We have previously established UPS as a novel, minimally invasive, mesh-free suspension technique for isolated or combined apical POP correction in five defined steps [16]. The uterus can be preserved unless uterine pathology warrants hysterectomy. The clinical justification for this technique is based on the tension-free attachment of two broadly used and thoroughly analyzed anatomical landmarks of POP surgery: the pectineal ligament and the anterior cervix. As opposed to bilateral fixation we intentionally chose unilateral suspension since it avoids tension on the suspended structures and allows physiologic mobility. The procedure respects the physiological direction and angulation of the vaginal axis by repositioning the uterus to its original place within the lesser pelvis.

In order to further examine the efficiency and safety of UPS during routine clinical application, we have retrospectively analyzed perioperative parameters and short-term treatment success after 3–6 months in a cohort of 47 women presenting with apical prolapse POP-Q stage 2 or higher, including stage 4 total prolapse with vaginal inversion. We also included patients with additional pre-planned surgical procedures for associated urogynecological indications such as stress urinary incontinence and rectum prolapse, as well as necessary supracervical hysterectomy due to enlarged uterus. Furthermore, patients with an intraoperative indication for additional vaginal correction of remaining pelvic floor defects after completion of UPS were included. Thus, a real-world pattern of individual settings for POP repair is depicted by this study. Our data show that reliable apical fixation is effectively accomplished by UPS in all POP stages, including stage 4 total prolapse. The vast majority of patients was satisfied by the result of their POP correction. Furthermore, UPS is showing excellent perioperative characteristics. It can be combined conveniently with additional surgical procedures.

We had defined treatment success as our primary outcome measure. When examining the outcome after prolapse surgery, it is important to consider both the anatomical and the subjective results. We applied the POP-Q criteria in the setting of a composite endpoint of anatomical and subjective components including the necessity for repeated surgery due to POP recurrence as previously described [13]. In our case series, short-term anatomic outcome stayed within the definition of a successful repair in 93.6%. There were no apical recurrences, and thus apical correction was 100% successful. Forty-four of 47 patients reported their satisfaction with the operative result in a standardized follow-up interview. Three patients needed repeated surgery due to symptomatic grade 2 cystocele upon follow-up examination.

When comparing UPS with other approaches for hysteropexy, our data show an excellent outcome. For example, a 92% composite endpoint success was achieved following mesh-free anterior sacrospinous hysteropexy at 7.6 months follow-up [20]. In a prospective analysis of transvaginal mesh hysteropexy, an 84% composite endpoint success was reported at a median follow-up of 12 months [21]. Finally, short-term outcome after laparoscopic lateral suspension with mesh showed anatomic success rates of 88.2% for the anterior, 86.1% for the apical, and 80.8% for the posterior compartment after 12 months [22].

Extensive search of the international literature has shown that apical POP correction can be performed using various different approaches including SCP, vault suspensions, sacrospinous fixation, and vaginal obliterative procedures [23, 24]. In recent guidelines and reviews, the use of the pectineal ligament as a fixation structure for POP repair has not yet been adopted. Nevertheless, pectineal ligament suspension has been successfully conducted in incontinence surgery such as Burch colposuspension for over 50 years, and has been analyzed thoroughly [25, 26].

We have previously postulated intra-/perioperative and general quality criteria for surgical correction of pelvic organ prolapse (16, Table 3). Applying the proposed criteria to the different procedures for hysteropexy, we find that UPS fulfills every single criterion, while all other known options fail to do so in more than one category each. Furthermore, our retrospective data show that UPS was safely conducted without perioperative complications. Bladder and bowel function were not negatively affected by the procedure.

We used the da Vinci robotic system to perform UPS, since when using robotic technology, especially in pelvic floor reconstruction, operation times can be shortened as compared to conventional laparoscopy. This is due to a significant reduction of surgical compromise as well as the simplification of suture and knot application. Anatomical dissection and minimized blood-loss add to accuracy and surgical ergonomy. When performing UPS as a stand-alone procedure, mean operation time was 46.5 min using the da Vinci® robotic system. In contrast, even in experienced hands, classic techniques of POP repair such as SCP display operation times of approximately 180 min even when performed robotically [27, 28]. This difference underscores the quality aspects of UPS combining anatomical POP correction with a fast procedure. Certainly, the procedure is also suitable for laparoscopy or open abdominal surgery.

A weak correlation was found towards a shorter operative time in patients with higher BMI in the group of patients who had received UPS as a stand-alone procedure, while in the published literature robotic-assisted SCP showed no impact of BMI on operation time [29]. Thus, the UPS concept may be favorable also in obese patients. This aspect should be further examined in future studies.

Certainly, the study is limited by its retrospective design as well as the very short follow-up interval, making our data preliminary. We will re-analyze outcome data for our patient cohort at a later time-point to provide intermediate and long-term results. Prospective multicenter studies are under way to gain a broad data basis for the UPS concept.

In summary, short-term analysis of POP repair by UPS shows highly favorable results when looking at an unselected cohort of patients in need of primary POP surgery. UPS fulfills a large panel of quality criteria for POP surgery in a real-world setting, making it a strong candidate for a new standard of care.