Cumulative Incidence and Surgical Risk Factors for Severe Postoperative Complications in the Treatment of Primary Uterovaginal Prolapse: A Systematic Review and Meta-Analysis

Introduction and Hypothesis Apical repairs for uterovaginal prolapse (UPOP) are generally elective procedures with significant quality-of-life benefit; however, uncommon and potentially severe complications may occur. Our goal was to perform a systematic review and meta-analysis to understand risks for and estimate the incidence of major complications of common surgical approaches to UPOP repair. Methods Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we searched MEDLINE and EMBASE through 11/11/25 for studies describing risk factors for, or incidence of, severe complications due to surgical UPOP repair. Data collected included risk factor analysis and incidence data for major intraoperative injury (bowel, bladder, ureteral, or nerve) and major surgical complications (transfusion, small bowel obstruction, perioperative death, mesh complication, reoperations, and readmissions, and sum of any major complication). Pooled proportions were estimated using a random-effects meta-analysis of proportions, and between-group comparisons were performed using mixed-effects meta-regression for major surgical approaches to UPOP repair (vaginal native tissue (VNT), minimally invasive sacrocolpopexy (MIS SCP), transvaginal mesh (TVM); all transabdominal MIS (laparoscopic/robotic), all vaginal reconstructive; VNT with hysterectomy, and VNT with hysteropexy). Results Of the 8890 abstracts screened, 46 studies met the inclusion criteria. Overall quality of evidence was moderate. MIS had higher pooled incidence of intraoperative bowel injury compared to vaginal approaches (0.48%; CI 0.27–0.84 vs 0.18%; CI 0.09–0.35, p = 0.028); however, with lower risk of transfusion (0.35%; CI 0.14%–0.87% vs 0.99%; CI 0.67%–1.46%, p = 0.04). Total intraoperative injury estimates were similar between groups (0.11%; CI 0.01–0.81 vs 0.65%; CI 0.20–2.06. p = 0.135). TVM was associated with higher total major complications (17.98%; CI 9.44–31.56) than VNT (5.01%; CI 3.07–8.07) or MIS SCP (6.41%; CI 4.13–9.84) p = 0.007. A narrative review of risk factors for surgical complications identified significant heterogeneity and low confidence in reported risk factors. Conclusions Severe complications following repair of primary UPOP are infrequent. Abdominal MIS carry higher risk of bowel injury, with lower risk of transfusion compared to vaginal approaches. These data should inform shared decision-making for surgeons and patients considering surgical repair for primary UPOP.