Dear Editor,

With interest, we have read the review article by de Oliveira et al. entitled “Hysteropreservation versus hysterectomy in the surgical treatment of uterine prolapse: systematic review and meta-analysis” [1].

Kapoor et al. wondered why the largest randomized controlled trial on this subject [2] was excluded in the meta-analysis by Oliveira et al. [3] and we were also surprised that this RCT performed by our group was not included. Kapoor et al. commented that inclusion would change the outcome of the analysis. The results of the meta-analysis by Oliveira et al. would then be in line with previous meta-analyses on this subject, showing no difference in recurrence rate between uterus-preserving sacrospinous hysteropexy and hysterectomy.

Oliveira et al. clarified that the results of our RCT were excluded because the failure rate could be biased because of the inclusion of a high number of women with less advanced POP (POPQ stage 2 with point C < 1). When reading the abstract and the eligibility criteria in the methods section of the original article, we agree with Kapoor et al. that our RCT seems to fulfill the inclusion criteria [4]. We believe that it would be clearer to readers if the primary outcome measure and stage of prolapse (POPQ point C > 0) involved in this review were described in more detail in the title and abstract so that the readers know that this review focuses on more advanced prolapse and is not generalizable to all women with symptomatic uterine prolapse. Second, the authors do not really explain why they use this cut-off point. POPQ point C > 0, meaning POPQ point C ≥ 1, follows neither the classic Baden–Walker classification nor the POPQ staging. This makes it difficult to interpret the results.

Although our RCT did not meet the criteria to analyze the primary outcomes, it could have been used to analyze the secondary outcomes. To our surprise, the other RCT comparing sacrospinous hysteropexy and vaginal hysterectomy by Dietz et al. [5] was included in this review. However, they used the same selection criteria as we did and had a comparable number of women with uterine POPQ stage 2 (sacrospinous hysteropexy n = 21 (57%) and vaginal hysterectomy n = 19 (60%). The authors seem to be inconsistent in using their exclusion criteria. Therefore, we agree with Oliveira et al. that their results should be interpreted with caution because of the potential biases and the use of studies with a low level of evidence.