A three-year experience of a post-hysterectomy apical prolapse surgical treatment in menopausal women

These days hysterectomy is considered to be a widely used method of treating benign and malignant pelvic diseases. According to world statistics, hysterectomy is one of the most frequently performed interventions in surgical gynecology [1]. Along with any other major surgical procedure, hysterectomy may carry long-term risks of both early postoperative complications and adverse outcomes. One of them is post-hysterectomy vaginal vault prolapse (PHVVP), the correction of which is becoming a new direction of research in the field of genital prolapse surgery. A joint task force of the International Urogynelogical Association (IUGA) and the International Continence Society (ICS) has come to a consensus defining the problem as “vaginal apical dysfunction” and attributes its underlying cause to loss of apical support [2, 3]. According to data provided by various authors, the incidence of PHVVP varies from 0.2% to 43% [4–6]. The results obtained by Robinson D. et al. demonstrate that the incidence of vaginal vault prolapse after vaginal hysterectomy is 9.8% higher than that after abdominal procedure [4]. Kuittinen T. et al. agreed with the above mentioned clinicians and conducted a comparative analysis on the impact of various surgical approaches for total hysterectomy (laparotomic, laparoscopic and vaginal) on the long-term risk of vaginal vault prolapse. The most notable result concerned vaginal hysterectomy, after which, in the overwhelming majority of cases, genital prolapse was detected in patients during outpatient visits [6]. Therefore, hysterectomy performed due to an existing prolapse is an independent risk factor for recurrence of genital prolapse in the postoperative period. On average, up to 8% of women require corrective surgery after a previous vaginal hysterectomy [7]. In addition, repeated surgery is often associated with such problems as tissue scarring, adhesions, and disruption of anatomical structures, which predictably increases the risk of surgical failure. Thus, when correcting posthysterectomy genital prolapse, the choice of the most optimal and effective scope of surgical intervention is of primary importance. In this research we present a retrospective analysis of postoperative outcomes in patients who required surgical correction of vaginal vault prolapse after hysterectomy.

The aim of this study is to compare the effectiveness of two different surgical approaches to the treatment of PHVVP in postmenopausal women: laparoscopic lateral vaginal dome fixation with a mesh implant and vaginal colpocleisis (median colporrhaphy) using autologous tissues.

Thid research is focused on the evaluation of the anatomical and subjective results of surgical treatment within three years after the intervention.

To achieve this goal, we set the following tasks:

• to determine which of the two methods provides higher anatomical effictiveness (according to the POP-Q system);
• to assess the quality of life of patients after surgery using the validated PFDI-20, PFIQ-7 and PGI-I questionnaires;
• to analyze the frequency of complications and recurrences of PHVVP in each group;
• to justify the choice of technique depending on the clinical situation, the somatic status of the patient and the need to preserve sexual function.

Materials and methods

Participants of the study

December 2020–December 2025 on the basis of the Department of Obstetrics and Gynecology with a course in Perinatology of the Patrice Lumumba Peoples' Friendship University of Russia, 85 patients were operated on with a diagnosis of "post-hysterectomy prolapse of the vaginal vault" in the Department of Operative Gynecology and Reproductive Medicine of the Bauman City Hospital No. 29 of the Health Department of Moscow; 61/85 (71.8%) fully completed the follow-up. Among them were 39 patients who underwent pelvic floor reconstruction surgery using a mesh implant (group P) and 22 patients who had surgery for genital prolapse through vaginal access (group B). Patients in both groups had a history of panhysterectomy for benign indications: in 26/39 cases (66.7%) and in 18/22 cases (81.8%), respectively, for previously diagnosed pelvic organ prolapse. Routine follow-up examinations and questionnaires on patients’ satisfaction were performed after 1, 6, 12, 24 months. Below is the flowchart showing the study design.

POP-Q classification

To stage genital prolapse in patients we used the POP-Q (Pelvic Organ Prolapse Quantification) system. The majority of patients in both groups had prolapse in the apical region. The association with an anterior compartment defect was more common and marked comparing to the posterior compartment defect. Thus, in group P 76.9% (30/39) of patients had concomitant cystocele, while rectocele was diagnosed in 43.5% (17/39). It was consistent with the results obtained for group B, where 100% (22/22) of women had prolapse in the anterior compartment, and 81.8% (18/22) in the posterior compartment, which corresponded to stages II-IV according to the POP-Q classification.

Indications for surgery

Indications for surgical correction of PHVVP are based on the following criteria: a significant impact of patients’ symptoms on their quality of life, refusal of elderly patients to use a gynecological pessary, the presence of stage II or higher genital prolapse as per the POP-Q assessment system.

Preoperational complications assessement

The surgical and anesthetic risk was assessed as indcated in the classification of the American Society of Anesthesiologists (ASA). In the group of patients who underwent reconstructive surgery, 36/39 (92.3%) had a history of at least 1 concomitant disease: 32 cases of arterial hypertension, 4 cases of ischemic heart disease, 14 cases of postinfarction cardiosclerosis, 10 cases of diabetes mellitus, 7 cases of diseases of the nervous system (in particular cerebrovascular disease), 8 cases of urolithiasis, 11 cases of varicose veins, and in 4 cases the somatic history was aggravated by chronic obstructive pulmonary disease (COPD). According to the above-mentioned ASA scale, 18/39 (46.2%) patients from group P had grade II risk, the remaining 21/39 (53.8%) patients had grade III risk. In the group of patients who underwent surgical correction of genital prolapse through the vaginal approach, 21/22 (95.5%) also had 1 or more somatic aggravating factors, including 20 patients with cardiovascular diseases, among which, in addition to hypertension, 1 woman had a history of myocardial infarction, and 6 patients had lower extremity varicose vein disease. In addition, 7 women suffered from diabetes mellitus, 7 patients had nervous system disorders, 3 women had COPD, 9 and 3 patients from groups P and group B, respectively, had hyperthyroidism, accompanied by the presence of thyroid nodular goiter. According to the ASA scale, 8/22 (36.4%) women from group B had grade II risk, and 14/22 (63.6%) – grade III risk.

Assessment of the scope of surgical intervention

The choice of surgical technique was based on the patients’ medical history, their desire to maintain sexual function, and the degree of genital prolapse in accordance with the POP-Q classification [3]. Thus, reconstructive surgery to eliminate PHVVP, in particular, laparoscopic lateral fixation (LLF) of the vaginal vault with a mesh implant, was offered to women planning to continue sexual activity and with a lower risk according to the ASA scale. At the dame time, a correction through vaginal access (the Neugebauer – LeFort operation) to those who did not require preservation of vaginal function and had contraindications to laparoscopic interventions [8].

According to the model proposed by DeLancey, when choosing a surgical technique for eliminating PHVVP in patients who wish to preserve sexual function in order to reduce the risk of recurrence of this problem in the future, it was obvious that, first of all, it was necessary to fix the apical compartment, despite the presence of concomitant cystocele and rectocele in some of them [9]. In this regard we chose LLF as the major method for the reconstruction of the vaginal vault with a mesh implant, isolated in 18 patients or in combination with sacrocolpopexy in 8 patients, or with preliminary “pleating” of the vaginal vault in 10 patients in order to shorten its length if the TVL (total vaginal length) exceeded 10 cm when staging according to the POP-Q system. After the main intervention, patients with posterior prolapse of more than grade II according to POP-Q were invited to perform colpoperineolevatoroplasty using their own tissues. Participants with pre-existing or de novo post-operative stress urinary incontinence also underwent delayed urethropexy and TVT-O sling placement, according to the Guidelines for the Surgical Treatment of Stress Urinary Incontinence in Women [10]. The surgical intervention was performed in a standardly equipped operating room using an Aesculap endoscopic HD-stand, as well as Karl Storz surgical instruments, an ultrasonic scalpel and an Ethicon tissue dissector. We used a polypropylene monofilament endoprosthesis made of Promilene Mesh and Lintex Esfil materials as a mesh implant.

Folow-up and results assessment

Subsequent gynecological examinations and questionnaires were conducted at 12 and 24 months after the operation. We assessed such parameters as the duration of the operation, intraoperative blood loss, length of hospital stay, and the degree of complications according to the Clavien–Dindo classification [11].

Criteria of successfully completed surgery

In order to evaluate the achieved surgical success in relation to group P, the following three criteria proposed by Vallabh-Patel V. et al. were adopted: (I) the distance between the most distal point of the prolapsing anterior vaginal wall and the genital hiatus (point Ba according to the POP-Q system) was equal to 0 or was a negative value, while the length of the prolapsing section of the vaginal vault was less than ½ of the total vaginal length (TVL); (II) relief of pelvic organ prolapse symptoms according to the third question in the PFDI-20 (Pelvic Floor Distress Inventory Questionnaire): “Do you usually have a bulge or something falling out that you can see or feel in your vaginal area?”; (III) no repeated surgical interventions for pelvic organ prolapse or use of a pessary during the follow-up period [12].

Objective and subjective assessment of treatment effectiveness

An objective assessment of the effectiveness of surgical treatment was primarily performed in accordance with the patient's gynecological status and was based on the values of such anatomical landmarks as points Aa, Ap, Ba, Bp, D, as well as the TVL parameter of the POP-Q system. Besides, during the follow-up examinations, the fact of mesh implant migration was excluded, which also objectively confirmed the effectiveness of the surgical correction performed. Subjective postoperative results were assessed using specialized questionnaires. The Patient Global Impression of Improvement (PGI-I) questionnaire has been validated for pelvic organ prolapse and classified into the following levels: I – very much better, II – much better, III – a little better, IV – no change, V – a little worse, VI – much worse, VII – very much worse [13]. Such responses of the study participants as “very much better” and “much better” were qualified as subjectively positive and indicated the patients’ satisfaction with the postoperative results, while other options, on the contrary, indicated dissatisfaction. The Russian version of the specific questionnaire for pelvic floor dysfunction – PFDI-20 (Pelvic Floor Distress Inventory) was used to identify the number of genital prolapse symptoms and the frequency of their occurrence and became a tool for subjective assessment of the effectiveness of surgical treatment [14]. The questionnaire for assessing the quality of life of patients with pelvic floor dysfunction – PFIQ-7 (Pelvic Floor Impact Questionnaire) was also adapted for the Russian-speaking population to assess subjective postoperative results. The higher the total score obtained by analyzing the questionnaire, the more marked the impact of POP symptoms on the patient's quality of life was found, and, conversely, a lower total score according to the questionnaire had a direct correlation with the best quality of life of the study participant.

In this study, precise criteria for the effectiveness of surgical examination of PHVVP were defined, including both objective and subjective indicators. Primary and secondary outcomes were identified to systematize the treatment results:

Primary outcomes:

1. Anatomical effectiveness of surgical intervention. Assessment criteria:

• Degree of prolapse according to the POP-Q system.
• No displacement of the apical point (point D) below the level of ½ TVL.
• No prolapse of the anterior vaginal wall below the level of the introitus (point Ba ≤ 0).
• No repeated operations for pelvic organ prolapse or use of a pessary within 24 months.

2. Subjective satisfaction with treatment results. Assessment criteria:

• Patients’ responses to question 3 of the PFDI-20 questionnaire (“Do you usually have a bulge or something falling out that you can see or feel in your vaginal area?”).
• Assessment on the PGI-I scale: levels I–II (“very much better” and “much better”) were considered positive.

Secondary outcomes:

3. Surgery-related complications. Assessment criteria:

• Clavien–Dindo classification.
• Frequency of complications, including bleeding, adjacent organ injury, infectious complications, and cases of implant erosion.

4. Perioperative period indicators. Assessment criteria:

• Duration of surgery (minutes).
• Intraoperative blood loss (ml).
• Duration of hospitalizat stay (bed days).

5. Quality of life after treatment. Assessment criteria:

• Total score on the PFDI-20 and PFIQ-7 questionnaires before and after surgery.
• The lower the total score, the higher the patient’s subjective quality of life.

         These outcomes and their assessment criteria were defined prior to data analysis and were used to guide the choice of surgical intervention tactics and subsequent interpretation of the results.

Statistical analysis

Statistical processing and interpretation of the obtained results were performed based on wide-spread methods of statistical analysis using StatTech v. 4.8.3 software (OOO StatTech, Russia). Quantitative indicators were assessed for normal distribution using the Shapiro – Wilk test. Quantitative indices corresponding to normal distribution were expressed using mean (M) and standard deviation (SD) and were further analyzed using parametric tests such as Student's t-test. In cases of non-normal distribution, quantitative indicators were expressed in the format of median (Me) and lower and upper quartiles (Q1; Q3). Quantitative variables were described using M, SD, Me, Q1, Q3, and categorical variables were identified as absolute values and percentages (n, %). For all categorical variables, 95% confidence intervals (CI) were automatically calculated using the Wilson method. When analyzing differences between two independent groups (P and B), the Student's t-test was used for quantitative data with normal distribution and equal variances. The Mann–Whitney U-test was utilized in case of deviation from normal results or unequal variances. For categorical data with n>5, the Pearson's chi-squared test was used in each cell. The Fisher exact test was used and for small group sizes. In addition to all comparisons, the effect size was calculated: Cohen’s d – for quantitative parameters with the t-test, Rank-biserial correlation (r) – with the Mann–Whitney test, Cramer’s V – when analyzing categorical variables. To analyze differences between three related time points (before surgery, 12 months after, 24 months after), RM-ANOVA was used for normal distributions. The Friedman test was used in case of non-normal values. Paired t-test and Wilcoxon signed-rank test were used for paired comparisons (before and after surgery). To assess the significance of differences between time points, p-values to two decimal places and effect sizes (r). Scores upon the PFDI-20 and PFIQ-7 questionnaires were analyzed as quantitative variables. The Wilcoxon test was used for intertemporal changes, and the Mann–Whitney U test was helped to analyze differences between groups. For multiple pairwise comparisons (e.g., POP-Q across time points), the Holm–Bonferroni method was used. In all tests, the differences were considered statistically significant at p≤0.05. The analysis method, p-values, and effect sizes were reported for each comparison.

Results

Perioperational period

A total of 39 patients from group P underwent LLF of the vaginal vault using a mesh implant. In 10/39 (25.6%) patients, the main volume of the operation was combined with preliminary “pleating” of the vagina in order to shorten its length and reduce its area; 8/39 (20.5%) patients underwent lateral fixation in combination with promontofixation, in 3/39 (7.6%) patients the above-mentioned volumes were combined, and the remaining 18/39 (46.2%) patients from group P underwent isolated LLF of the vaginal vault. On average, the surgery lasted for 130 minutes (70–235 minutes), and the volume of intraoperative blood loss was 50 ml (20–100 ml). In 23/39 (59%) patients from group P an adhesion process in the abdominal cavity was noted, which necessitated adhesiolysis before the main stages of the surgery. The largest volume of blood loss was 100 ml in a patient who underwent LLF of the vaginal vault with promontofixation, which was associated with technical difficulties and increased tissue bleeding at the stages of adhesiolysis and dissection. No patient suffered from intra-abdominal bleeding in the postoperative period, and no patient required a blood transfusion. There were also no cases of intraoperative trauma to the intestines and ureters. In two patients from group P who underwent LLF with vaginal pleating and LLF with pleating and promontofixation, the stage of bladder dissection from the anterior wall of the vaginal dome was accompanied by deserosation of the bladder wall, which was eliminated intraoperatively by applying a vicryl suture to the area of the serous membrane damage. In both cases, the period of catheterization of the bladder took 7 days, after which the urinary catheter was removed and the urination process was completely restored. In addition, during the 24-month follow-up period after surgery, 1 case of asymptomatic “exposure” of the mesh implant was identified. The erosion area measured 1.0×0.5 cm and was removed by local excision of the open fragment of the implant. Overall, all complications associated with the surgical intervention corresponded to grade I of the Clavien–Dindo system [11]. The average hospital stay after surgery was 3 days (2–6 days), and became maximum in the two previously described cases when patients required permanent bladder catheterization and control cystoscopy.

The duration of surgery in patients from group B who underwent midline colporrhaphy (the Neugebauer–LeFort method) averaged 75 minutes (60–115 minutes), and intraoperative blood loss was 50 ml (50–250 ml). Increased blood loss in all cases was associated with increased tissue bleeding, but none of the patients required blood transfusion in the intra- or postoperative period. There were also no cases of bladder trauma during surgery, as well as no cases of hematoma formation in the perineal area. The average hospital stay was 3 days (2–5 days).

The age of the women was significantly lower (p<0.05) in group P compared to group B, but the duration of surgery in patients who underwent laparoscopic pelvic floor reconstruction exceeded the value of the same parameter in the group of participants who underwent total colpocleisis. No statistically significant differences (p>0.05) between the two groups in such parameters as body mass index, parity, intraoperative blood loss, length of hospitalization, were obtained as demonstrated in Table 1.

Objective assessment of effectiveness

61 patients completed the full follow-up. All of them were invited twice for a follow-up examination – 12 and 24 months after surgery.

During the follow-up examination of patients from group P (n=39), significant positive dynamics were observed on Ba, Bp points and total vaginal length (TVL). Thus, the median value of the Ba point before surgery was 0.00 cm (-1.00; 1.00), and 12 months after surgery it was -2.50 cm (-3.00; -2.00), p=0.02.  24 months after surgery this parameter remained at -2.50 cm (-3.00; -2.00) without statistically significant changes relative to the annual result (p=0.12; Wilcoxon test). Similar dynamics were noted in relation to point Bp: before the surgery the median was 0.00 cm (-1.00; 1.00), 12 months after surgery it was -2.50 cm (-3.00; -2.00), p=0.01, and 24 months afer surgery the value was the same  (-3.00; -2.00), p=0.09 compared to the 12 months period. The TVL index increased from 6.00 cm (5.50; 7.00) to 8.00 cm (7.00; 9.00) 12 months after surgery (p=0.01), and then remained stable as 8.00 cm (7.00; 9.00) at p=0.09. Changes in parameter D (apical position of the vaginal vault) did not reach statistical significance: the median was -8.00 cm (-9.00; -6.00) at 12 months relative to -7.00 cm (-9.00; -5.00) at the time of the patient's hospital admission (p=0.11) and did not show significant dynamics between 12 and 24 months (p=0.17). There were also no cases of prolapse of the anterior vaginal wall below the level of the genital hiatus, and all point Ba values corresponded to stage I< of cystocele according to POP-Q. 6/39 (15.4%) cases of rectocele with the most distal point of the posterior vaginal wall at the level of the genital hiatus (Bp=0) were identified as shown in Table 2. No patient in Group P required reintervention for apical prolapse after 2 years, nor did any patient have to use a gynecological pessary for recurrent prolapse. However, 6 patients answered “sometimes” and “often” to question 3 of the PFDI-20 questionnaire, which was probably associated with the persistence of the rectocele. Thus, the overall objective effectiveness rate, including 3 criteria (see the section “Materials and Methods”, criteria for a successfully performed operation), was 84.6% (33/39).

During follow-up examinations of Group B patients (n=22), the TVL parameter was assessed 12 and 24 months after surgery. The total vaginal length significantly differed in all patients 12 months after surgery from the initial value, but there was no statistically significant difference between the results obtained 12 and 24 months after surgery, as demonstrated in Table 3. We revealed 2 cases of recurrence of apical prolapse as a result of control examinations; accordingly, 20 patients answered “no” or “no, but have experienced it before” to question 3 of the PFDI-20 questionnaire, which amounted to 90.9% of the objective effectiveness of the operation.

Subjective assessment of effectiveness

Patients’ own assessment of the effectiveness of surgical treatment in both groups was performed using the PGI-I questionnaire, adapted for patients who underwent surgery aimed at correcting pelvic organ prolapse.

According to this survey, 36 patients from group P were satisfied, and the level of subjective effectiveness of the surgery was 92.3%. (36/39). Only 3 patients were dissatisfied with the results, giving the following answers to question 2: “slightly better”, “no change”, “significantly worse” (in 1 of them, an area of the mesh implant erosion was identified and subsequently eliminated, and in the other two cases, stress urinary incontinence de novo was corrected after urethropexy and installation of the urethral sling in a delayed manner). According to the PFDI-20 questionnaire, 5 patients had symptoms of difficult defecation before surgery requiring manual assistance, which was corrected in all 5 cases after surgery. Overall, the sum of the PFDI-20 and PFIQ-7 scores was significantly (P≤0.05) lower after surgery than before it.

According to the results of the questionnaire, 19/22 (86.3%) patients in group B were satisfied with the postoperative results. In 2 women negative answers to the second question of the PGI-I survey were associated with recurrence of apical prolapse of the vaginal vault, which subsequently required a repeat Neugebauer–LeFort operation in one patient and LLF of the vaginal vault in the second case. The negative response regarding overall satisfaction in the third case was related to the lack of symptoms relief of difficult defecation after colpocleisis. None of the patients in group B regretted the loss of sexual activity. Overall, the PFDI-20 and PFIQ-7 scores after surgery in group B were significantly (P≤0.05) lower than before surgery, which also indicates the subjective effectiveness of surgical correction.

Discussion

In modern studies, more than 20 surgical techniques aimed at eliminating PHVVP have been described. However, given the heterogeneity of most clinical studies, comparison of surgeries and their outcomes, as well as concluding upon the best of them, do not seem possible today [15]. Based on the international practice, all reconstructive interventions for pelvic organ prolapse are divided into 2 types: abdominal and vaginal. The choice of a specific surgical technique should be individualized based on the localization of genital prolapse, the degree of its severity, the patient's desire to preserve sexual function, the patient's somatic status, and the history of previous surgeries for pelvic organ prolapse [3]. In our study we present the results of observation over a medium period of time, but the obtained data cover both surgical techniques using native tissues and reconstructive surgery using mesh implant to create neo-fascia.

Vaginal vault LLF in patients with PHVVP

The most important difference between LLF of the vaginal vault with a mesh implant and median colporrhaphy is undoubtedly the possibility of preserving the physiological function of the vagina, which is the main reason why most patients prefer this technique [16]. Apart from this, prolapse of the vaginal vault after previously performed hysterectomy is formed due to the loss of apical support, and LLF of the vaginal vault is aimed at restoring this defect [17]. In our study, the number of patients who underwent isolated LLF procedure comprised 18/39 (46.2%). It was accompanied by promontofixation in patients whose apical prolapse stage according to POP-Q exceeded III, and their number was 8/39 (20.5%). Preliminary “pleating” of the vaginal vault was indicated for those women whose TVL exceeded 10 cm and was performed to shorten the overall length of the vagina and to increase the degree of the mesh implant adhesion to the walls of the vaginal vault. This also contributed to reducing the risk of recurrence of posthysterectomy apical prolapse. However, like any other procedure to restore apical support, this type of surgical correction cannot completely solve the problem of combined rectocele. In this regard, when symptomatic defects of the posterior compartment are detected during control examinations, it is necessary to decide on their elimination in a delayed manner [18]. In our study, there were only 3 cases of rectocele progression to stage III according to POP-Q after LLF, in each of which the patients underwent posterior colpoperineoplasty. In other patients with a posterior compartment defect, the distance from the most distal point of the prolapsing section of the posterior vaginal wall to the hymen did not exceed 1 cm and did not affect the quality of life, therefore, did not require surgical correction.

The Neugebauer–LeFort procedure in patients with PHVVP

Median colporrhaphy, in terms of anatomical outcome in patients with PHVVP, is an extremely effective procedure, regardless of the severity of prolapse. However, the main limitation of its use is fairly considered to be the virtually complete loss of vaginal function. According to the results of our study, compared with endoscopic reconstruction of the pelvic floor, colpocleisis has an obvious advantage only in terms of the duration of the operation. It is also worth recognizing the long-term effectiveness associated with the Neugebauer–LeFort procedure, which stipulates the fact that median colporrhaphy has remained popular since it was proposed by Geradin in 1823 [19].

The average age of patients in group B was 75 years (63–88 years), which was absolutely consistent with previously published studies on similar topics [20]. The reason why the American Society of Anesthesiologists (ASA) scale was used in our study to assess perioperative risks was that this scale allows us to predict the possible outcomes of a particular type of surgical correction of vaginal vault prolapse, which are mainly related to the type of anesthesia used during the surgical procedure. According to the characteristics of all patients participating in the study, there was no statistically significant difference between the two groups. In Group B and Group P the parameters of the participants corresponded to either II or III class of the ASA scale. In addition, there was no significant difference in the severity of adverse surgical outcomes, since all of them conformed to level 1 according to the Clavien–Dindo classification [11]. The result obtained allows us to assume that the choice of surgical tactics for the correction of PHVVP should not be based only on the available information about the physical status of the patient, but it should be recognized that colpocleisis is associated with an obviously lower risk of injury to adjacent organs and blood vessels.

In our study, such late complications of vaginal vault LLF as sacral osteomyelitis, chronic pelvic pain and hematomas were not registered. However, according to the international literature, these complications are described in certain categories of patients [21–23]. The absence of these complications in our research may be firstly associated with the absence of the stage of the apical section fixation to the sacrum, and secondly, with the limited number of observations and strict inclusion criteria. It should also be noted that LLF was used in women with preserved sexual activity. Meanwhile, the Neugebauer–LeFort procedure in modern modifications is recognized to be effective in elderly women who are not interested in preserving sexual function [24, 25]. Thus, the choice of surgical treatment method should be strictly individualized.

Conclusion

Given the relatively small sample size in our study, 2 cases of recurrent PHVVP after correction by the Neugebauer–LeFort are noteworthy, which required repeated surgical intervention, probably due to the compromise of the perineal tissues themselves. Undoubtedly, LLF of the vaginal vault with a mesh implant implies a longer duration of procedure compared to midline colporrhaphy. However, the absence of recurrent cases of prolapse within 24 months makes it possible to conclude that LLF has demonstrated anatomical effectiveness under conditions of strict patient selection. Moreover, the incidence of postoperative complications occurring within two years after endoscopic pelvic floor reconstruction using a mesh implant did not exceed the one after partial colpocleisis. The combination of all the above factors doubts the role of vaginal surgery using native tissues for the correction of recurrent forms of pelvic organ prolapse and increasingly specifies the need to continue studying the effectiveness of methods for restoring apical support with the creation of neo-fascia. However, the choice of surgical treatment for apical prolapse should be individualized based on the patient's age, sexual activity, and functional status.