Management of Major Non-mesh Complications After Primary Uterovaginal Prolapse Surgery: A Systematic Review.

INTRODUCTION: Major complications following uterovaginal prolapse (UPOP) repair are rare but carry significant morbidity. High quality evidence regarding their management is scarce. Our objective was to perform a systematic review of available evidence and develop standardized consensus-based clinical principles and algorithms for these complications. METHODS: Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we retrieved studies from MEDLINE, EMBASE, and clinicaltrials.gov through 11/11/25 describing management of major complications following UPOP surgery. GRADE criteria were used to assess quality. Expert opinion and Delphi process were used to develop consensus-based management algorithms and clinical principles. RESULTS: Of the 8890 abstracts screened, 24 studies met eligibility criteria. Most studies were retrospective and case reports with overall low to very low quality of evidence. Studies on management of complications such as bowel and ureteral injury, neuropathic pain, pyometra, and hemorrhage were retrieved. CONCLUSIONS: This systematic review and consensus document addresses a critical void in pelvic floor surgery by establishing the first structured management framework for bowel, ureteral, neuropathic, pyometra, and hemorrhagic complications following UPOP surgery.