Prolapse phenotypes and 12-month postoperative prolapse recurrence after apical native tissue surgery: a combined...

Recurrence after pelvic organ prolapse surgery is not uncommon, and recurrence rates differ based on baseline prolapse characteristics, such as genital hiatus size and prolapse stage. Better understanding the relationship between anatomic prolapse subgroups and surgical outcomes may allow surgeons to individualize treatment decisions and improve outcomes. Clinically relevant prolapse phenotypes (subgroups) defined using the Pelvic Organ Prolapse Quantification system were previously identified. Therefore, study associations between these phenotypes and surgical outcomes in a large, prospectively collected dataset are sought.

The primary aim of this study was to determine the association between a novel system of phenotyping prolapse and prolapse symptom recurrence 12 months postoperatively in women who underwent vaginal native-tissue apical prolapse surgery. Different prolapse phenotypes that would have different risks of prolapse recurrence were hypothesized. The secondary aims of the study were to determine the associations between the phenotypes and anatomic prolapse recurrence and new-onset stress urinary incontinence.

This was a secondary analysis of data combined from 3 multicenter randomized trials and 1 prospective, multicenter patient registry. Participants from these studies who underwent uterosacral ligament suspension or sacrospinous ligament fixation without mesh and had 12-month follow-up data were included and categorized into 1 of 8 phenotypes based on the Pelvic Organ Prolapse Quantification system: (1) no prolapse (n=5, excluded), (2) isolated anterior, (3) isolated posterior, (4) isolated apical, (5) anterior and posterior, (6) anterior-predominant and apical, (7) posterior-predominant and apical, and (8) anterior and posterior and apical. The primary outcome was symptomatic recurrence 12 months after surgery, which was defined as a positive response to the Pelvic Floor Distress Inventory "bulge" question with at least "somewhat" bother. Univariate and multivariate logistic regression analyses (adjusted for prolapse stage [stage II vs stage III/IV] and previous hysterectomy) were developed for each outcome.

Of 704 participants, most (473 [67.2%]) had anterior-predominant and apical prolapse (used as the reference group), followed by the anterior and posterior and apical (101 [14.3%]) and isolated apical (45 [6.4%]) phenotypes. Overall, 184 patients (26.1%) had sacrospinous ligament fixation, 520 patients (73.9%) had uterosacral ligament suspension, and 454 patients (64.5%) had midurethral slings. Overall, symptomatic prolapse recurrence occurred in 65 patients (9.2%), ranging from 0.0% to 29.0% across phenotype groups, and was particularly uncommon in the isolated posterior (0.0%) and isolated apical (2.2%: 1 participant) phenotypes. However, the phenotype group was not significantly associated with symptomatic recurrence in univariate or multivariate analysis. Hispanic ethnicity (odds ratio, 2.25 [95% confidence interval, 1.17-4.35]; P=.015), private insurance (odds ratio, 0.58 [95% confidence interval, 0.35-0.98]; P=.042), and vaginal parity (odds ratio, 1.19 [95% confidence interval, 1.02-1.40]; P=.030) were significantly associated with recurrence. Similarly, the phenotype was not significantly associated with anatomic recurrence or new or worsening stress urinary incontinence.

Prolapse Pelvic Organ Prolapse Quantification phenotypes were not associated with symptomatic recurrence after native tissue repair surgery. Most women who underwent native tissue apical prolapse surgery have anterior-predominant and apical prolapse. Larger studies may be needed to identify differences in outcomes among less common phenotype groups.