ORIGINAL ARTICLE Association between method of pelvic organ prolapse repair involving the vaginal apex and re-operation: a population-based, retrospective cohort study You (Maria) Wu 1 & Jennifer Reid 2 & Queena Chou 1 & Barry MacMillan 1 & Yvonne Leong 1 & Blayne Welk 2,3,4 Received: 9 August 2018 /Accepted: 8 October 2018 # The International Urogynecological Association 2018 Abstract Introduction and hypothesis Vaginal apical suspension is essential for the surgical treatment of pelvic organ prolapse (POP). We aim to evaluate whether the method of apical repair is associated with different re-operation rates for POP recurrence or surgical complications. Methods Population-based, retrospective cohort study of all Ontario women receiving primary apical POP repairs from 2003 to 2015. Primary exposure was the method of apical POP repair. Primary outcome was re-operation for recurrent POP, and secondary outcomes were surgical procedures for genito-intestinal (GI) or genitourinary (GU) complications, fistula repair, and mesh revision or removal. Results Forty-three thousand four hundred fifty-eight women were included. Overall, the number of mesh-based apical repairs decreased over time, while the number of native-tissue repairs slightly increased (p < 0.001). Multivariable Cox proportional hazards (Cox PH) analysis demonstrated a significant increase in repeat POP operations for transvaginal mesh apical repairs (adjusted HR 1.28 [95% CI: 1.10–1.48]), but not in abdominal mesh repairs (adjusted HR 0.96 [95% CI: 0.81–1.13]) compared with vaginal native tissue apical repairs. Overall risk of repeat surgery for fistulas or GI and GU complications remained low (< 0.5%). Risk of mesh removal or revision was 11.5–11.9%, with no difference between abdominal versus vaginal mesh on multivariable analysis (adjusted HR 0.99 [95% CI: 0.78–1.26]). Conclusions Re-operation for recurrent POP is highest in transvaginal mesh apical repairs; however, this risk did not differ between abdominal mesh and vaginal native tissue apical repairs. GI and GU re-operations are rare. There is no difference in mesh removal or revision rates between abdominal and vaginal mesh repairs. Keywords Apical repair . Pelvic organ prolapse . Mesh use . Re-operation Introduction Pelvic organ prolapse (POP) affects 30–40% of women in their lifetime [ 1] and may have detrimental impacts on women’ s qual- ity of life. Surgery for POP is often indicated when conservative therapies fail. Adequate support of the vaginal apex is increasing- ly recognized as the essential component of a durable POP repair [2, 3], since repair of the anterior or posterior compartment alone in the setting of severe POP is associated with a higher failure rate. As such, the number of POP repairs involving vaginal apex fix- ation has steadily increased over the past 2 decades [ 4]. Vaginal apical suspension can be achieved using multiple techniques, including abdominal sacrocolpopexy (ASCP), sacrospinous ligament suspension (SSLS), uterosacral ligament fixation (USLF) and McCall culdoplasty. Among these, ASCP has long been regarded as the gold standard for vaginal apical Electronic supplementary material The online version of this article (https://doi.org/10.1007/s00192-018-3792-2) contains supplementary material, which is available to authorized users. * You (Maria) Wu ymariawu@gmail.com 1 Department of Obstetrics and Gynecology, London Health Sciences Centre, Victoria Hospital, Room B4-401, 800 Commissioners Road, East London, ON N6H 5W9, Canada 2 Institute for Clinical Evaluative Sciences, Toronto, ON, Canada 3 Department of Epidemiology and Biostatistics, London Health Sciences Centre, London, ON, Canada 4 Department of Surgery, London Health Sciences Centre, London, ON, Canada International Urogynecology Journal https://doi.org/10.1007/s00192-018-3792-2