Fascial fixation versus non-fixation in vNOTES lateral suspension after vaginal hysterectomy for pelvic organ prolapse

Abstract

BACKGROUND:

Mesh-based vNOTES lateral suspension is an emerging minimally invasive technique for apical pelvic organ prolapse repair, but the clinical value of fascial fixation of the lateral mesh arms remains unclear.

OBJECTIVES:

To compare 12-month anatomical outcomes and recurrence rates between fascial fixation and non-fixation of the lateral mesh arms during mesh-based vNOTES lateral suspension after vaginal hysterectomy.

DESIGN:

Retrospective comparative study

SETTINGS:

Tertiary referral center

PATIENTS AND METHODS:

We reviewed women who underwent vaginal hysterectomy combined with mesh-based vNOTES lateral suspension for pelvic organ prolapse between March 2022 and March 2026. Patients were grouped according to whether the lateral mesh arms were fixed to the fascia. Preoperative and 12-month postoperative Pelvic Organ Prolapse Quantification (POP-Q) measurements, recurrence, perioperative outcomes, postoperative complications, and mesh erosion were evaluated.

MAIN OUTCOME MEASURES:

The primary outcome was recurrence at 12 months, defined as POP-Q point C >−1 cm, reflecting clinically significant apical prolapse. Secondary outcomes included POP-Q values and change scores, operative time, estimated blood loss, length of hospital stay, complications, and mesh erosion.

SAMPLE SIZE:

101 patients; 46 in the non-fixation group and 55 in the fixation group.

RESULTS:

Both groups demonstrated significant improvement in all evaluated POP-Q points at 12 months compared with baseline (P<.001). Recurrence occurred in four patients (8.7%) in the non-fixation group and four patients (7.3%) in the fixation group (P=1.0). Operative time, estimated blood loss, and length of hospital stay were comparable between groups (P=.347, P=.187, and P=.274, respectively). Similarly, no significant between-group differences were observed in perioperative complications (P=.59), postoperative complications (P=.426), or mesh erosion (P=1.0).

CONCLUSIONS:

Fascial fixation of the lateral mesh arms was not associated with improved short-term anatomical, perioperative, or postoperative outcomes at 12 months following mesh-based vNOTES lateral suspension after vaginal hysterectomy.

LIMITATIONS:

Retrospective design, single-center setting, modest sample size, and 12-month follow-up period.

INTRODUCTION

Pelvic organ prolapse (POP) is a prevalent pelvic floor disorder that can substantially impair quality of life and often requires surgical management, particularly when apical support is compromised. Contemporary epidemiologic syntheses identify POP as a major and growing women's health concern, driven by aging populations and cumulative obstetric and connective tissue risk factors.¹

Minimally invasive abdominal approaches such as laparoscopic sacrocolpopexy are widely regarded as a reference standard for durable apical suspension; however, promontory dissection and presacral work may be technically demanding and may be undesirable in selected patients. Laparoscopic lateral suspension (LLS) with mesh was developed as an alternative apical repair that avoids sacral promontory fixation by providing bilateral suspension through lateral mesh arms.² Over the last decade, evidence has expanded from observational cohorts to comparative studies and systematic reviews, supporting favorable anatomic and subjective success.^3,4 Reported mesh-related complication rates have also remained relatively low in the short- to mid-term and longer-term follow-up series.^5,6

Another evolving aspect of prolapse surgery is uterus preservation. Uterus-sparing strategies are increasingly requested and may offer advantages related to patient preference, body image, and recovery, while maintaining effective apical support in appropriately selected patients. In the context of LLS, recent comparative data evaluating uterus-preserving versus hysterectomy-based approaches have further supported a tailored, patient-centered application of lateral suspension techniques.⁷

In parallel, transvaginal natural orifice transluminal endoscopic surgery (vNOTES) has emerged as a minimally invasive platform that may further reduce abdominal wall morbidity while preserving endoscopic visualization. Recent systematic evaluation of vNOTES in urogynecologic surgery suggests feasibility and acceptable perioperative outcomes in selected cases, although the available evidence remains heterogeneous and technique-specific.⁸ Within this framework, vNOTES lateral suspension using a standardized V-shaped polypropylene mesh has been described.⁹ In addition, comparative prospective evidence has demonstrated meaningful improvements in anatomic and functional outcomes compared with native-tissue sacrospinous fixation.¹⁰

Despite these advances, several technical details of lateral suspension remain non-uniform across centers, including whether the lateral mesh arms should be anchored to the fascia at the abdominal exit sites. Some techniques incorporate fascial fixation as a routine operative step, whereas others emphasize a tension-free approach without fixation, suggesting ongoing uncertainty regarding the necessity and clinical implications of this maneuver.^11,12 From a mechanistic standpoint, fascial fixation may improve immediate positional stability and reduce slippage or asymmetric tensioning; conversely, it may increase local pain, tissue reaction, or foreign-body burden and may be unnecessary if subperitoneal tunneling alone provides sufficient stability. We therefore hypothesized that fascial fixation may not be strictly necessary when the mesh arms are adequately positioned, given that the original description of the technique relies on bilateral subperitoneal tunnels to distribute apical tension along the lateral abdominal wall.⁹ To date, comparative clinical data specifically evaluating fascial fixation versus non-fixation in vNOTES-based lateral suspension remain limited.

Because definitions of success and recurrence after prolapse surgery vary across studies, the use of clearly prespecified anatomic outcome criteria is important for meaningful comparison and interpretation.¹³ Similarly, standardized reporting using the Pelvic Organ Prolapse Quantification (POP-Q) system remains essential for consistent assessment of compartment-specific anatomic outcomes.¹⁴ Therefore, the present study aimed to compare anatomic outcomes and recurrence rates between patients who underwent fascial fixation of the lateral mesh arms and those in whom fixation was omitted during mesh-based vNOTES lateral suspension for POP.

PATIENTS AND METHODS

Study design and patient selection

This retrospective comparative study was conducted at the Department of Obstetrics and Gynecology, Gaziosmanpaşa Training and Research Hospital, a tertiary referral center in Istanbul, Türkiye. Medical records of patients who underwent vNOTES lateral suspension for POP after vaginal hysterectomy between March 2022 and March 2026 were reviewed. Only patients with at least 12 months of follow-up and available preoperative and postoperative data were included in the analysis.

Patients were classified into two groups according to whether fascial fixation of the lateral mesh arms was performed at the end of the procedure: the fixation group and the non-fixation group. Group allocation was non-randomized. The decision to perform fascial fixation was based on the operating surgeon's preference and intraoperative judgment. Although some surgeons routinely performed fascial fixation during their initial experience with the technique, no institutional protocol or predefined patient-selection criteria determined whether fascial fixation was applied. Three patients were excluded because group-allocation data were missing, and the final analysis included 101 patients, comprising 55 patients in the fixation group and 46 patients in the non-fixation group.

The study protocol was approved by the Non-Interventional Clinical Research Ethics Committee of Gaziosmanpaşa Training and Research Hospital, Istanbul, Türkiye, on 4 February 2026 (decision no. 09), and the study was conducted in accordance with the principles of the Declaration of Helsinki.

Surgical technique

All patients underwent vNOTES lateral suspension after vaginal hysterectomy using a technique based on the previously described Salman–Ketenci Gencer approach.⁹ In the original description, a V-shaped polypropylene macroporous mesh is prepared from a 30×30 cm mesh by creating two lateral arms approximately 2 cm in width. After access through the vaginal vault, bilateral subperitoneal tunnels are created toward the lateral abdominal wall. The lateral skin exit point is described approximately 3 cm posterolateral to the anterior superior iliac spine and about 2 cm above the iliac crest. The corner of the V-shaped mesh is fixed to the vaginal vault with 1/0 polypropylene, after which the lateral mesh arms are drawn through the bilateral tunnels to provide apical support. In the originally described technique, the excess mesh is trimmed, leaving approximately 1 cm, and the remaining lateral ends are fixed to the fascia with 1/0 polypropylene.

In the fixation group, after appropriate tensioning and trimming of the lateral mesh arms, the remaining mesh ends were fixed to the fascia. In the non-fixation group, the same operative steps were performed except that fascial fixation of the lateral mesh arms was omitted.

Data collection

Demographic, clinical, perioperative, and postoperative variables were obtained from hospital records. Baseline variables included age, body mass index (BMI), gravidity, parity, number of cesarean sections, number of normal spontaneous deliveries, smoking status, comorbidity status, previous abdominal surgery, and preoperative POP-Q measurements. Perioperative and postoperative variables included operative time, estimated blood loss, length of hospital stay, perioperative complications, 12-month POP-Q findings, clinically relevant apical recurrence, postoperative complications, and mesh erosion. The statistical dataset also shows that both absolute 12-month POP-Q values and change scores from baseline to 12 months were evaluated.

Outcome measures

The primary outcome was clinically relevant apical recurrence at 12 months. Recurrence was defined solely according to the predefined anatomical criterion of postoperative POP-Q point C >−1 cm at the 12-month follow-up. Symptoms or reoperation were not required for the definition of recurrence in this study. This anatomical threshold was selected because it is widely considered clinically relevant and may warrant consideration of further treatment in appropriate clinical settings.

The secondary outcomes were postoperative POP-Q values at 12 months, change in POP-Q measurements from baseline to 12 months, perioperative complications, postoperative complications, mesh erosion, estimated blood loss, operative time, and length of hospital stay. Pelvic support was assessed using the Pelvic Organ Prolapse Quantification (POP-Q) system.

Statistical analysis

All statistical analyses were performed using IBM SPSS Statistics for Windows, version 26.0 (IBM Corp., Armonk, NY, USA. Continuous variables were expressed as mean ± standard deviation for normally distributed data and as median (interquartile range) for non-normally distributed data. Between-group comparisons for continuous variables were performed using Welch's t test for normally distributed variables and the Mann–Whitney U test for non-normally distributed variables. Categorical variables were presented as number (percentage) and compared using the chi-square test or Fisher's exact test, as appropriate. For POP-Q analyses, within-group preoperative-to-12-month changes were evaluated using the paired t test or Wilcoxon signed-rank test, depending on data distribution. Between-group comparisons of POP-Q improvement were performed using delta values calculated as 12 months minus preoperative values. All tests were two-sided, and P<.05 was considered statistically significant.

RESULTS

A total of 104 patients who underwent vNOTES lateral suspension after vaginal hysterectomy between March 2022 and March 2026 were initially identified. After exclusion of 3 patients with missing group-allocation data, 101 patients were included in the final analysis. Of these, 46 patients were assigned to the non-fixation group and 55 patients to the fixation group. The patient selection process is summarized in Figure 1.

Figure 1.

Flow diagram of patient selection and study cohort allocation.

Baseline demographic and clinical characteristics were comparable between the two groups. There were no statistically significant differences in age, body mass index, gravidity, parity, number of normal vaginal deliveries, smoking status, comorbidity, previous abdominal surgery, or concomitant compartment prolapse distribution between the groups (Table 1). No patient in either group had a history of cesarean delivery.

Table 1.

Baseline demographic and clinical characteristics of the study groups.

Variables	Non-fixation (n=46)	Fixation (n=55)	P value
Age, years	58.5±8.9	60.2±7.8	.336
BMI (kg/m2)	28.4±3.7	28.1±3.6	.653
Gravidity	4.0 (3.0–5.0)	4.00 (3.0–5.0)	.854
Parity	3.0 (2.0–4.0)	3.00 (2.0–4.5)	.886
Number of normal vaginal deliveries	3.0 (2.0–4.0)	3.00 (2.0–4.5)	.833
Concomitant compartment prolapse, n (%)
None	36 (78)	46 (84)	.733
Anterior compartment prolapse (cystocele)	7 (15)	7 (13)
Posterior compartment prolapse (rectocele)	3 (6)	2 (4)
Smoking, n (%)	7 (15)	10 (18)	.692
Comorbidity, n (%)	15 (33)	23 (42)	.341
Previous abdominal surgery, n (%)	13 (28)	9 (16)	.149

Note: Values are presented as mean±SD, median (interquartile range), or n (%), as appropriate. Welch's t test or Mann–Whitney U test was used for continuous variables, and Chi-square test or Fisher's exact test for categorical variables. The P value for concomitant compartment prolapse reflects the overall comparison across categories.

Perioperative and postoperative clinical outcomes are summarized in Table 2. Mean operative time was 83.9±23.3 minutes in the non-fixation group and 88.2±21.7 minutes in the fixation group (P=.347). Estimated blood loss and length of hospital stay were also similar between the groups (P=.187 and P=.274, respectively). Intraoperative bladder injury occurred in 2 patients (4.3%) in the non-fixation group and 1 patient (1.8%) in the fixation group (P=.590). At 12 months, recurrence was observed in 4 patients (8.7%) in the non-fixation group and 4 patients (7.3%) in the fixation group (P=1.000). Mesh erosion occurred in 2 patients (4.3%) and 2 patients (3.6%), respectively (P=1.0). Postoperative complications were infrequent and did not differ significantly between the groups (P=.426) (Table 2).

Table 2.

Perioperative and postoperative outcomes of the study groups.

Variables	Non-fixation (n=46)	Fixation (n=55)	P value
Perioperative outcomes
Operative time, min	83.9±23.3	88.2±21.7	.347
Estimated blood loss, mL	495.0 (342.5–687.5)	360.0 (300.0–575.0)	.187
Length of hospital stay, days	3.0 (2.0–3.0)	3.0 (2.0–3.0)	.274
Intraoperative complication (bladder injury), n (%)	2 (4)	1 (2)	.590
Postoperative outcomes
Recurrence at 12 months, n (%)*	4 (9)	4 (7)	1.000
Postoperative complication, n (%)
None	46 (100)	53 (96)	.426
Ecchymosis	0	1 (2)
Wound site infection	0	1 (2)
Mesh erosion, n (%)	2 (4)	2 (4)	1.000

Note: Values are presented as mean±standard deviation, median (interquartile range), or n (%), as appropriate. Continuous variables were compared using Welch's t test for normally distributed data and the Mann–Whitney U test for non-normally distributed data. Categorical variables were compared using the chi-square test or Fisher's exact test, as appropriate. The p value for postoperative complication refers to the overall comparison across categories. A two-sided P value <.05 was considered statistically significant.

^*Recurrence was defined solely by the prespecified anatomical criterion of POP-Q point C >−1 cm at 12 months; neither symptoms nor reoperation was required for this definition.

POP-Q outcomes are shown in Table 3. In both groups, all evaluated POP-Q points demonstrated significant improvement at the 12-month follow-up compared with preoperative values. In the non-fixation group, median Aa, Ba, Ap, and Bp values improved from positive preoperative measurements to -3.00 at 12 months (all P<.001). Point C improved from 2.5 (0–3.75) preoperatively to -7.0 (-7.0 to -6.0) at 12 months (P<.001). In the fixation group, similar significant improvements were observed in all POP-Q points, including point C, which improved from 3.0 (1.5–6.0) preoperatively to -7.0 (-7.0 to -6.0) at 12 months (all P<.001). Total vaginal length changed slightly but significantly in both groups (Table 3).

Table 3.

Preoperative and 12-month postoperative POP-Q measurements of the study groups.

Variables	Non-fixation Preoperative (n=46)	Non-fixation 12 months (n=46)	P value	Fixation Preoperative (n=55)	Fixation 12 months (n=55)	P value
Aa	2.0 (1.0–2.75)	-3.0 (-3.0–-2.0)	<.001	2.0 (1.0–3.0)	-3.0 (-3.0–-2.0)	<.001
Ba	2.0 (1.0–3.75)	-3.0 (-3.0–-2.0)	<.001	2.0 (1.0–4.0)	-3.0 (-3.0–-2.0)	<.001
Ap	2.0 (1.0–2.0)	-3.0 (-3.0–-2.0)	<.001	2.0 (1.0–2.0)	-3.0 (-3.0–-2.0)	<.001
Bp	2.0 (1.0–2.0)	-3.0 (-3.0–-2.0)	<.001	2.0 (1.0–2.0)	-3.0 (-3.0–-2.0)	<.001
C	2.5 (0–3.75)	-7.0 (-7.0–-6.0)	<.001	3.0 (1.5–6.0)	-7.0 (-7.0–-6.0)	<.001
TVL	8.0 (8.0–9.0)	8.0 (7.0–8.0)	.001	8.0 (8.0–9.0)	8.0 (7.5–8.5)	<.001

Note: Values are presented as median (interquartile range), except where otherwise indicated. Within-group preoperative to 12-month comparisons were performed using the Wilcoxon signed-rank test for Aa, Ba, Ap, Bp, and TVL, and the paired t test for point C. Point D was not included in postoperative comparisons because all patients underwent vaginal hysterectomy. A two-sided P value <.05 was considered statistically significant.

Between-group comparison of changes in POP-Q measurements from baseline to 12 months is presented in Table 4. No statistically significant differences were found between the fixation and non-fixation groups in the magnitude of change for Aa, Ba, Ap, Bp, C, or TVL. Although the fixation group showed a numerically greater improvement in Aa, this difference did not reach statistical significance (P=.097) (Table 4). Overall, fascial fixation of the lateral mesh arms was not associated with superior anatomical improvement compared with non-fixation.

Table 4.

Between-group comparison of changes in POP-Q measurements from baseline to 12 months.

Variables	Non-fixation (n=46)	Fixation (n=55)	P value
Aa Δ (12 months – preoperative)	-4.0 (-5.0 to -3.0)	-5.0 (-5.0 to -4.0)	.097
Ba Δ (12 months – preoperative)	-5.0 (-6.0 to -3.0)	-5.0 (-7.0 to -3.0)	.593
Ap Δ (12 months – preoperative)	-4.0 (-5.0 to -3.0)	-4.0 (-5.0 to -3.0)	.566
Bp Δ (12 months – preoperative)	-4.0 (-5.0 to -3.0)	-4.0 (-5.0 to -3.0)	.578
C Δ (12 months – preoperative)	-8.8±3.3	-9.6±3.7	.227
TVL Δ (12 months – preoperative)	0 (-1.0 to 0)	0 (-1.0 to 0)	.911

Note: Values are presented as mean ± standard deviation or median (interquartile range), as appropriate. Between-group comparisons of delta values were performed using Welch's t test for normally distributed variables and the Mann–Whitney U test for non-normally distributed variables. Negative delta values indicate greater anatomical improvement. A two-sided P value <.05 was considered statistically significant.

DISCUSSION

In this retrospective comparative study, fascial fixation of the lateral mesh arms during vNOTES lateral suspension after vaginal hysterectomy did not confer measurable perioperative or postoperative advantages over non-fixation. Operative time, estimated blood loss, length of hospital stay, intraoperative complications, postoperative complications, 12-month clinically relevant apical recurrence, and mesh erosion rates were all comparable between the two groups. Moreover, both techniques resulted in marked improvement in POP-Q measurements, and the magnitude of anatomical change from baseline to 12 months did not differ significantly between groups.

These findings are broadly consistent with the existing literature on lateral suspension and vNOTES-based prolapse repair. Laparoscopic lateral suspension has repeatedly been associated with favorable anatomical and subjective outcomes, acceptable recurrence rates, and relatively low mesh-related morbidity in both cohort studies and recent pooled analyses.^2,3,5,6 Likewise, the current vNOTES literature suggests that this platform is feasible and effective for apical prolapse repair, with generally high success rates and predominantly low-grade complications.^8-10 In this context, our recurrence and mesh erosion rates in both groups appear to fall within the range reported in the contemporary lateral suspension literature, and our findings do not suggest that adding fascial fixation improves short-term clinical safety or durability.

The POP-Q results in our series also support the anatomical effectiveness of vNOTES lateral suspension irrespective of fascial fixation. In both groups, Aa, Ba, Ap, Bp, and C improved significantly at 12 months, indicating that the procedure itself provided substantial restoration of apical and compartmental support. This is in line with the original Salman–Ketenci Gencer report and with randomized data comparing mesh-based vNOTES lateral suspension with sacrospinous fixation, both of which demonstrated significant postoperative anatomical improvement after vNOTES lateral suspension.^9,10 Our between-group analysis also suggests that although both groups improved significantly, fixation of the lateral mesh arms to fascia did not translate to greater anatomical gain.

From a technical standpoint, this absence of difference is noteworthy, because anchoring of the lateral mesh arms remains a non-uniform step across centers and is often driven by surgical preference rather than comparative evidence.^11,12 One biologically plausible explanation is that once the polypropylene mesh arms are adequately tunneled and positioned, long-term stabilization may depend less on the presence of an additional fascial stitch and more on subsequent tissue integration around the mesh. Experimental and translational studies have shown that polypropylene implants induce host responses characterized by collagen deposition, fibrosis, and progressive incorporation into surrounding tissue.^15-18 Human explant studies further suggest that collagen deposition and fibrotic remodeling are central components of the mesh–tissue interface, although excessive or dysregulated fibrosis may also contribute to complications.^19,20 Taken together, these data support the interpretation that the mesh arms may acquire secondary stability through tissue ingrowth and organized fibrotic incorporation, thereby reducing the incremental long-term contribution of fascial fixation. This interpretation should be viewed as a biologically plausible explanation for our clinical findings rather than a directly measured mechanism in the present study.

Another point that supports this interpretation is the recurrence pattern observed in our cohort. In our series, recurrences were not documented in the early postoperative period. If omission of fascial fixation had caused a clinically important immediate mechanical failure, one would expect recurrence to emerge relatively early after surgery. Prior prolapse literature suggests that a meaningful proportion of recurrences becomes evident during the first postoperative year or early follow-up, particularly when the repair is mechanically vulnerable.^21,22 Against that background, the lack of early recurrence in our non-fixation group argues against absence of fascial fixation as the main driver of failure. Instead, recurrence is more likely to be multifactorial, reflecting underlying tissue quality, compartment-specific biomechanics, progressive pelvic floor dysfunction, and patient-related risk factors rather than the presence or absence of a single anchoring suture.

The present study has several strengths. All patients underwent the same general operative concept in a single center, all procedures were performed after vaginal hysterectomy, and postoperative anatomical outcomes were assessed using standardized POP-Q measurements.¹⁴ In addition, we used a prespecified anatomical recurrence definition, which improves internal consistency in a field where outcome definitions have historically varied considerably.¹³ At the same time, several limitations should be acknowledged. First, the retrospective design introduces an inherent risk of selection bias and unmeasured confounding. Furthermore, because the decision to perform fascial fixation was based on the operating surgeon's individual preference and intraoperative judgment rather than randomization or a predefined institutional protocol, selection bias cannot be excluded. This limitation should be considered when interpreting the observed between-group comparisons. Second, the modest sample size and the low number of recurrence events may have limited our ability to detect small between-group differences. In addition, the small number of recurrence events precluded reliable multivariable modeling of the primary outcome. Therefore, the absence of statistically significant differences should not be interpreted as evidence of equivalence between the two techniques. Rather, our findings indicate that no large differences were detected within the limits of the present study. Third, follow-up was limited to 12 months and therefore reflects only short-term outcomes. Delayed mesh-related complications, structural migration, and late recurrence cannot be excluded without longer-term follow-up. Finally, standardized patient-reported outcome measures were not consistently available because of the retrospective design of the study. Consequently, postoperative pain scores, quality-of-life assessments, sexual function, patient satisfaction, and other symptom-based outcomes could not be evaluated. Therefore, our findings should be interpreted primarily in terms of short-term anatomical outcomes rather than overall clinical benefit. We also did not evaluate time-to-recurrence analyses in this comparison.

In conclusion, fascial fixation of the lateral mesh arms during mesh-based vNOTES lateral suspension after vaginal hysterectomy was not associated with improved perioperative outcomes, postoperative morbidity, recurrence, mesh erosion, or anatomical improvement at 12 months. Our findings suggest that routine fascial fixation may not be necessary in every case, particularly when mesh positioning and subperitoneal tunneling are adequate. Larger prospective studies with longer follow-up are needed to confirm these short-term findings, determine whether any subgroup derives specific benefit from fixation, and clarify the relative contributions of surgical mechanics and mesh–tissue remodeling to long-term success, including delayed mesh-related complications.

Funding Statement

None.