Evidence-based recommendations of the International Society for Gynecologic Endoscopy (ISGE) for the prevention of apical prolapse following vaginal hysterectomy for prolapsed and non-prolapsed uterus

Apical vaginal vault prolapse is a common complication after hysterectomy, especially in multiparous women, causing significant discomfort and impairing quality of life due to urinary, anorectal, and sexual dysfunction.

The International Society for Gynecologic Endoscopy (ISGE) aimed to provide evidence-based recommendations for preventing post-hysterectomy vault prolapse (PHVP) following vaginal hysterectomy (VH) for benign uterine conditions, whether the uterus is prolapsed or not.

The ISGE Working Group formulated key clinical questions and conducted a comprehensive literature review using Medline/PubMed and Cochrane databases, covering studies from January 2006 to January 2025, alongside guidelines from the American College of Obstetricians and Gynecologists (ACOG) and the American Association of Gynecologic Laparoscopists(AAGL). Evidence was graded according to the GRADE framework.

Four main recommendations were established: (1) Suturing the cardinal and uterosacral ligaments to the vaginal cuff during VH is effective in preventing PHVP in cases of non-prolapsed or stage I prolapsed uterus (Grade 2B). (2) McCall's culdoplasty is recommended for VH performed in stage II uterovaginal prolapse (Grade 1B). (3) Sacrospinous ligament fixation (SSLF) and sacrocolpopexy (SCP), or alternatives like pectopexy, should be considered for stages III and IV prolapse (Grade 1B). (4) SSLF and SCP are not advised for PHVP prevention when no prolapse is present (Grade 2B).

The ISGE recommendations emphasize adapting surgical techniques based on prolapse severity to reduce PHVP risk, thereby improving surgical outcomes and enhancing patients' quality of life.

Published by European journal of obstetrics, gynecology, and reproductive biology, 2025. The guideline itself is at the source linked here.

doi.org/10.1016/j.ejogrb.2025.114559