Risk factors for the recurrence of pelvic organ prolapse: a meta-analysis

Figures & data

Figure 1. Flow diagram of the selection process.

Table 1. Characteristics of included studies.

Auther	Research area	Follow up years	sample size(n)	Definition of recurrence	Incidence of recurrence % (n)	Factors related to POP recurrence after surgery
Tegerstedt and Hammarström (2004)	Sweden	11.3	128	Stage ≥ 2 POP-Q	44% (56)	Previous pelvic floor surgery, BMI> 25 kg/m^2, preoperative stage (III-IV), smoker, bronchopulmonary diseases, constipation
Whiteside et al. (2004)	USA	1	176	Stage ≥ 2 POP-Q	58% (102)	Preoperative stage (III-IV), hysterectomy, history of diabetes mellitus
Jin L et al. (2005)	China	2.62	74	Baden–Walker half way system grade ≥ 1	54% (40)	History of diabetes mellitus, bronchopulmonary diseases, constipation
Diez-Itza et al. (2007)	Spain	5	134	Stage ≥ 2 POP-Q	31.3% (42)	Preoperative stage (III-IV), parity, constipation
Fialkow et al. (2008)	USA	≤10	142	≥Grade 1 Oslen’s classification	25% (36)	BMI> 25 kg/m^2, preoperative stage (III-IV), smoker, previous hysterectomy
Denman et al. (2008)	USA	10	374	repeat POP-UI surgery	14.7% (55)	Previous pelvic floor surgery
Salvatore et al. (2009)	Italy	2.17	360	Stage ≥ 2 POP-Q	10% (36)	BMI> 25 kg/m^2, preoperative stage (III-IV), Previous hysterectomy, Bronchopulmonary diseases, constipation
Dietz et al. (2010)	Australia	4.5	83	Stage ≥ 2 POP-Q	40% (33)	Levator muscle avulsion
Model et al. (2010)	Australia	NM	727	Stage ≥ 2 POP-Q	50.6% (368)	Levator muscle avulsion
Weemhoff et al. (2012)	Netherlands	2	156	Stage ≥ 2 POP-Q	51.3% (80)	Previous pelvic floor surgery, preoperative stage (III-IV), constipation, levator avulsion
Wong et al. (2013)	Australia	2.2	209	Stage ≥ 2 POP-Q	33% (54)	Levator avulsion
Edenfield et al. (2013)	USA	1.17	219	Stage ≥ 2 POP-Q	24.6% (54)	BMI> 25 kg/m^2
Rodrigo et al. (2014)	Australia	2.51	334	POP-Q Point Ba≥-1	42% (141)	Previous hysterectomy, levator avulsion, hiatal area on Valsalva
Vergeldt et al. (2015)	Netherlands	1	139	Stage ≥ 2 POP-Q	54.7% (76)	Levator avulsion, hiatal area on Valsalva
Lu et al. (2015)	China	1–11	170	Stage ≥ 2 POP-Q	29.4% (50)	Preoperative stage (III-IV)
Xuan et al. (2016)	China	5.64	143	Stage ≥ 2 POP-Q	44.8% (64)	Levator avulsion
Vergeldt et al. (2016)	Netherlands	2	287	Stage ≥ 2 POP-Q	51.9% (149)	Preoperative stage (III-IV), levator avulsion, hiatal area on Valsalva
Abdul Jalil et al. (2016)	Australia	1.3	207	Stage ≥ 2 POP-Q	45.9% (95)	Levator avulsion
Rappa and Saccone (2016)	Italy	≥ 0.5	360	Stage ≥ 2 POP-Q	19.7% (71)	BMI> 25 kg/m^2
Turner et al. (2016)	USA	1	126	Stage ≥ 2 POP-Q	33.3% (42)	BMI> 25 kg/m^2, preoperative stage (III-IV)
Cho et al. (2017)	Korea	0.6	107	Stage ≥ 2 POP-Q	6.5% (7)	Previous pelvic floor surgery, previous hysterectomy, history of diabetes mellites, bronchopulmonary diseases
Manodoro et al. (2018)	Italy	2.67	519	Stage ≥ 2 POP-Q	13.7% (71)	BMI> 25 kg/m^2, preoperative stage (III-IV), menopause, constipation
Oversand et al. (2019)	Norway	1	189	Stage ≥ 2 POP-Q	NM	Preoperative stage (III-IV), previous hysterectomy, Levator avulsion
Schulten et al. (2022)	Netherlands	5	207	Stage ≥ 2 POP-Q	71% (147)	Preoperative stage (III-IV), smoker
Liu et al. (2022)	China	2.5	102	Ultrasound detected cystocele, enterocele or rectocele.	52.9% (54)	Levator avulsion, hiatal area on Valsalva
Kim et al. (2022)	Korea	1	415	Stage ≥ 2 POP-Q or subjective recurrence symptoms	9.6% (40)	Previous pelvic floor surgery, smoker, menopause
Kayondo et al. (2022)	Uganda	1	127	Stage ≥ 2 POP-Q	25.2% (32)	Preoperative stage (III-IV)
Bodner-Adler et al. (2022)	Austria	7.55	188	Objective recurrence or subjective recurrence.	66% (124)	Menopause, parity
Yang et al. (2022)	China	6.7	195	Subjective recurrence	5.6% (11)	Previous hysterectomy, history of diabetes mellitus, parity

NM: Not mention.

Figure 2. Meta-analysis of association between levator avulsion and pelvic organ prolapse (POP) recurrence. Each study is shown by an odds ratio estimate with the corresponding 95% confidence interval.

Figure 3. Meta-analysis of association between preoperative stage（III-IV）and pelvic organ prolapse (POP) recurrence. Each study is shown by an odds ratio estimate with the corresponding 95% confidence interval.

Table 2. The meta-analysis of risk factors for the recurrence of POP after surgery.

Risk factor	Stuides n	Heterogeneity (I^2)	Heterogeneity (p-value)	Effects model	OR	95%CI	P	Reference
Levator avulsion	11	56.9%	0.01	Random	2.46	1.80–3.36	0.00	Abdul Jalil et al. (2016), Dietz et al. (2010), Liu Z et al. (2022), Model et al. (2010), Oversand et al. (2019), Rodrigo et al. (2014), Vergeldt et al. (2015), Vergeldt et al. (2016), Weemhoff et al. (2012), Wong et al. (2013), Xuan et al. (2016).
Preoperative stage (III-IV)	13	23.8%	0.19	Fixed	1.87	0.53–2.27	0.00	Diez-Itza et al. (2007), Fialkow et al. (2008), Kayondo et al. (2022), Lu et al. (2015), Manodoro et al. (2018), Oversand et al, (2019), Salvatore et al. (2009), Schulten et al. (2022), Tegerstedt and Hammarström (2004), Turner et al (2016), Vergeldt et al. (2016), Weemhoff et al. (2012), Whiteside et al. (2004).
BMI> 25 kg/m^2	7	11.2%	0.34	Fixed	1.13	0.90–1.40	0.30	Edenfield et al. (2013), Fialkow et al. (2008), Manodoro et al. (2018), Rappa and Saccone (2016), Salvatore et al. (2009), Tegerstedt and Hammarström (2004), Turner et al. (2016).
Parity	3	80.0%	0.01	Random	4.02	0.44–37.11	0.22	Bodner-Adler et al. (2022), Yang et al. (2022), Diez-Itza et al. (2007).
Menopause	4	83.6%	0.00	Random	0.51	0.24–1.10	0.09	Bodner-Adler et al. (2022), Kim et al. (2022), Manodoro et al. (2018), Whiteside et al. (2004).
Previous hysterectomy	7	29.7%	0.20	Fixed	.89	0.70–1.13	0.33	Cho et al. (2017), Fialkow et al. (2008), Oversand et al. (2019), Rodrigo et al. (2014), Salvatore et al. (2009), Whiteside et al. (2004), Yang et al. (2022).
Constipation	6	14.8%	0.32	Fixed	1.05	0.75–1.46	0.32	Dietz (2008), Jin et al. (2005), Manodoro et al. (2018), Salvatore et al. (2009), Tegerstedt and Hammarström (2004), Weemhoff et al. (2012).
Hiatal area on Valsalva	4	73.0%	0.01	Random	1.08	1.03–1.12	0.00	Liu et al. (2022), Rodrigo et al. (2014), Vergeldt et al. (2015), Vergeldt et al. (2016).
Chronic-pulmonary diseases	4	0.0%	0.71	Fixed	1.36	0.72–2.57	0.35	Cho et al. (2017), Jin et al. (2005), Salvatore et al. (2009), Tegerstedt and Hammarström (2004),
History of diabetes mellites	4	0.0%	0.58	Fixed	1.10	0.53–2.31	0.79	Cho et al. (2017), Jin et al. (2005), Whiteside et al. (2004), Yang et al. (2022).
Previous pelvic floor surgery	5	6.6%	0.37	Fixed	1.60	1.07–2.39	0.02	Cho et al. (2017), Denman et al. (2008), Kim et al. (2022), Tegerstedt and Hammarström (2004), Weemhoff et al. (2012).
Smoker	4	72.4%	0.01	Random	1.59	0.67–3.77	0.29	Fialkow et al. (2008), Kim et al. (2022), Schulten et al. (2022), Tegerstedt and Hammarström (2004).

Table 3. Sensitivity analysis and publication bias.

Risk factor	Fixed effects model		Random effects models		Publication bias
	OR	95%CI	OR	95%CI	Egger’s（P）	Begg’s（P）
Levator avulsion	2.28	1.88–2.78	2.46	1.80–3.36	0.04	0.04
Preoperative stage（III-IV）	1.87	1.53–2.27	1.88	1.49–2.37	0.35	0.51
BMI> 25 kg/m^2	1.13	0.90–1.40	113	0.88–1.44	0.86	0.37
Parity	0.96	0.89–1.04	4.02	0.44–37.11	0.24	1.00
Menopause	0.93	0.86–1.00	0.51	0.244–1.10	0.16	1.00
Previous hysterectomy	0.89	0.70–1.13	0.90	0.66–1.22	0.37	1.00
Constipation	1.05	0.75–1.46	1.05	0.73–1.52	0.53	0.45
Hiatal area on Valsalva	1.06	1.04–1.08	1.08	1.03–1.12	0.06	0.31
Chronic pulmonary diseases	1.36	0.72–2.57	1.36	0.72–2.57	0.36	0.31
History of diabetes mellites	1.10	0.53–2.31	1.10	0.53–2.31	0.20	0.31
Previous pelvic floor surgery	1.60	1.07–2.39	1.59	1.04–2.44	0.84	0.81
Smoker	1.53	0.99–2.38	1.59	0.67–3.77	0.81	0.73

BMI: body mass index.

Tegerstedt, G. and Hammarström, M., 2004. Operation for pelvic organ prolapse: a follow-up study. Acta Obstetricia et Gynecologica Scandinavica, 83 (8), 758–763.

 PubMed Web of Science ®Google Scholar

Whiteside, J.L., et al., 2004. Risk factors for prolapse recurrence after vaginal repair. American Journal of Obstetrics and Gynecology, 191 (5), 1533–1538.

 PubMed Web of Science ®Google Scholar

Jin, L., Wang, J. and Zhang, X., 2005. Clinical analysis of the relapse and its related factors in patients with pelvic organ prolapse. Chinese Journal of Clinical Obstetric and Gynecology, 6 (1), 8–12.

 Google Scholar

Diez-Itza, I., Aizpitarte, I. and Becerro, A., 2007. Risk factors for the recurrence of pelvic organ prolapse after vaginal surgery: a review at 5 years after surgery. International Urogynecology Journal and Pelvic Floor Dysfunction, 18 (11), 1317–1324.

 PubMed Web of Science ®Google Scholar

Fialkow, M.F., Newton, K.M. and Weiss, N.S., 2008. Incidence of recurrent pelvic organ prolapse 10 years following primary surgical management: a retrospective cohort study. International Urogynecology Journal and Pelvic Floor Dysfunction, 19 (11), 1483–1487.

 PubMed Web of Science ®Google Scholar

Denman, M.A., et al., 2008. Reoperation 10 years after surgically managed pelvic organ prolapse and urinary incontinence. American Journal of Obstetrics and Gynecology, 198 (5), 555.e1–555.e5555–555.e5.

 Web of Science ®Google Scholar

Salvatore, S., et al., 2009. Identification of risk factors for genital prolapse recurrence. Neurourology and Urodynamics, 28 (4), 301–304.

 PubMed Web of Science ®Google Scholar

Dietz, H.P., Chantarasorn, V. and Shek, K.L., 2010. Levator avulsion is a risk factor for cystocele recurrence. Ultrasound in Obstetrics & Gynecology, 36 (1), 76–80.

 PubMed Web of Science ®Google Scholar

Model, A.N., Shek, K.L. and Dietz, H.P., 2010. Levator defects are associated with prolapse after pelvic floor surgery. European Journal of Obstetrics, Gynecology, and Reproductive Biology, 153 (2), 220–223.

 PubMed Web of Science ®Google Scholar

Weemhoff, M., et al., 2012. Avulsion of puborectalis muscle and other risk factors for cystocele recurrence: a 2-year follow-up study. International Urogynecology Journal, 23 (1), 65–71.

 PubMed Web of Science ®Google Scholar

Wong, V., et al., 2013. Is levator avulsion a predictor of cystocele recurrence following anterior vaginal mesh placement? Ultrasound in Obstetrics & Gynecology : The Official Journal of the International Society of Ultrasound in Obstetrics and Gynecology, 42 (2), 230–234.

 PubMed Web of Science ®Google Scholar

Edenfield, A.L., et al., 2013. Vaginal prolapse recurrence after uterosacral ligament suspension in normal-weight compared with overweight and obese women. Obstetrics and Gynecology, 121 (3), 554–559.

 PubMed Web of Science ®Google Scholar

Rodrigo, N., et al., 2014. The use of 3-dimensional ultrasound of the pelvic floor to predict recurrence risk after pelvic reconstructive surgery. The Australian & New Zealand Journal of Obstetrics & Gynaecology, 54 (3), 206–211.

 PubMed Web of Science ®Google Scholar

Vergeldt, T.F., et al., 2015. Levator hiatal area as a risk factor for cystocele recurrence after surgery: a prospective study. BJOG : An International Journal of Obstetrics and Gynaecology, 122 (8), 1130–1137.

 PubMed Web of Science ®Google Scholar

Lu, C., Wei, W. and Lu, D., 2015. The risk factors for pelvic organ prolapse treated by traditional surgical procedures. Chinese Clinical Doctor, 43, 76–79.

 Google Scholar

Xuan, Y., et al., 2016. Study on postoperative application of trasnspreineal 3d ultrasound for pelvic organ prolapse. Chinese Journal of Clinical Obstetrics and Gynecology, 17 (3), 216–219.

 Google Scholar

Vergeldt, T.F., et al., 2016. Anatomical Cystocele Recurrence: Development and Internal Validation of a Prediction Model. Obstetrics and Gynecology, 127 (2), 341–347.

 PubMed Web of Science ®Google Scholar

Abdul Jalil, S.S., Guzman Rojas, R. and Dietz, H.P., 2016. Does it matter whether levator avulsion is diagnosed pre- or postoperatively? Ultrasound in Obstetrics & Gynecology, 48 (4), 516–519.

 PubMed Web of Science ®Google Scholar

Rappa, C. and Saccone, G., 2016. Recurrence of vaginal prolapse after total vaginal hysterectomy with concurrent vaginal uterosacral ligament suspension: comparison between normal-weight and overweight women. American Journal of Obstetrics and Gynecology, 215 (5), 601.e1–601–e4.

 Web of Science ®Google Scholar

Turner, L., et al., 2016. The impact of obesity on intraoperative complications and prolapse recurrence after minimally invasive sacrocolpopexy. Female Pelvic Medicine & Reconstructive Surgery, 22 (5), 317–323.

 PubMed Web of Science ®Google Scholar

Cho, M.K., Moon, J.H. and Kim, C.H., 2017. Factors associated with recurrence after colpocleisis for pelvic organ prolapse in elderly women. International Journal of Surgery, 44, 274–277.

 PubMed Web of Science ®Google Scholar

Manodoro, S., et al., 2018. Risk factors for recurrence after hysterectomy plus native-tissue repair as primary treatment for genital prolapse. International Urogynecology Journal, 29 (1), 145–151.

 PubMed Web of Science ®Google Scholar

Oversand, S.H., et al., 2019. Impact of levator muscle avulsions on Manchester procedure outcomes in pelvic organ prolapse surgery. Acta Obstetricia et Gynecologica Scandinavica, 98 (8), 1046–1054.

 PubMed Web of Science ®Google Scholar

Schulten, S.F., et al., 2022. Risk factors for pelvic organ prolapse recurrence after sacrospinous hysteropexy or vaginal hysterectomy with uterosacral ligament suspension. American Journal of Obstetrics and Gynecology, 227 (2), 252.e1–252–e9.

 Web of Science ®Google Scholar

Liu, Z., et al., 2022. Clinical and pelvic floor ultrasound characteristics of pelvic organ prolapse recurrence after transvaginal mesh pelvic reconstruction. BMC Women’s Health, 22 (1), 102.

 PubMed Web of Science ®Google Scholar

Kim, J.H., et al., 2022. Outcomes of vaginal hysterectomy combined with anterior and posterior colporrhaphy for pelvic organ prolapse: a single center retrospective study. Obstetrics & Gynecology Science, 65 (1), 74–83.

 PubMedGoogle Scholar

Kayondo, M., et al., 2022. Risk factors for recurrence of pelvic organ prolapse after vaginal surgery among Ugandan women: a prospective cohort study. International Urogynecology Journal, 33 (7), 1933–1939.

 PubMed Web of Science ®Google Scholar

Bodner-Adler, B., et al., 2022. Clinical risk factors for recurrence of pelvic organ prolapse after primary native tissue prolapse repair. Wiener Klinische Wochenschrift, 134 (1–2), 73–75.

 PubMed Web of Science ®Google Scholar

Yang, J., et al., 2022. Long-term observation on postoperative recurrence and complications of transvaginal mesh surgery for pelvic organ prolapse. Gynecologic and Obstetric Investigation, 87 (1), 30–37.

 PubMed Web of Science ®Google Scholar

Dietz, H.P., 2008. The aetiology of prolapse. International Urogynecology Journal, 19 (10), 1323–1329.

 Web of Science ®Google Scholar