Surgical Strategies for Apical Pelvic Organ Prolapse: A Systematic Review and Network Meta-Analysis.

INTRODUCTION AND HYPOTHESIS: Comparative effectiveness of surgical approaches to apical pelvic organ prolapse (POP) remains uncertain, particularly regarding recurrence, reoperation and mesh-related outcomes over the available follow-up. The objective was to compare the effectiveness and safety of surgical treatments for primary apical pelvic organ prolapse (POP) using a systematic review and network meta-analysis of randomised controlled trials (RCTs). METHODS: Comprehensive searches were conducted in Web of Science, Scopus, Embase, Medline, Cochrane Library, WHO, and ICTRP databases from inception to 30 June 2025. English-language RCTs comparing surgical interventions for apical POP, alone or with other compartment repairs, were included if they reported anatomical recurrence after ≥ 1-year follow-up. Studies on non-surgical interventions were excluded. The primary outcome was anatomical recurrence; secondary outcomes included subjective recurrence, reoperation rates and mesh complications. Risk of bias was assessed using the Cochrane tool, and study integrity was evaluated with the Trustworthiness in Randomised Controlled Trials checklist. A random-effects network meta-analysis (NMA; NMAstudio 2.0) was performed, grouping interventions by clinical similarity. Native tissue repair (NTR) served as the reference. RESULTS: Fifty-eight RCTs (6,846 participants) were included. Vaginal, abdominal and laparoscopic mesh repairs significantly reduced anatomical recurrence versus NTR (relative risk 0.59-0.66). Vaginal mesh and laparoscopic sacrocolpopexy with posterior plication lowered subjective recurrence (relative risk 0.22-0.51). Abdominal sacrocolpopexy was associated with fewer recurrence-related reoperations (relative risk 0.40), whereas vaginal mesh had higher mesh-related reoperations (relative risk 5.19). CONCLUSIONS: Mesh-augmented vaginal, laparoscopic and abdominal repairs reduce prolapse recurrence compared with NTR but carry increased mesh-related risks. Sacrocolpopexy was associated with favourable anatomical durability for apical POP.