Introduction and hypothesisVaginal apical suspension is essential for the surgical treatment of pelvic organ prolapse (POP). We aim to evaluate whether the method of apical repair is associated with different re-operation rates for POP recurrence or surgical complications.MethodsPopulation-based, retrospective cohort study of all Ontario women receiving primary apical POP repairs from 2003 to 2015. Primary exposure was the method of apical POP repair. Primary outcome was re-operation for recurrent POP, and secondary outcomes were surgical procedures for genito-intestinal (GI) or genitourinary (GU) complications, fistula repair, and mesh revision or removal.ResultsForty-three thousand four hundred fifty-eight women were included. Overall, the number of mesh-based apical repairs decreased over time, while the number of native-tissue repairs slightly increased (p < 0.001). Multivariable Cox proportional hazards (Cox PH) analysis demonstrated a significant increase in repeat POP operations for transvaginal mesh apical repairs (adjusted HR 1.28 [95% CI: 1.10–1.48]), but not in abdominal mesh repairs (adjusted HR 0.96 [95% CI: 0.81–1.13]) compared with vaginal native tissue apical repairs. Overall risk of repeat surgery for fistulas or GI and GU complications remained low (< 0.5%). Risk of mesh removal or revision was 11.5–11.9%, with no difference between abdominal versus vaginal mesh on multivariable analysis (adjusted HR 0.99 [95% CI: 0.78–1.26]).ConclusionsRe-operation for recurrent POP is highest in transvaginal mesh apical repairs; however, this risk did not differ between abdominal mesh and vaginal native tissue apical repairs. GI and GU re-operations are rare. There is no difference in mesh removal or revision rates between abdominal and vaginal mesh repairs.