The Association Between Morbid Obesity and Recurrence of Pelvic Organ Prolapse and Stress Urinary Incontinence Status Post Surgical Management: A Retrospective Cohort Study Utilizing TriNetX Data

INTRODUCTION: Stress urinary incontinence (SUI) and pelvic organ prolapse (POP) are common pelvic floor disorders that significantly affect quality of life in reproductive-age d and post-menopausal women. Shared risk factors include age, parity, obesity, connective tissue dysfunctions, chronic straining, and a history of pelvic surgery. As obesity rates continue to rise, disproportionately among women, recurrence of SUI and POP is a growing concern. Midurethral sling (MUS) is one of the most effective treatments for SUI, while surgical options for POP include sacrospinous ligament suspension, uterosacral suspension, sacrocolpopexy, vaginal hysterectomy, and related reconstructive procedures. Outcomes in severely obese women remain poorly defined. While some studies report higher rates of MUS failure or POP recurrence with BMI ≥40, others show no difference. No study has specifically evaluated BMI ≥45 as a threshold. This study examines the association between obesity and surgical outcomes after MUS and POP repair, focusing on reoperation, recurrence, and need for additional treatment in women with BMI ≥45. OBJECTIVE: To evaluate the association between obesity and surgical outcomes after MUS and procedures for pelvic organ prolapse, with a focus on reoperation, recurrence, and the need for additional treatment in women with BMI ≥45. METHODS: We conducted a retrospective cohort study using the TriNetX U.S. Collaborative Network, a database of de-identified electronic health records from 68 healthcare organizations. Patients with POP who underwent related surgical procedures, including MUS, were included. A BMI cutoff of ≥45 kg/m2 was applied. Propensity score matching (1:1) was used to balance age, comorbidities, and prior pelvic surgeries. Outcomes assessed over 10 years included prolapse recurrence, reoperation, repeat sling, additional treatments (e.g., bladder Botox, bulking agent injection, high-intensity focused ultrasound), and pessary use. RESULTS: Among women undergoing MUS, BMI ≥45 was not associated with differences in pessary use, procedure reversal, repeat sling, or overall failure, excluding sling. However, women with BMI ≥45 had higher rates of additional treatment (4.2% vs 2.2%, p=0.006). For POP repair, BMI ≥45 likewise did not affect pessary use, procedure reversal, repeat sling, or overall failure excluding sling, but was associated with an increased risk of additional treatment (2.8% vs 1.4%, p=0.016). No other statistically significant differences were identified between groups. CONCLUSIONS: In this large, multicenter cohort, morbid obesity (BMI ≥45) was not associated with an increased risk of structural failure after MUS or POP repair. However, women with BMI ≥45 were more likely to require additional treatment interventions, suggesting that while surgical durability is preserved, obesity may contribute to persistent or recurrent lower urinary tract symptoms. These findings underscore the importance of preoperative counseling, close postoperative follow-up, and individualized management for women with severe obesity undergoing pelvic floor reconstructive surgery.Table 1Table 2