How is Subjective Surgical Success Defined Using the Pelvic Floor Distress Inventory (PFDI-20) After Primary Uterovaginal Prolapse Repair? A Systematic Review and Consensus Statements from the U-POP & LUTD 2026 Global Consensus Conference

INTRODUCTION AND HYPOTHESIS: Anatomic success after pelvic organ prolapse (POP) surgery correlates poorly with symptom relief, prompting reliance on patient-reported outcomes (PROs). The Pelvic Floor Distress Inventory (PFDI-20) is widely used, yet how it is applied to define subjective surgical success is unclear. We aimed to evaluate how subjective success is defined using the PFDI-20 and its components after primary uterovaginal prolapse repair. METHODS: As part of the U-POP & LUTD 2026 Global Consensus Conference, a systematic review (PRISMA; PROSPERO CRD420251171050) of MEDLINE, EMBASE, and ClinicalTrials.gov was conducted from inception to 8 December 2025. English-language studies of women undergoing primary uterovaginal prolapse repair that reported a PFDI-20- or POPDI-6-based definition of success were included. Screening and extraction were performed in duplicate, and the certainty of evidence was assessed using GRADE. Findings informed expert consensus statements. RESULTS: Of 5379 records, 28 studies (4196 women) were included. Surgical success was most commonly defined as the absence of a vaginal bulge symptom-a negative response to question 3 of the PFDI-20-in 21 of 28 studies. Other definitions combined question 3 with additional items, required a negative POPDI-6 subscale, or used a statistically significant change in total PFDI-20 score. Only one study applied a minimal clinically important difference (MCID), and none applied a patient acceptable symptom state (PASS). CONCLUSIONS: Subjective success after primary uterovaginal prolapse repair is most often defined by a single PFDI-20 item, with MCID and PASS thresholds rarely applied. Consistent, validated definitions are needed to improve comparability across trials.