Risk Factors for Recurrence Following Surgery for Apical Prolapse: A Systematic Review and Meta-Analysis

Most of the existing literature focuses on patient-level risk factors for recurrence after prolapse surgery in general, rather than specifically for uterovaginal prolapse (U-POP). As uterine-preserving procedures are increasingly performed, understanding patient-level risk factors for recurrence after U-POP is essential.

Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we searched for studies including women undergoing U-POP surgery to evaluate risk factors for recurrence. Risk of bias was assessed using the Grading of Recommendations Assessment, Development and Evaluation framework. Odds ratios were pooled using random-effects meta-analysis. Findings informed a Delphi process at the Global Consensus Conference on Controversies in Surgical Management of Primary U-POP (April 2026) resulting in consensus statements (≥80% agreement threshold).

Of the 4,149 abstracts screened, 25 studies (14,860 women; median follow-up 24 months) met the eligibility criteria. Meta-analyses were performed for 9 of the 16 risk factors identified. Advanced preoperative prolapse stage (OR 2.75; 95% CI 1.39-5.46), prior prolapse surgery (OR 2.09; 95% CI 1.16-3.75), and higher body mass index (BMI; OR 1.10 per unit increase; 95% CI 1.06-1.15) were each significantly associated with an increased risk of recurrence. No significant associations were identified for age, diabetes, smoking, parity, menopause, or preoperative estrogen use. Where there were insufficient data, expert consensus identified levator ani avulsion, enlarged genital hiatus, and connective-tissue disorders as additional risk factors.

Advanced preoperative prolapse stage, prior prolapse surgery, and higher BMI were each significantly associated with U-POP recurrence. Together with expert consensus, these findings should inform preoperative counseling and individualized surgical planning to improve long-term outcomes.