Clinical and cost-effectiveness of surgical options for the management of anterior and/or posterior vaginal wall prolapse: two randomised controlled trials within a Comprehensive Cohort Study
One in ten women will need surgery for vaginal prolapse at some point, yet surgeons lack clear evidence on which operation works best. This matters because new mesh-based surgical techniques were introduced without proper testing against standard repairs. The study directly compares three options for first-time prolapse repair—standard surgery, standard surgery with a biological graft, and standard surgery with a non-absorbable mesh—and three options for repeat repairs, including a newer mesh kit. Women who decline randomisation still have their outcomes tracked in a comprehensive cohort, giving real-world data alongside trial results. If the research succeeds, it will give surgeons and patients reliable evidence on which operations relieve prolapse symptoms most effectively and for longest, without relying on marketing or anecdote. That could reduce the number of women who need repeat surgeries, cut NHS costs from failed repairs, and end the current uncertainty that leaves treatment decisions to individual surgeon preference rather than robust data. The primary outcome is symptom improvement as reported by the women themselves, not just clinical measurements—meaning the results will reflect what actually matters to patients.
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Around 1 in 10 women will need prolapse surgery at some point in their lives. There is insufficient information to identify which operation is best. New techniques have been introduced which use mesh to reinforce the surgery, but these have not been properly evaluated, especially in terms of how well they improve prolapse symptoms. The study will be carried out in at least 15 hospitals in the UK. We will randomise women having anterior and/or posterior vaginal wall prolapse surgery to one of two trials: (1) Women having a first repair operation may be randomised to one of: a) a standard anterior or posterior prolapse repair, b) a standard repair with a biological graft inlay; or c) a standard repair with a non-absorbable mesh inlay. (2) Women having a second or subsequent repair may be randomised to: d) a standard anterior or posterior prolapse repair, e) a standard repair with a non-absorbable mesh inlay to support the stitches, or f) a new mesh repair using an introducer (mesh kit). Mesh kits will only be used for women having a secondary operation for prolapse as it is thought that it is more invasive than the other options and so should be reserved for such women, because they have a higher risk of failure. All women having prolapse operations will be eligible for our study. They will be given information about the study before they are admitted to hospital. After discussion with their gynaecologist, women will be able to choose whether or not they are willing to be randomised to one of the specified operations if the doctor is also willing to randomise her. Those women who do not wish to be randomised to a particular procedure but are happy for their outcomes to be monitored will be examined and will complete the questionnaires in the same way as the randomised groups as part of a Comprehensive Cohort. All women will have a routine gynaecological examination before surgery and they will complete questionnaires both before and after their operation. Further symptom questionnaires will also be completed 6, 12 and 24 months later. The women in the randomised trials will also be examined and reviewed in outpatients at 12 months after surgery. Our primary outcome is the cure or improvement of prolapse symptoms, as reported by the women themselves.
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