ORIGINAL ARTICLE Long-term outcomes and predictors of failure after surgery for stage IV apical pelvic organ prolapse Brian J. Linder 1 & Sherif A. El-Nashar 1 & Alain A. Mukwege 1 & Amy L. Weaver 1 & Michaela E. McGree 1 & Deborah J. Rhodes 1 & John B. Gebhart 1 & Christopher J. Klingele 1 & John A. Occhino 1 & Emanuel C. Trabuco 1 Received: 15 June 2017 /Accepted: 6 September 2017 # The International Urogynecological Association 2017 Abstract Introduction and hypothesis The aim of this study was to compare outcomes after uterosacral ligament suspension (USLS) or sacrocolpopexy for symptomatic stage IV apical pelvic organ prolapse (POP) and evaluate predictors of pro- lapse recurrence. Methods The medical records of patients managed surgically for stage IV apical POP from January 2002 to June 2012 were reviewed. A follow-up survey was sent to these patients. The primary outcome, prolapse recurrence, was defined as recur- rence of prolapse symptoms measured by validated question- naire or surgical retreatment. Survival time free of prolapse recurrence was estimated using the Kaplan–Meier method, and Cox proportional hazards models evaluated factors for an association with recurrence. Results Of 2633 women treated for POP, 399 (15.2%) had stage IV apical prolapse and were managed with either USLS (n = 355) or sacrocolpopexy (n = 44). Those managed with USLS were significantly older (p < 0.001) and less likely to have a prior hysterectomy (39.7 vs 86.4%; p < 0.001) or prior apical prolapse repair (8.2 38.6%; p < 0.001). Median follow-up was 4.3 years [interquartile range (IQR) 1.1–7.7]. Survival free of recurrence was similar between USLS and sacrocolpopexy (p = 0.43), with 5-year rates of 88.7 and 97.6%, respectively. Younger age [adjusted hazard ratio (aHR) 1.55, 95% confidence interval (CI) 1.12–2.13; p = 0.008] and prior hysterectomy (aHR 2.8, 95% CI 1.39– 5.64; p = 0.004) were associated with the risk of prolapse recurrence, whereas type of surgery approached statistical sig- nificance (aHR 2.76, 95% CI 0.80–9.60; p = 0.11). Conclusions Younger age and history of prior hysterectomy were associated with an increased risk of recurrent prolapse symptoms. Notably, excellent survival free of prolapse recur- rence were obtained with both surgical techniques. Keywords Pelvic organ prolapse . Surgery . Uterosacral ligament suspension . Sacrocolpopexy Introduction Pelvic organ prolapse (POP) is a prevalent issue in adult wom- en that can have a large impact on quality of life (QoL), lead- ing to discomfort, decreased energy, and increased social iso- lation [1]. Notably, the prevalence of prolapse increases with advancing age, and it is estimated that the lifetime risk of a woman undergoing surgery for bothersome prolapse is as high as 13% [2]. Given the present age distribution in the United States, the number of women seeking treatment for this issue in the future will continue to increase [2, 3]. Recurrence of prolapse after surgical repair is not uncommon, with as many as 17% of patients undergoing a repeat prolapse treatment [4–7]. However, conflicting data regarding risk factors for prolapse recurrence after a native tissue vaginal repair exist [6–11]. In fact, a recent systematic review identified preoper- ative stage as the only consistently reported risk factor for recurrence after prolapse surgery [12]. Additionally, while there are numerous studies evaluating the outcomes of various apical prolapse surgeries [13, 14], given the purported differ- ences in success rates and risks, the optimal management of apical prolapse (native tissue vs sacrocolpopexy) remains * Brian J. Linder Linder.Brian@mayo.edu 1 Departments of Obstetrics and Gynecology (BJL, SAE, AAM, JBG, CJK, JAO, ECT), Internal Medicine (DJR), and Health Science Research (ALW, MEM), Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA Int Urogynecol J DOI 10.1007/s00192-017-3482-5