Disentangling Procedural and Patient-Specific Drivers of Perioperative Outcomes in Pelvic Organ Prolapse Surgery: A...

Background: Perioperative outcomes in pelvic organ prolapse (POP) surgery remain difficult to predict due to substantial heterogeneity in both surgical techniques and patient characteristics. Existing studies typically evaluate these factors in isolation, limiting their ability to support individualized risk stratification. This study introduces a stratified analytical framework to disentangle the relative impact of procedural and patient-related determinants across common vaginal reconstructive approaches. Methods: A retrospective cohort of 376 women undergoing POP surgery between 2020 and 2025 was analyzed. Patients were stratified into three procedure groups: sacrospinous fixation with mid-urethral sling (SFM + TOT/TVT), anterior and posterior repair with sling (A&P + TOT/TVT), and isolated anterior and posterior repair (A&P alone). Key outcomes included intraoperative blood loss, length of hospitalization, postoperative hospital stay and catheterization time. Within-group predictors were assessed using stratified odds ratios and synthesized via a random-effects model. Results: Procedure type was consistently associated with recovery-related outcomes, although it explained only a modest proportion of outcome variability. Patients undergoing A&P repair exhibited significantly prolonged hospitalization (8.00 vs. 6.29 and 6.94 days), postoperative recovery (4.99 vs. 3.48 and 4.17 days), and catheterization duration (3.31 vs. 2.33 and 2.86 days) (all p < 0.001). In contrast, intraoperative blood loss was primarily driven by patient-specific factors, including concomitant hysterectomy, prolapse severity, obesity, age, and obstetric history. Prolonged hospitalization was strongly associated with combined procedural complexity and clinical burden, while catheterization duration was influenced by postoperative complications and parity. Conclusions: This study demonstrates that perioperative outcomes in POP surgery arise from distinct and interacting domains: procedural factors predominantly shape recovery trajectories, whereas patient characteristics govern intraoperative risk. The proposed stratified random-effects framework enables integrated evaluation across heterogeneous surgical groups and provides an exploratory basis for identifying domains that may inform future individualized perioperative risk models.