbilical multi-channel port together with two small lateral stab incisions for mesh fixation, reducing the total number of abdominal incisions compared with conventional multiport laparoscopy. The surgeon had performed more than 50 LLS procedures prior to the study period, suggesting that results reflect a post-learning-curve experience. Nevertheless, the operative time difference between LLSHE and LLSHR (approximately 22 min) is at least partly attributable to the technically simpler cervical stump closure in STH compared with vaginal vault closure required in TH under single-port constraints. Whether similar time advantages for STH would persist with conventional multiport laparoscopy remains to be assessed.

The present study should also be contextualized within the rapidly evolving landscape of minimally invasive prolapse surgery. Beyond conventional laparoscopy, lateral suspension has been adapted to the vNOTES (vaginal natural orifice transluminal endoscopic surgery) platform. Uluutku Bulutlar et al. recently demonstrated that vNOTES lateral suspension achieves comparable anatomic outcomes to laparoscopic LLS with the additional advantage of a completely scarless abdominal approach and potentially faster recovery.31 As these techniques mature, future comparative studies should evaluate whether the relative merits of STH versus TH observed here are preserved across surgical platforms, including vNOTES-based LLS.

Our study has several limitations that must be acknowledged. First, group allocation by patient preference introduces selection bias and confounding by indication that IPTW only partially mitigates: unmeasured variables — preoperative sexual activity, partner status, anatomic variation, and patient expectations — may have independently influenced outcomes and cannot be controlled. The PISQ-12 findings are particularly vulnerable to this limitation. All LLSHE associations should be interpreted as hypothesis-generating, not causal. Second, the requirement for lifelong cervical cytology in STH patients may have systematically deterred women with limited healthcare access from choosing LLSHE, representing an unmeasured confounder affecting group composition. Third, the single-center, single-surgeon design limits external generalizability; results reflect one institution’s expertise and case selection and may not be reproducible at lower-volume centers. Fourth, follow-up decreased to 79% at 24 months. Although attrition was balanced between groups, missing data at 24 months were handled by complete-case analysis; MCAR was assumed but not formally tested, which may have introduced attrition bias particularly for late adverse events such as mesh exposure, where even small numbers of missing events could materially alter the observed rates. Fifth, concomitant procedures (posterior colporrhaphy more frequent in LLSHR; Burch colposuspension slightly more in LLSHE) were not controlled in the primary analyses and may have influenced sexual function and urinary outcomes. Sixth, no correction for multiple comparisons was applied to secondary endpoints; some statistically significant secondary findings may represent type I error. Seventh, 24-month follow-up does not capture late mesh complications or cervical stump pathology; longer surveillance is needed.

Conclusion

In this prospective comparative study of women undergoing LLS for symptomatic uterovaginal prolapse, LLSHE was associated with superior apical anatomic support and better sexual function through 24 months of follow-up, achieved in less operative time, with a numerically lower rate of mesh exposure compared with LLSHR. Given the non-randomized design, these findings are hypothesis-generating and should not be interpreted as evidence of causal superiority of STH. They provide preliminary evidence sufficient to motivate a prospective randomized controlled trial to establish causality and provide definitive clinical guidance.

Abbreviations

BMI

body mass index

IPTW

inverse probability of treatment weighting

IQR

interquartile range

IRB

institutional review board

LLS

laparoscopic lateral suspension

LLSHE

laparoscopic lateral suspension with subtotal (supracervical) hysterectomy

LLSHR

laparoscopic lateral suspension with total hysterectomy

MCAR

missing completely at random

MCID

minimal clinically important difference

MMRM

mixed-effects model for repeated measures

POP

pelvic organ prolapse

POP-Q

Pelvic Organ Prolapse Quantification system

PFDI-20

Pelvic Floor Distress Inventory–20

PFIQ-7

Pelvic Floor Impact Questionnaire–7

PISQ-12

Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire–12

PRO

patient-reported outcome

SD

standard deviation

SMD

standardized mean difference

STH

subtotal (supracervical) hysterectomy

SUI

stress urinary incontinence

TH

total hysterectomy

vNOTES

vaginal natural orifice transluminal endoscopic surgery

Authors’ contributions

Hong-Mei Wu, Ning Xu and Yuan-hong Li conceived the study; Rui Xiong, Zhi-Gui Luo and Min Li performed data acquisition; Hong-Mei Wu and Ning Xu analyzed data and drafted the manuscript; all authors critically revised the manuscript and approved the final version.

Funding

This work was supported by the Medical Scientific Research Project of Chengdu City (Grant No. 2023023). The funder had no role in study design, data collection/analysis, or manuscript preparation.

Data availability

The datasets used and analyzed during the current study are available from the corresponding author on reasonable request, subject to institutional review board approval and patient privacy protection requirements.

Declarations

Ethics approval and consent to participate

This study was approved by the Institutional Review Board of Chengdu Integrated TCM&Western Medicine Hospital (IRB ID: 2021.XJS.019). Written informed consent was obtained from all participants prior to inclusion. All procedures adhered to the Declaration of Helsinki. This trial was retrospectively registered in the Chinese Clinical Trial Registry (ChiCTR) under the registration number ChiCTR2600118158 (February 2, 2026). The trial was retrospectively registered; data collection commenced following institutional ethics approval prior to registration completion due to institutional administrative procedural requirements.

Consent for publication

Not Applicable.

Competing interests

The authors declare no competing interests.