Functional Outcomes After Vaginal Natural Orifice Transluminal Endoscopic Surgery Hysterectomy: A Systematic Review of Sexual Function and Pelvic Floor Integrity.

The authors have nothing to report.

This review was conducted in accordance with the PRISMA 2020 and Cochrane Handbook guidelines [ 26 , 27 ]. A protocol was registered with PROSPERO prior to study selection (CRD420251247524). Eligibility criteria were defined using the PICOS framework. Population: Adult women (≥ 18 years) undergoing hysterectomy for benign (e.g., uterine fibroids, adenomyosis, abnormal uterine bleeding) or early‐stage malignant gynaecological indications. Intervention: vNOTES hysterectomy, utilising a multichannel vaginal port with endoscopic instrumentation via the vaginal vault. Concomitant procedures, including apical suspension or prolapse repair, were permitted where performed as part of the same surgical episode. Where present, these are noted explicitly in study characteristics (Table  1 ). Comparator: Minimally invasive laparoscopic approaches, including total laparoscopic hysterectomy (TLH), conventional multiport laparoscopy, VH and laparoendoscopic single‐site surgery (LESS). Outcomes: Studies reporting at least one validated functional measure of sexual function or pelvic floor outcomes, including PROMs (e.g., FSFI, PFDI‐20, ICIQ) or objective anatomical assessment (POP‐Q). Study design: RCTs and comparative observational studies (prospective or retrospective) were included. Studies were required to include ≥ 25 participants in the vNOTES arm to reduce small‐sample imprecision and minimise distortion from early learning curve effects (approximately 25–30 procedures are required to achieve proficiency) [ 28 , 29 , 30 , 31 ]. Case reports, non‐comparative case series, animal studies and conference abstracts or posters without full peer‐reviewed texts were excluded. Population: Adult women (≥ 18 years) undergoing hysterectomy for benign (e.g., uterine fibroids, adenomyosis, abnormal uterine bleeding) or early‐stage malignant gynaecological indications. Intervention: vNOTES hysterectomy, utilising a multichannel vaginal port with endoscopic instrumentation via the vaginal vault. Concomitant procedures, including apical suspension or prolapse repair, were permitted where performed as part of the same surgical episode. Where present, these are noted explicitly in study characteristics (Table  1 ). Comparator: Minimally invasive laparoscopic approaches, including total laparoscopic hysterectomy (TLH), conventional multiport laparoscopy, VH and laparoendoscopic single‐site surgery (LESS). Outcomes: Studies reporting at least one validated functional measure of sexual function or pelvic floor outcomes, including PROMs (e.g., FSFI, PFDI‐20, ICIQ) or objective anatomical assessment (POP‐Q). Study design: RCTs and comparative observational studies (prospective or retrospective) were included. Studies were required to include ≥ 25 participants in the vNOTES arm to reduce small‐sample imprecision and minimise distortion from early learning curve effects (approximately 25–30 procedures are required to achieve proficiency) [ 28 , 29 , 30 , 31 ]. Case reports, non‐comparative case series, animal studies and conference abstracts or posters without full peer‐reviewed texts were excluded. Characteristics of included studies. PubMed/MEDLINE, Embase, Cochrane Library (including CENTRAL) and Scopus were searched electronically from inception to February 2026. The search strategy was developed in consultation with a university librarian and combined controlled vocabulary (MeSH/Emtree) and free‐text keywords related to vNOTES (‘vNOTES’, ‘vaginal NOTES’, ‘transvaginal NOTES’, ‘natural orifice transluminal endoscopic surgery’), hysterectomy (‘hysterectomy’, ‘total hysterectomy’) and functional outcomes (‘sexual function’, ‘sexual dysfunction’, ‘dyspareunia’, ‘pelvic floor dysfunction’, ‘urinary incontinence’, ‘FSFI’, ‘PFDI’, ‘ICIQ’, ‘POP‐Q’). The full PubMed/MEDLINE search strategy is provided in Appendix  S1 . To minimise publication bias and identify ongoing or unpublished studies, grey literature sources included trial registries (ClinicalTrials.gov, WHO International Clinical Trials Registry Platform and the EU Clinical Trials Register), preprint servers (medRxiv and Research Square) and conference proceedings. Thesis repositories (ProQuest and institutional repositories) were also searched. Reference lists of included studies and relevant reviews were manually searched for additional citations. No language, date or geographic restrictions were applied. Records were imported into Covidence [ 32 ] for de‐duplication and screening. Two reviewers independently screened titles, abstracts and full texts systematically against predefined eligibility criteria. Discrepancies were resolved by consensus or third reviewer consultation. Study selection was documented using a PRISMA flow diagram (Figure  1 ) [ 26 ] and selected studies were imported into RefWorks reference management software. PRISMA flow diagram. Adapted from Page et al. [ 26 ]. Data were extracted independently by two reviewers using a standardised template (Covidence) [ 32 ]. Extracted variables included study characteristics (author, year, country, design, funding), participant demographics (sample size per arm, age, parity, BMI, indication), operative details (vNOTES technique, comparator approach, port type, apical suspension techniques, concomitant procedures), follow‐up duration and completeness, outcome measures (instrument and timing) and numerical outcome data (baseline and follow‐up values, means and standard deviations where available and effect estimates as reported). The primary outcome was postoperative sexual function assessed using validated PROMs such as the FSFI (scores evaluating desire, arousal, lubrication, orgasm, satisfaction and pain). As there is no specifically validated MCID for women undergoing hysterectomy, interpretation of FSFI results was guided by previously proposed clinical cut‐offs (e.g., ≤ 26.55 for sexual dysfunction) and exploratory references to MCID estimates from non‐hysterectomy populations [ 22 , 24 , 25 , 33 , 34 ]. Secondary outcomes included pelvic floor symptoms, quality of life impact and objective anatomical pelvic support where reported (e.g., POP‐Q measurements) [ 23 ]. Risk of bias assessment was assessed independently by two reviewers using the Cochrane Risk of Bias 2.0 (RoB 2) tool [ 27 ] and the Newcastle–Ottawa Scale (NOS) for observational studies [ 35 ]. Discrepancies were resolved through discussion. Studies were not excluded based on methodological quality alone, but rather risk of bias informed the weighting and interpretation of findings. Overall certainty of evidence was assessed using principles adapted from Grading of Recommendations Assessment, Development and Evaluation (GRADE) for narrative synthesis [ 36 ], considering risk of bias, inconsistency, imprecision, indirectness and publication bias. A meta‐analysis was planned but not performed due to heterogeneity in outcome measures, instruments and follow‐up timing. Heterogeneity was not formally explored via subgroups due to limited studies. Accordingly, results were synthesised guided by Synthesis Without Meta‐analysis (SWiM reporting guidelines) [ 37 ]. Studies were grouped by outcome domain (sexual function and pelvic floor outcomes), with sexual function presented first as the primary outcome, followed by pelvic floor outcomes. Evidence was prioritised hierarchically to support robust inference (RCTs, prospective comparative cohorts, then retrospective comparative cohorts). Direction of effect was summarised relative to baseline and/or comparator, prioritising clinical relevance over p ‐values alone. Sources of heterogeneity were explored qualitatively by examining study design, population, vNOTES technique, comparator and outcome assessment timing.

A total of 418 records were identified from database and supplementary grey literature searches. After duplicate removal and screening of titles and abstracts, 19 full‐text articles were assessed, with five comparative studies ( n  = 526) meeting inclusion criteria. Included studies comprised one multicentre RCT and four cohort studies (one prospective, three retrospective) [ 2 , 7 , 17 , 38 , 39 ]. Three studies used TLH as the primary comparator, one used single‐port laparoscopy (LESS) and one included a mixed laparoscopic comparator group [ 2 , 7 , 17 , 38 , 39 ]. Studies were conducted in Belgium (Baekelandt, Timmermans), Turkey (Haliscelik, Gungorduk) and China (Xu) [ 2 , 7 , 17 , 38 , 39 ]. Sample sizes in vNOTES arms ranged from 35 to 61 participants. Follow‐up was 3–6 months across four of the five included studies; Timmermans et al. reported variable follow‐up with some participants assessed beyond 6 months and statements regarding outcomes at this timeframe apply to that cohort specifically. Key study characteristics are summarised in Table  1 . The HALON RCT had some concerns on Cochrane RoB 2, as functional outcomes were secondary and underpowered [ 7 , 27 ]. Cohort studies demonstrated moderate‐to‐high risk of bias on the NOS. Timmermans et al. was downweighted due to high risk of bias (NOS 4/9) and unadjusted confounders [ 17 ]. Certainty of evidence was low for sexual outcomes due to study design limitations, imprecision and short follow‐up. Detailed assessments are in Appendices  S2 and S3 . Sexual function was the most frequently reported functional outcome across all included studies; however, it demonstrated substantial heterogeneity in assessment instruments (FSFI vs. non‐validated scales), follow‐up timing and reporting methods, limiting direct comparability. FSFI‐based outcomes: Timmermans et al. reported significantly higher postoperative FSFI scores in the vNOTES group compared with TLH (28.97 vs. 24.99, p  = 0.003), with improvements observed in arousal, orgasm and satisfaction domains [ 17 ]. However, interpretation is limited by high risk of bias (NOS 4/9), lack of baseline FSFI assessment (precluding interpretation of change from preoperative status) and unadjusted confounders [ 17 ]. A higher proportion of patients in the vNOTES group had resumed sexual activity within 3 months postoperatively compared to the TLH group (75.0% vs. 42.9%; p  < 0.01) and vNOTES patients in this cohort were discharged significantly earlier (1.8 vs. 2.6 days; p  = 0.011) [ 17 ]. Although directionally favouring vNOTES, changes in total FSFI scores did not consistently reach thresholds that have been proposed as clinically meaningful in other populations, suggesting the magnitude of benefit may be modest. Overall FSFI comparisons are presented in Table  2 . FSFI total scores [ 2 , 17 , 39 ]. Note: The FSFI total score ranges from 2.0 to 36.0, with higher scores indicating better sexual function [ 22 , 33 ]. A score of ≤ 26.55 is often used as a clinical cut‐off for sexual dysfunction [ 22 , 33 ]. Where studies did not report confidence intervals for between‐group differences, only reported means and p ‐values are presented. No additional effect size calculations were performed. Halisçelik et al. reported no significant differences in total or domain FSFI scores between groups at 6 months ( p  = 0.179) [ 2 ]. Similarly, Xu et al. did not detect a significant difference in FSFI scores between vNOTES and comparator groups at 6 months ( p  > 0.05), supporting equivalence in sexual recovery trajectories between approaches at mid‐term [ 39 ]. Resumption of sexual activity and dyspareunia: Findings on resumption of sexual activity were mixed. Timmermans et al. reported higher sexual activity rates at ≥ 6 months in the vNOTES group (75% vs. 42.9%, p  < 0.01), though resumption timing was not specified [ 17 ]. In contrast, Xu et al. found slightly delayed resumption to sexual activity in the vNOTES group (39.34 vs. 37.86 days, p  < 0.05) despite comparable total FSFI scores at 6 months, although the absolute difference was small and clinical significance uncertain [ 39 ]. The HALON RCT demonstrated no differences in dyspareunia using VAS between groups at 6 weeks or 6 months, indicating comparable sexual outcomes [ 7 ]. Güngördük et al. similarly reported no significant difference in dyspareunia rates between vNOTES and SPLS (6.9% vs. 9.5%, p  > 0.05) [ 38 ]. Across studies, no statistically significant worsening of sexual function following vNOTES hysterectomy was observed compared with laparoscopic approaches, though studies were not powered to exclude clinically meaningful harm. Most evidence supported equivalence, with some cohorts demonstrating directionally favourable results for vNOTES. Pelvic floor outcomes were reported inconsistently and were limited, restricting synthesis. None of the included studies reported urinary incontinence using validated tools such as ICIQ, precluding synthesis of this outcome. Halisçelik et al. reported POP‐Q outcomes at 6 months postoperatively [ 2 ]. Definitions of POP‐Q anatomical landmarks are provided in Appendix  S4 . The vNOTES group demonstrated significantly improved anterior vaginal compartment support (point Aa; p  < 0.003) compared with the TLH group [ 2 ]. No significant differences were observed in point Ba ( p  = 0.076), apical support (point C; p  = 0.450) or posterior compartments, suggesting comparable support overall with a possible anatomical advantage in the mid‐anterior compartment (Appendix  S5 ) [ 2 ]. No other studies reported objective validated pelvic floor support outcomes. Given baseline imbalances, limited follow‐up and multiple unadjusted comparisons, these findings should be considered exploratory. Validated PROMs (PFDI‐20, PFIQ‐7) were inconsistently reported across studies. Where assessed, both vNOTES and comparator groups demonstrated postoperative improvement, with no evidence of a differential effect between approaches. Limited pelvic floor PROM reporting and follow‐up duration represent a significant evidence gap. Although not the primary focus, perioperative metrics that may influence patient‐centred recovery were reported across all included studies. vNOTES was consistently associated with shorter operative time in the HALON trial and selected cohort studies, along with shorter length of stay and lower early postoperative pain in other studies compared with comparators [ 7 ]. Estimated blood loss ranged from 118 to 286 mL across groups [ 2 , 7 , 17 , 38 , 39 ]. These perioperative findings align with existing literature suggesting improved early recovery following vNOTES, although direct relationships to long‐term sexual and pelvic floor outcomes remain incompletely defined. Narrative synthesis demonstrated broadly comparable functional outcomes between vNOTES and comparator approaches. Sexual function outcomes were largely equivalent across studies, with limited evidence of positivity in one study (higher FSFI scores favouring vNOTES) and another suggesting slightly delayed early resumption of sexual activity [ 17 ]. Pelvic floor outcomes were underreported, with limited objective data suggesting possible improved anterior compartment support without compromise in apical or posterior support [ 2 ]. However, certainty of evidence was low due to sparse reporting and methodological heterogeneity. Overall, current evidence does not demonstrate mid‐term functional deterioration following vNOTES, but is insufficient to establish causality or long‐term safety, highlighting the need for standardised long‐term PROM reporting. A summary of findings, including GRADE certainty ratings, is presented in Table  3 [ 36 ]. Summary of findings [ 36 ].

This review examined patient‐centred function outcomes following vNOTES hysterectomy. Across five comparative studies (one RCT, four cohort studies; n  = 526) vNOTES did not adversely affect sexual function or pelvic floor outcomes compared with other minimally invasive approaches at 3–6 months; one study reported variable follow‐up beyond 6 months [ 2 , 7 , 17 , 38 , 39 ]. Pelvic floor outcomes suggested improved anterior compartment support (POP‐Q point Aa) without compromise of apical or posterior support [ 2 ]. No study demonstrated functional deterioration related to vNOTES‐specific techniques (vaginal port manipulation, dual colpotomy, or pneumoperitoneum). Sexual function was the most frequently assessed endpoint. Four studies used the FSFI, whereas one (HALON RCT) used VAS for dyspareunia. Despite heterogeneity in measurement and timing, the overall direction of effect was consistent with sexual function following vNOTES being comparable to laparoscopic comparators with no signal of harm. Timmermans et al. reported higher FSFI scores in vNOTES for arousal ( p  = 0.014), orgasm ( p  = 0.003) and satisfaction ( p  = 0.002), with a global score of p  = 0.003, though limited by retrospective design [ 17 ]. The difference in total FSFI score (~3.98 points) approached reported MCID thresholds (ranging from 2 to 4.5 in related studies), suggesting clinical equivalence rather than clear superiority and is reassuring regarding dyspareunia risk. In contrast, Halisçelik et al. and Xu et al. found no significant differences in FSFI scores between vNOTES and TLH at 6 months [ 2 , 39 ]. This supports the view that improvements are primarily driven by resolution of underlying pathology (e.g., chronic pelvic pain, adenomyosis, symptomatic leiomyomas or heavy bleeding) rather than surgical approach [ 17 ]. This is important for patient counselling as vNOTES can be positioned as providing comparable functional recovery while maintaining minimally invasive perioperative advantages. Findings on timing of resumption to sexual activity were inconsistent. Timmermans et al. reported higher sexual activity rates at ≥ 6 months (75% vs. 42.9%, p  < 0.01), potentially reflecting reduced abdominal wall pain and faster global recovery [ 17 ]. However, Xu et al. reported delayed resumption in the vNOTES cohort (39.34 vs. 37.86 days, p  < 0.05), despite similar 6‐month FSFI outcomes [ 39 ]. This discrepancy likely reflects contextual factors (e.g., patient anxiety regarding the vaginal wound, counselling differences, variable guidance around vault healing) [ 39 ], rather than biological inferiority. The highest quality evidence came from the HALON RCT, which demonstrated comparable sexual outcomes between vNOTES and TLH using VAS for dyspareunia assessment [ 7 ]. The HALON trial used blinding via sham abdominal incisions, reducing the risk of reporting bias [ 7 ]. Pelvic floor outcomes were less frequently reported than sexual outcomes and remain a key limitation. A small proportion of data included objective POP‐Q measurements or pelvic floor PROMs and follow‐up rarely exceeded 12 months. Halisçelik et al. reported improved anterior vaginal wall support (point Aa; p  < 0.003), with no significant differences in apical or posterior compartments [ 2 ]. This may be clinically relevant given the contribution of anterior compartment dysfunction to postoperative pelvic floor morbidity. From an anatomical standpoint, an anterior compartment advantage is plausible as vNOTES allows enhanced visualisation and precise dissection. Compared with other hysterectomy routes where dissection may be partially tactile and performed without magnification, vNOTES is a dual‐colpotomy approach that offers an endoscopic view, facilitating accurate uterosacral identification and enabling precise plane development and vault closure under magnification [ 7 , 9 , 17 , 18 , 19 ]. Theoretical concerns regarding sustained vault manipulation and rigid vaginal port use, including predisposition to postoperative dyspareunia, vaginal shortening or altered pelvic floor mechanics, were not supported by current evidence [ 2 , 7 , 17 , 38 , 39 ]. It remains possible that very late outcomes such as progressive vault descent or prolapse could emerge beyond 12 months, and this limitation should be highlighted during interpretation. Earlier reviews of vNOTES have primarily focused on perioperative outcomes, consistently demonstrating reduced pain, shorter length of hospital stay and favourable operative efficiency compared with laparoscopy [ 7 , 39 ]. This review extends current literature by prioritising long‐term and patient‐centred outcomes that are typically valued more by patients than marginal differences in perioperative metrics. Improved recovery may indirectly contribute to earlier return to function, particularly through reduced pain, faster mobilisation, and improved psychological readiness for resumption of activities [ 7 ]. Although proposed mechanisms such as reduced abdominal wall trauma (resulting in reduced somatic pain and systemic inflammatory response) should be interpreted cautiously, observed perioperative benefits may influence early functional recovery [ 7 ]. The findings of this review are consistent with emerging evidence on sexual function outcomes following other vNOTES procedures beyond hysterectomy. A combined analysis of two RCTs by Prekatsounaki et al. reported that sexual functioning following vNOTES was broadly equivalent to conventional laparoscopic approaches across gynaecological indications [ 21 ]. This convergence across both hysterectomy and non‐hysterectomy vNOTES contexts supports the conclusion that the vaginal port and colpotomy approach do not impose an inherent functional disadvantage relative to laparoscopy. Comparison with the established literature on sexual function following alternative hysterectomy approaches is also informative. Studies comparing laparoscopic, vaginal and abdominal hysterectomy have reported broadly equivalent postoperative sexual function at 6 to 12 months, with improvements attributable primarily to resolution of underlying pathology rather than surgical route [ 9 ]. Longer‐term cohort data suggest sexual function stabilises or continues to improve beyond 12 months following minimally invasive hysterectomy [ 10 ]. Equivalent data do not yet exist for vNOTES, representing a critical gap this review cannot address. Strengths include adherence to PRISMA 2020, use of SWiM for transparent narrative synthesis and focus on validated functional outcomes. Inclusion of the HALON RCT provides higher‐quality comparative evidence, although functional outcomes remain limited [ 7 ]. However, the overall evidence base is small (five studies, modest cumulative sample size, mostly observational), with limited follow‐up duration, restricting assessment of long‐term outcomes. Selection bias is likely present, as vNOTES may be preferentially offered to patients with favourable anatomy (e.g., lower BMI, smaller uteri, fewer adhesions). Heterogeneity in outcome measures (FSFI vs. VAS/binary reporting) and reporting limited comparability and precluded meta‐analysis. Functional endpoints were frequently secondary outcomes, limiting power to detect differences. vNOTES appears to be a viable minimally invasive option for selected patients, offering perioperative benefits without evidence of medium‐term functional compromise. These findings support its use in preoperative counselling, particularly for patients prioritising recovery and abdominal incision avoidance. Future research should prioritise multicentre RCTs and prospective cohort studies with standardised outcome reporting and objective pelvic floor measures beyond 24 months. Direct comparison with conventional VH remains a major evidence gap and is essential to define whether the additional technical complexity and resource requirements of vNOTES yield measurable functional benefit. Subgroup analyses by baseline pelvic floor status, surgical indication and concomitant apical suspension technique would further clarify applicability.

vNOTES hysterectomy demonstrates comparable medium‐term sexual and pelvic floor outcomes to laparoscopic approaches, with no clear signal of harm, with evidence being largely equivalent across studies and some suggesting modest improvements in selected domains, including anterior compartment support. However, the current evidence base remains constrained by small sample size, predominantly observational designs, methodological heterogeneity and limited follow‐up. Definitive conclusions regarding long‐term pelvic floor durability or functional superiority cannot yet be drawn. Further multicentre RCTs with longer follow‐up and standardised outcome measures are required to confirm vNOTES as a functionally safe minimally invasive option.

Optimising hysterectomy to balance rapid recovery with long‐term quality of life remains a central challenge in gynaecologic surgery. Vaginal hysterectomy (VH) for benign disease remains the guideline‐preferred approach due to superior recovery profiles [ 1 , 2 ], yet global rates continue to decline in favour of laparoscopic and robotic approaches [ 3 ]. This trend creates clinical uncertainty regarding long‐term patient‐centred outcomes surrounding pelvic floor integrity, continence and sexual function, where marginal perioperative gains may not justify potential trade‐offs. Transvaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES) adapts the vaginal route, eliminating abdominal incisions utilising a multichannel port for endoscopic visualisation of the vesicovaginal space and apical suspension points [ 1 , 4 , 5 , 6 ]. The HALON randomised controlled trial (RCT) reported shorter operative times and accelerated recovery with vNOTES relative to laparoscopic hysterectomy (LH), although functional outcomes were secondary and underpowered [ 3 , 7 , 8 ]. Pelvic floor and sexual dysfunction are recognised sequelae of hysterectomy, irrespective of surgical route, often resulting from anatomical disruption or changes [ 9 , 10 ]. For many patients, preservation of pelvic floor function may outweigh differences in operative time or hospital stay, underscoring the need to evaluate functional outcomes alongside perioperative metrics. Whilst the dual‐colpotomy approach of vNOTES facilitates enhanced visualisation of uterosacral ligaments, potentially preserving apical support [ 3 , 5 , 7 , 8 , 9 , 11 , 12 ] and reducing subsequent prolapse risk [ 13 , 14 , 15 , 16 ], the use of a rigid multichannel port and sustained pneumocolpos involves significant vaginal manipulation, which could theoretically impact dyspareunia or urinary continence [ 6 , 7 , 16 , 17 , 18 , 19 , 20 ]. Despite increasing adoption of vNOTES, functional outcomes remain unclear due to heterogeneous reporting and limited comparative data [ 17 , 21 ]. Accurate assessment of functional recovery following hysterectomy requires validated patient‐reported outcome measures (PROMs) that capture symptom burden and impact beyond anatomical findings or perioperative endpoints. Instruments such as the Female Sexual Function Index (FSFI), Pelvic Floor Distress Inventory (PFDI) and International Consultation on Incontinence Questionnaire (ICIQ) provide domain‐specific assessments of pelvic floor symptomatology and quality of life [ 20 , 22 , 23 ]. Objective measures including the Pelvic Organ Prolapse Quantification (POP‐Q) add value but do not fully reflect patient experience [ 2 , 10 , 13 , 24 , 25 ]. Variability in PROM selection, timing of follow‐up and reporting standards across studies has limited the direct quantitative synthesis and obscured the comparative functional outcome profile of vNOTES. Given the increasing uptake of vNOTES and the clinical importance of long‐term pelvic health outcomes, whether preserved sexual function and pelvic floor integrity accompany these objective benefits requires clarification through structured evidence synthesis. The primary objective of this review was to determine whether vNOTES hysterectomy provides comparable sexual function to minimally invasive approaches. Secondary objectives included assessment of pelvic floor symptom, quality of life impact and anatomical support using validated measures.

The authors declare no conflicts of interest.

Appendix S1: PubMed/MEDLINE search strategy. Appendix S2: Risk of bias assessment for RCTs (RoB 2.0). Appendix S3: Risk of bias assessment for cohort studies (NOS). Appendix S4: Definitions of POP‐Q anatomical landmarks [2]. Appendix S5: Pelvic floor anatomical support (POP‐Q at 6 months) [2].