Highlights
In this combined analysis of three multicenter randomized trials and one prospective registry involving 704 women undergoing native tissue apical prolapse surgery:
Prolapse phenotypes failed to predict symptomatic recurrence 12 months after surgery, despite wide variation in recurrence rates (0–29%) across phenotype groups.
Most women (67.2%) presenting for native tissue apical repair had anterior-predominant and apical prolapse, making this the dominant clinical phenotype in surgical practice.
Hispanic ethnicity, lack of private insurance, and higher vaginal parity emerged as significant predictors of recurrence, suggesting socioeconomic and demographic factors may outweigh anatomic phenotype in determining surgical outcomes.
The study’s large sample size and multicenter design provide robust evidence that the current POP-Q phenotype classification system may require refinement for clinical prognostic utility.
Background
Pelvic organ prolapse (POP) represents one of the most common conditions affecting women, with lifetime surgical intervention rates approaching 11–12% in developed countries. The disorder involves descent of one or more pelvic organs (uterus, vaginal vault, bladder, or rectum) through the vaginal canal, causing significant bothersome symptoms including vaginal bulge, pressure, and functional impairment. As populations age and life expectancy increases, the burden of POP on healthcare systems and women’s quality of life continues to grow substantially.
Surgical management remains a cornerstone of treatment for moderate to severe prolapse, with approximately 300,000 prolapse surgeries performed annually in the United States alone. Among the various surgical approaches, native tissue repair using the uterosacral ligament suspension (USLS) or sacrospinous ligament fixation (SSLF) continues to be widely performed, particularly in centers where mesh-related complications have prompted a return to traditional techniques. However, recurrence after prolapse surgery remains a persistent clinical challenge, with anatomic recurrence rates reported between 10–40% depending on definitions, surgical approach, and patient characteristics.
Previous research has suggested that baseline prolapse characteristics, including genital hiatus size and prolapse stage, may influence surgical outcomes. This observation led researchers to hypothesize that specific prolapse phenotypes—defined using the standardized Pelvic Organ Prolapse Quantification (POP-Q) system—might serve as meaningful prognostic markers. The POP-Q system provides objective, reproducible measurements of vaginal topography that can classify prolapse according to the leading edge of descent and compartment involvement. Understanding whether these phenotypes predict differential recurrence risks could enable more personalized surgical counseling and potentially guide operative approach selection.
Study Design
This investigation employed a secondary analysis framework, combining prospectively collected data from three multicenter randomized trials and one prospective multicenter patient registry. The pooled dataset encompassed participants who underwent vaginal native-tissue apical prolapse surgery at multiple academic medical centers, providing substantial sample size and demographic diversity.
Eligible participants included women undergoing either uterosacral ligament suspension or sacrospinous ligament fixation without mesh augmentation. Key inclusion criteria required availability of 12-month follow-up data and complete POP-Q measurements enabling phenotype classification. Participants were excluded if they had no evidence of prolapse (n=5) or missing necessary data elements.
Phenotype classification utilized the POP-Q system to categorize participants into eight distinct groups: isolated anterior prolapse, isolated posterior prolapse, isolated apical prolapse, anterior and posterior prolapse, anterior-predominant and apical prolapse, posterior-predominant and apical prolapse, and anterior and posterior and apical prolapse. This classification system was designed to capture the anatomic distribution and severity pattern of prolapse at baseline.
The primary outcome was symptomatic recurrence, defined as a positive response to the Pelvic Floor Distress Inventory “bulge” question with at least “somewhat” bother. Secondary outcomes included anatomic recurrence and new-onset or worsening stress urinary incontinence (SUI). The study employed univariable and multivariable logistic regression analyses, with adjustments for prolapse stage (stage II versus stage III-IV) and prior hysterectomy status.
Key Findings
The final analysis included 704 participants, reflecting the substantial scale achievable through data pooling across multiple studies. Surgical procedures were distributed between sacrospinous ligament fixation (184 participants, 26.1%) and uterosacral ligament suspension (520 participants, 73.9%). Concomitant midurethral slings were placed in 454 women (64.5%), reflecting the common clinical scenario of addressing both prolapse and potential stress incontinence in a single operative setting.
The distribution of prolapse phenotypes revealed marked heterogeneity but with a clear dominant pattern. The anterior-predominant and apical phenotype comprised the largest group by far, accounting for 473 participants (67.2%), establishing this as the predominant clinical presentation in women seeking apical prolapse surgery. The anterior and posterior and apical phenotype represented the second most common group (101 participants, 14.3%), followed by isolated apical prolapse (45 participants, 6.4%). Remaining phenotypes were comparatively rare in this surgical population.
Overall symptomatic prolapse recurrence occurred in 65 participants (9.2%) at 12 months, a figure consistent with contemporary recurrence rates reported in the literature. However, substantial variation existed across phenotype groups, ranging from 0% in the isolated posterior phenotype to 29% in the anterior and posterior phenotype. Notably, the isolated apical phenotype demonstrated remarkably low recurrence (2.2%, affecting only one participant), while the anterior-predominant and apical phenotype—used as the reference group—had a recurrence rate consistent with the overall population.
Despite these apparent differences in point estimates, formal statistical analysis revealed that prolapse phenotype was not significantly associated with symptomatic recurrence in either univariable or multivariable models. This null finding represents the study’s most clinically relevant conclusion, suggesting that the POP-Q-based phenotype classification does not provide meaningful prognostic information for recurrence risk after native tissue apical repair.
Exploratory analyses identified several factors that demonstrated statistically significant associations with recurrence in the adjusted models. Hispanic ethnicity emerged as an independent predictor (odds ratio 2.25, 95% confidence interval 1.17–4.35, p=0.015), suggesting approximately twice the odds of recurrence compared to non-Hispanic participants. Conversely, private insurance status was associated with reduced recurrence risk (odds ratio 0.58, 95% confidence interval 0.35–0.98, p=0.042), potentially reflecting differences in healthcare access, surgical timing, or other socioeconomic factors. Higher vaginal parity showed a modest but significant association with recurrence (odds ratio 1.19 per birth, 95% confidence interval 1.02–1.40, p=0.030).
For secondary outcomes, phenotype was similarly not significantly associated with anatomic recurrence or new-onset or worsening stress urinary incontinence. These consistent null findings across multiple outcome definitions strengthen the conclusion that POP-Q phenotype classification lacks clinical utility for predicting surgical outcomes in this context.
Expert Commentary
The findings from this analysis challenge prevailing assumptions about the prognostic value of prolapse phenotype classification. While intuitive reasoning might suggest that specific anatomic patterns—such as multi-compartment involvement or isolated apical descent—would correlate with differential recurrence risks, the data demonstrate that this is not the case for symptomatic outcomes following native tissue apical repair.
Several factors may explain the disconnect between phenotype and recurrence. First, the pathophysiology of prolapse recurrence after apical suspension is complex and likely involves factors beyond static anatomic measurements, including connective tissue quality, neuromuscular function, surgical technique nuances, and postoperative activity restrictions. Second, the POP-Q system, while highly reliable for research standardization, may not capture all clinically relevant anatomic features that influence repair durability. Third, symptomatic recurrence depends heavily on patient perception and bother thresholds, which are influenced by numerous non-anatomic factors including baseline symptom severity, expectations, and psychosocial characteristics.
The study’s limitations warrant careful consideration. The relatively small sample sizes within less common phenotype groups limit statistical power to detect moderate differences in these subgroups. The 12-month follow-up period, while appropriate for initial outcome assessment, may not capture later recurrences that develop beyond this timeframe. Additionally, the study population comprised women specifically undergoing apical surgery, potentially limiting generalizability to women with less severe or different prolapse patterns who might be managed conservatively or with compartment-specific repairs.
The identification of Hispanic ethnicity, insurance status, and vaginal parity as significant predictors of recurrence introduces important considerations regarding health disparities and surgical outcomes. These findings suggest that social determinants of health and reproductive history may exert stronger influences on prolapse surgery outcomes than detailed anatomic phenotyping, highlighting potential areas for targeted intervention or risk stratification. However, these observations require replication and further investigation to clarify underlying mechanisms.
From a clinical practice perspective, these results indicate that surgeons should not rely on POP-Q phenotype classification alone for prognostic counseling about recurrence risk. While thorough anatomic assessment remains essential for surgical planning, patients should be informed that the specific pattern of prolapse compartments involved does not strongly predict their individual recurrence risk after apical native tissue repair.
Conclusion
This large, multicenter combined analysis provides compelling evidence that POP-Q-based prolapse phenotypes do not predict symptomatic recurrence 12 months after native tissue apical prolapse surgery. Despite significant variation in recurrence rates across phenotype groups, these differences did not achieve statistical significance, and the anterior-predominant and apical phenotype dominated the surgical population at 67.2%.
The findings carry important implications for clinical practice and research. For clinicians, the results suggest that detailed anatomic phenotyping should not be the primary basis for recurrence risk counseling or surgical approach selection. For researchers, the study highlights the need to explore alternative prognostic markers—whether genetic, imaging-based, or biomarker-driven—that might better capture underlying biological susceptibility to prolapse recurrence.
The emergence of Hispanic ethnicity, lack of private insurance, and higher vaginal parity as significant recurrence predictors points toward the importance of addressing health disparities in pelvic floor care. Future studies should investigate whether targeted interventions—such as enhanced preoperative counseling, modified surgical techniques, or more intensive postoperative surveillance—might mitigate recurrence risk in higher-risk populations.
Larger studies with extended follow-up will be necessary to definitively characterize outcomes among less common phenotype groups and to determine whether longer-term recurrence patterns differ by anatomic subtype. In the meantime, the current evidence suggests that while prolapse phenotypes provide valuable information for research standardization and epidemiologic description, their clinical utility for predicting individual surgical outcomes remains limited.
Funding
Data were derived from three multicenter randomized trials and one prospective multicenter patient registry. Specific funding sources for the parent studies are detailed in the original publications.
References
1. Weston K, Kenne KA, Bradley CS, Wendt L, Kowalski JT. Prolapse phenotypes and 12-month post-operative prolapse recurrence after apical native tissue surgery: a combined analysis using multicenter randomized trials and registry data. American Journal of Obstetrics and Gynecology. 2026 Apr 10. PMID: 41967740.
