Complications After Vaginal Vault Suspension: A Nationwide Cohort Study Comparing Six Apical Procedures.

INTRODUCTION AND HYPOTHESIS: To compare complication profiles following six surgical procedures for vaginal vault prolapse in women with prior hysterectomy. METHODS: Nationwide cohort study with 3-14 years' follow-up. Patients were identified in a national database and validated by chart review. The population included 1374 women with prior hysterectomy undergoing primary vaginal vault suspension from January 1, 2010, to December 31, 2020: sacrocolpopexy (SCP), laparoscopic uterosacral ligament suspension (LUSLS), ipsilateral uterosacral ligament suspension (IUSLS), vaginal extraperitoneal uterosacral ligament suspension (VEULS), sacrospinous ligament fixation (SSLF), and SSLF with graft. Complications recorded within the first 30 days were classified by Clavien-Dindo. Cox regression was adjusted for demographics. Primary outcome was intra- and postoperative complications. Secondary outcomes included mesh exposure, length of hospital stay, readmission, and subsequent stress urinary incontinence surgery. RESULTS: Complication recording disclosed that SSLF had the lowest intraoperative (aOR 0.32, 95% CI 0.14-0.74) and severe Clavien-Dindo ≥ III rates (aOR 0.32, 95% CI 0.12-0.87). Mesh exposure occurred in 12.0% of SCP and 12.2% of SSLF with graft. Vaginal perforation during laparoscopic/robotic SCP increased the risk eightfold (OR 8.08; 95% CI 2.16-30.15). IUSLS disclosed a higher rate of catheter use and urinary tract infections. SSLF was associated with increased risk of hematoma and pain treatment. De novo incontinence and subsequent SUI surgery were most frequent after SCP. Readmission rates were low across procedures. CONCLUSIONS: Complication profiles differed between procedures. SSLF was associated with lower rates of severe complications, whereas mesh exposure was comparable across mesh-based repairs. Findings support individualized surgical decision-making.