The LCSP and LCSS techniques were performed laparoscopically with 3 standard 5-mm accesses in the pelvis and 10-mm transumbilical optics. All patients under study underwent hysterectomy prior to colposuspension following the steps described by Gueli Alletti et al. (11). LCSP was performed according to the steps described by Henniger et al. in 2015 (19, 20), and LCSS followed the steps described by Restaino et al. in 2016 (21). Cystopexy was, on the other hand, performed vaginally with colpoincision and raffia of the bladder fascia with natural vaginal tissue repair technique (NVTR) (22).

The primary endpoint was the rate of post-operative complications in the first 30 days. The null hypothesis (H0) of the primary endpoint of the study is devised as no difference in the prevalence of post-operative complications in the first 30 days in patients undergoing laparoscopic hysterectomy for uterine prolapse with colposuspension, compared to the same technique combined with cystopexy, (H0: π-π1 = 0; one-way). To test H0, the significance level α was set = 0.05. Fisher's exact test and Chi- squared test were used to calculate p in comparing dichotomous variables and Wilcoxon's test in the case of ordinal variables. Rejection of H0 for p ≤ α. The parameter of the presence or absence of postoperative complications in the first 30 days was estimated as a dichotomous prevalence variable. The effect of the addition of cystopexy on postoperative complications was expressed as an Odds Ratio (OR) with a 95% confidence interval. Quantitative variables such as age and BMI were expressed as medians. R software version 4.2.3 was used for statistical analysis.

Missing data were addressed using multiple imputation techniques, ensuring the preservation of statistical power and reducing potential bias. The imputed values were cross-validated using complete case analysis to verify consistency. Sensitivity analyses involved excluding extreme values, testing alternative statistical models, and assessing subgroup-specific trends.

The study was conducted in two university clinics where all patients treated must sign a dedicated consent for anonymous data processing. According to the regulations in force in the state where the study was conducted, no IRB is required due to the study's retrospective nature.

Operative time was comparable in the two groups (p = 0.042): mean surgery length is 153 min in LCSP or LCSS (data concerning 84 procedures are missing) and 126 min in colposuspension associated with cystopexy. The primary endpoint was the evaluation of post-operative complications. The post-operative complications rate in Group A was 2.4% compared to 16% in Group B (p = 0.016). Only 3 complications occurred in Group A and 4 in Group B. Adding cystopexy at the time of colposuspension resulted in a statistically significant Odds Ratio of 7.62 (95% CI 1.59–36.51; p = 0.017) to develop post-operative complications in the early 30 days. The secondary outcome was the recurrence rate of prolapse at 24 months. Group A presented a recurrence rate of 13% compared to 12% of Group B (p > 0.9). Surgical Outcomes are summarized in Table 2.

The types of complications are summarized in Table 3.

As reported in the previous paragraph, group A reported 3 complications: 1 case (33%) of pulmonary embolism and 2 cases (66%) of fever. On the other hand, group B reported 4 cases of postoperative complications: 3 patients had post-operative anemia with the necessity of blood transfusion (75%), and 1 patient had a post-operative fever (25%).

The present retrospective study demonstrates that adding cystopexy to LCSP or LCSS at the time of uterine prolapse treatment increases on 7 times the risk of postoperative complications in the early 30 days after surgery. The operation time seems to be slightly longer in group A (without cystopexy). However, the results of this outcome are weakened by a high presence of missing data and also could be attributed to the higher percentage of LCSP in group A. Moreover, cystopexy was not found to decrease the rate of prolapse recurrence when combined with LCSP or LCSS.

Despite the common use of cystopexy, there are only a few studies on its precise indications and post- operative complication rates.

As already demonstrated, the key advantage of the laparoscopic approach for POP treatment is the magnified view of the operative field, which facilitates easier dissection and a more precise suture placement, thus helping minimize potential damage to the ureter. These benefits align with existing literature demonstrating minimal ureteric injury rates associated with this laparoscopic procedure (6, 7, 23, 24).

Otherwise, it is used in continent women at the time of surgical correction of POP to prevent genuine stress after corrective surgery for urogenital prolapse (24). In particular, Fianu et al. showed that 16% of their patients developed stress incontinence following anterior colporrhaphy (14), and Stanton et al. (13) reported an incidence of 11%. In contrast, Colombo et al. (25) observed an overall incidence of 8% of significant stress incontinence that required further treatment in two cases. The underlying causes of genuine stress incontinence following prolapse surgery remain not fully understood. In the literature (13), no differences have been found in age, parity, weight, and past pelvic surgery between the subjects who remained continent postoperatively and those who did not. In addition, it has been shown that the addition of hysterectomy does not affect postoperative outcomes in the case of surgery for urodynamic correction, as long as the surgery is not related to other clinical conditions that may alter pelvic structures (26–28). Postoperative bladder neck descent because of ineffective urethorvescical junction stabilization, and/or periuretral fibrosis with urethral denervation seem to be direct consequences of stress incontinence after POP surgery (13, 29). Our research group has previously shown that corrective surgery with a purely laparoscopic approach has an increased risk of symptom recurrence and organ prolapse (30). We believe that the occurrence of stress incontinence after prolapse surgery may have a multifactorial origin. For this reason, although the preventive execution of cystopexy could play a fundamental role in reducing this undesirable outcome, it must be remembered that cystopexy is not free from potential postoperative complications. Therefore, a careful selection of patients who could genuinely benefit from this procedure should be conducted to avoid adding unnecessary risks.

A major strength of the present study is its focus on cystopexy and its association with postoperative outcomes. Indeed, there are only a few studies in the literature regarding cystopexy, and most are outdated or in non-English language (23). Moreover, the cystopexy technique is never described in a standardized way. Nevertheless, all patients reported in the study underwent the same cystopexy methods by the Natural Vaginal Tissue repair technique. Hence, we believe that our work, besides presenting new data on the increased postoperative complications in patients undergoing cystopexy, also plays a fundamental role in highlighting the need for further studies helping in a better selection of patients.

A limitation of the present study is its retrospective nature, which limits the ability to establish causality and resulted in an abundance of “missing data” in the sample characteristics. This may limit the reproducibility of the study and its translation into clinical practice. Moreover, we have no data on post-surgical stress incontinence in the two groups with/without cystopexy, which is usually one of the main indications for cystopexy after surgery for POP (23). Hence, we would expect results in favor of adding the procedure routinely to prevent this unpleasant outcome. Moreover, since POP significantly impacts patients' quality of life, data on subjective patient satisfaction after surgical correction of POP would be needed, but they are still missing. Finally, laparoscopic and vaginal techniques involve two different skills, which may not coexist in the same operator (4, 31).

Therefore, the higher complication rate might be operator-dependent. Designs of prospective studies may clarify these doubts.