Hysterectomy with Minimally Invasive Sacrocolpopexy Versus Native Tissue Repair for Primary Uterovaginal Prolapse: A Systematic Review and Meta-Analysis.

INTRODUCTION AND HYPOTHESIS: Sacrocolpopexy (SCP) is regarded as the gold-standard apical suspension procedure for vaginal vault prolapse; however, systematic reviews informing this reputation have largely included post-hysterectomy populations. Comparative evidence for primary uterovaginal prolapse (U-POP) remains limited. We aimed to evaluate failure and retreatment rates after hysterectomy with minimally invasive SCP compared with vaginal hysterectomy and native tissue repair (TVH + NTR). METHODS: A systematic review and meta-analysis were conducted following PRISMA guidelines (PROSPERO CRD420251171050) as part of the 2026 U-POP Global Consensus Conference. MEDLINE and Embase were searched through October 31, 2025. Eligible studies included randomized trials and comparative cohort studies (≥ 30 participants) evaluating hysterectomy with minimally invasive SCP for primary U-POP, with or without a comparator group undergoing TVH + NTR. Outcomes included retreatment and failure. Pooled proportions of outcomes were estimated and between-group differences were evaluated using mixed-effects meta-regression. Study quality was assessed using Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) criteria. RESULTS: Of 5262 abstracts and 189 full texts screened, 24 studies met inclusion criteria: 6329 patients underwent hysterectomy with SCP and 681 underwent TVH + NTR. Compared with TVH + NTR, hysterectomy with SCP demonstrated significantly lower retreatment rates (1.59% vs 10.23%, p < 0.0001), subjective failure (5.09% vs 17.55%, p = 0.002), objective failure (6.80% vs 18.16%, p = 0.002), and composite failure (9.23% vs 18.19%, p = 0.005). Certainty of evidence was moderate to low. CONCLUSIONS: For women undergoing surgery for U-POP, hysterectomy with minimally invasive SCP is associated with significantly lower failure and retreatment rates compared with TVH + NTR and thus may be preferred for patients at higher risk of recurrence.