Surgical management of uterine prolapse, especially advanced prolapse, remains a challenge for urogynaecologists and gynaecologists. Surgical techniques with technically simple, feasible, and effective features are continuously sought. The aim of this study is to demonstrate a uterus-sparing, technically simple surgical technique, Natural Orifice Uterine Suspension (NOUS) technique, for the treatment of advanced uterine prolapse in elderly patients, using a polypropylene mesh to suspend the uterus to the anterior abdominal wall through the natural orifice uterine cavity, and to present its feasibility, efficacy and safety profile of this technique.

This is a prospective study from a high-volume tertiary referral center, including 20 elderly patients with advanced uterine prolapse who underwent Natural Orifice Uterine Suspension procedure (Figure 1. An overviews of the Natural Orifice Uterine Suspension procedure) between 2022 and 2023. The demographic data, perioperative variables were collected. The follow-up schedule consisted of physical examination and administration of questionnaires at 1, 3, 6, and 12 mo after surgery and every 12 mo thereafter. The outcomes were measured by the pelvic organ prolapse-quantification (POP-Q) system and validated health-related quality of life instruments, including Pelvic Floor Distress Inventory-20 (PFDI-20) and the Pelvic Floor Impact Questionnaire (PFIQ-7). The definition of objective success was as follows: no recurrent uterine prolapse beyond the hymen according to the postoperative C point. All adverse events reported by patients or observed by the researchers were recorded and graded according to the Clavien-Dindo classification.

The mean age and body mass index (BMI) of the participants were 76.0 ± 6.0 yr and 24.7 ± 4.2 kg/m2, respectively. The median operative duration and estimated intraoperative blood loss were 51.0 min (IQR, 42.5-60.0) and 10.0 ml (IQR, 10.0-15.0), respectively. Objective success rates were 100% at all follow-ups (The definition of objective success was as follows: no recurrent uterine prolapse beyond the hymen according to the postoperative C point). The C point decreased significantly from 5.2 ± 1.5 preoperatively to -8.2 ± 1.8 three months after surgery (P < 0.001) and it remained high with the median of -8.0 (IQR, -9.0 - -6.3) at the final postoperative follow-up (P < 0.001). Significant improvements were also demonstrated in the scores of PFIQ-7 and PFDI-20 after NOUS procedure compared to baseline (p<0.0001) (Table 1).

In this initial experience, the NOUS technique is feasible for the treatment of advanced uterine prolapse with potential advantages including technically simple operative procedure, high efficacy and low complication rate. We believe that this novel approach has the potential to provide a technically simpler alternative surgical procedure for elderly patients with advanced uterine prolapse.

In conclusion, our study indicated that the Natural Orifice Uterine Suspension (NOUS) technique is found to be technically simple and is associated with high cure rates with a low risk of complications, which could be an alternative in the surgical management of advanced uterine prolapse in elderly patients who do not wish to undergo hysterectomy. Further studies with larger sample sizes and longer follow-up periods are needed to confirm these results.