{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,3,31]],"date-time":"2026-03-31T03:46:01Z","timestamp":1774928761734,"version":"3.50.1"},"reference-count":46,"publisher":"MDPI AG","issue":"22","license":[{"start":{"date-parts":[[2025,11,17]],"date-time":"2025-11-17T00:00:00Z","timestamp":1763337600000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JCM"],"abstract":"<jats:p>Background\/Objectives: Pelvic organ prolapse (POP) surgery can lead to postoperative stress urinary incontinence (SUI) in previously continent women, termed de novo SUI. This study assessed the incidence and risk factors of de novo SUI after apical POP repair, hypothesizing that reduced bladder neck elasticity\u2014particularly within the zone of critical elasticity (ZCE) described by the Integral Theory\u2014contributes to its development. Methods: A retrospective single-center analysis was performed in 206 postmenopausal women (\u226560 years) who underwent apical POP surgery without concomitant anti-incontinence procedures. Patients were classified by surgical approach as laparoscopic sacrocolpopexy (SCP) or vaginal native tissue repair. Results: The overall incidence of de novo SUI was 8.7%. Laparoscopic SCP for vaginal vault prolapse was significantly associated with a higher risk of postoperative SUI (OR 10.37, 95% CI 2.70\u201339.79, p = 0.001), whereas other procedures showed no significant association. Neither prior hysterectomy nor cystocele stage was an independent predictor of de novo SUI. Conclusions: These results suggest that surgical alteration of the ZCE\u2014particularly excessive tension or reduced elasticity near the bladder neck\u2014may impair urethral closure. Therefore, preserving ZCE integrity and carefully adjusting mesh tension during apical POP repair may reduce the risk of de novo SUI.<\/jats:p>","DOI":"10.3390\/jcm14228153","type":"journal-article","created":{"date-parts":[[2025,11,19]],"date-time":"2025-11-19T12:55:31Z","timestamp":1763556931000},"page":"8153","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":3,"title":["De-Novo Stress Urinary Incontinence After Apical Prolapse Surgery: Potential Link with the Zone of Critical Elasticity"],"prefix":"10.3390","volume":"14","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-3713-9490","authenticated-orcid":false,"given":"Yaman","family":"Degirmenci","sequence":"first","affiliation":[{"name":"Department of Obstetrics and Gynecology, University Medical Center of the Johannes Gutenberg University Mainz, 55131 Mainz, Germany"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-9506-9219","authenticated-orcid":false,"given":"Ceren","family":"Efe Say\u0131n","sequence":"additional","affiliation":[{"name":"Department of Biostatistics and Medical Informatics, Faculty of Medicine, Kahramanmara\u015f S\u00fct\u00e7\u00fc \u0130mam University, 46040 Kahramanmara\u015f, T\u00fcrkiye"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0009-0001-3304-5040","authenticated-orcid":false,"given":"Ina","family":"Shehaj","sequence":"additional","affiliation":[{"name":"Department of Obstetrics and Gynecology, University of Frankfurt, 60590 Frankfurt am Main, Germany"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Mona Wanda","family":"Schmidt","sequence":"additional","affiliation":[{"name":"Department of Obstetrics and Gynecology, University Medical Center of the Johannes Gutenberg University Mainz, 55131 Mainz, Germany"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-5358-2751","authenticated-orcid":false,"given":"Gilbert Georg","family":"Klamminger","sequence":"additional","affiliation":[{"name":"Department of Obstetrics and Gynecology, University Medical Center of the Johannes Gutenberg University Mainz, 55131 Mainz, Germany"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1968","published-online":{"date-parts":[[2025,11,17]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"141","DOI":"10.1097\/AOG.0000000000000057","article-title":"Prevalence and trends of symptomatic pelvic floor disorders in U.S. women","volume":"123","author":"Wu","year":"2014","journal-title":"Obstet. Gynaecol."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"1460","DOI":"10.1111\/j.1471-0528.2000.tb11669.x","article-title":"The prevalence of pelvic floor disorders and their relationship to gender, age, parity and mode of delivery","volume":"107","author":"MacLennan","year":"2000","journal-title":"BJOG"},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"497","DOI":"10.1007\/s00192-005-1326-1","article-title":"Prevalence of symptomatic pelvic organ prolapse in a Swedish population","volume":"16","author":"Tegerstedt","year":"2005","journal-title":"Int. Urogynecol. J. Pelvic Floor Dysfunct."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"1037","DOI":"10.1007\/s00192-009-0902-1","article-title":"The prevalence of pelvic organ prolapse symptoms and signs and their relation with bladder and bowel disorders in a general female population","volume":"20","author":"Hove","year":"2009","journal-title":"Int. Urogynecol. J. Pelvic Floor Dysfunct."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"819","DOI":"10.1002\/nau.24288","article-title":"Cough stress tests to diagnose stress urinary incontinence in women with pelvic organ prolapse with indication for surgical treatment","volume":"39","author":"Covernton","year":"2020","journal-title":"Neurourol. Urodyn."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"982","DOI":"10.1097\/01.AOG.0000142708.61298.be","article-title":"Pelvic symptoms in women with pelvic organ prolapse","volume":"104","author":"Burrows","year":"2004","journal-title":"Obstet. Gynecol."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"165","DOI":"10.1007\/s00192-015-2932-1","article-title":"An International Urogynecological Association (IUGA)\/International Continence Society (ICS) joint report on the terminology for female pelvic organ prolapse (POP)","volume":"27","author":"Haylen","year":"2016","journal-title":"Int. Urogynecol. J."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"609","DOI":"10.1016\/j.ajog.2003.09.027","article-title":"A randomized comparison of tension-free vaginal tape and endopelvic fascia plication in women with genital prolapse and occult stress urinary incontinence","volume":"190","author":"Meschia","year":"2004","journal-title":"Am. J. Obstet. Gynecol."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"488","DOI":"10.1111\/j.1600-0412.2011.01087.x","article-title":"Can de novo stress incontinence after anterior wall repair be predicted?","volume":"90","author":"Engh","year":"2011","journal-title":"Acta Obstet. Gynecol. Scand."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"279","DOI":"10.1097\/AOG.0000000000000094","article-title":"A model for predicting the risk of de novo stress urinary incontinence in women undergoing pelvic organ prolapse surgery","volume":"123","author":"Jelovsek","year":"2014","journal-title":"Obstet. Gynecol."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"629","DOI":"10.1016\/S0197-2456(03)00073-4","article-title":"A randomized trial of colpopexy and urinary reduction efforts (CARE): Design and methods","volume":"24","author":"Brubaker","year":"2003","journal-title":"Control. Clin. Trials"},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"162","DOI":"10.1177\/1740774509102605","article-title":"Outcomes following vaginal prolapse repair and mid urethral sling (OPUS) trial--design and methods","volume":"6","author":"Wei","year":"2009","journal-title":"Clin. Trials"},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"305","DOI":"10.1007\/s00192-019-04041-5","article-title":"De novo urinary incontinence after pelvic organ prolapse surgery-a national database study","volume":"31","author":"Khayyami","year":"2020","journal-title":"Int. Urogynecol. J."},{"key":"ref_14","doi-asserted-by":"crossref","unstructured":"Baessler, K., Christmann-Schmid, C., Maher, C., Haya, N., Crawford, T.J., and Brown, J. (2018). Surgery for women with pelvic organ prolapse with or without stress urinary incontinence. Cochrane Database Syst. Rev., 8.","DOI":"10.1002\/14651858.CD013108"},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"23","DOI":"10.1097\/SPV.0000000000000717","article-title":"Assessing the Performance of the De Novo Postoperative Stress Urinary Incontinence Calculator","volume":"27","author":"Ross","year":"2021","journal-title":"Female Pelvic Med. Reconstr. Surg."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"1719","DOI":"10.1007\/s00192-018-3805-1","article-title":"External validation of de novo stress urinary incontinence prediction model after vaginal prolapse surgery","volume":"30","author":"Sabadell","year":"2019","journal-title":"Int. Urogynecol. J."},{"key":"ref_17","doi-asserted-by":"crossref","unstructured":"Kim, M.J., Lee, Y., Suh, D.H., Lee, S., and Jeon, M.J. (2023). External validation of the de novo stress urinary incontinence prediction model after pelvic organ prolapse surgery in Korean women: A retrospective cohort study. BMC Womens Health, 23.","DOI":"10.1186\/s12905-023-02812-3"},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"487.e1","DOI":"10.1016\/j.ajog.2011.07.006","article-title":"De novo stress urinary incontinence after negative prolapse reduction stress testing for total vaginal mesh procedures: Incidence and risk factors","volume":"205","author":"Kasturi","year":"2011","journal-title":"Am. J. Obstet. Gynecol."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"498","DOI":"10.1111\/luts.12401","article-title":"Predictive urodynamic factors for de novo stress urinary incontinence after laparoscopic sacrocolpopexy for pelvic organ prolapse","volume":"13","author":"Yoshio","year":"2021","journal-title":"Low. Urin. Tract Symptoms"},{"key":"ref_20","doi-asserted-by":"crossref","unstructured":"Falah-Hassani, K., Reeves, J., Shiri, R., Hickling, D., and McLean, L. (2021). The pathophysiology of stress urinary incontinence: A systematic review and meta-analysis. Int. Urogynecol. J., 32, Erratum in Int. Urogynecol. J. 2021, 32, 501\u2013552.","DOI":"10.1007\/s00192-020-04622-9"},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"3","DOI":"10.1159\/000280024","article-title":"A concept of urinary continence","volume":"31","author":"Enhorning","year":"1976","journal-title":"Urol. Int."},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"1713","DOI":"10.1016\/S0002-9378(12)91840-2","article-title":"Structural support of the urethra as it relates to stress urinary incontinence: The hammock hypothesis","volume":"170","author":"DeLancey","year":"1994","journal-title":"Am. J. Obstet. Gynecol."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"7","DOI":"10.1111\/j.1600-0412.1990.tb08027.x","article-title":"An integral theory of female urinary incontinence. Experimental and clinical considerations","volume":"153","author":"Petros","year":"1990","journal-title":"Acta Obstet. Gynecol. Scand. Suppl."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"74","DOI":"10.1007\/BF02764822","article-title":"Role of the pelvic floor in bladder neck opening and closure I: Muscle forces","volume":"8","author":"Petros","year":"1997","journal-title":"Int. Urogynecol. J. Pelvic Floor Dysfunct."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"208","DOI":"10.5173\/ceju.2014.02.art21","article-title":"Use of Martius flaps in complex female urethral surgery and the tethered vagina syndrome","volume":"67","author":"Petros","year":"2014","journal-title":"Central Eur. J. Urol."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"1201","DOI":"10.1007\/s00192-014-2366-1","article-title":"Is de novo stress incontinence after sacrocolpopexy related to anatomical changes and surgical approach?","volume":"25","author":"LeClaire","year":"2014","journal-title":"Int. Urogynecol. J."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"204","DOI":"10.1002\/iju5.12189","article-title":"\u201cCentral Road\u201d cystoscopic finding: The road to worsened incontinence following laparoscopic sacrocolpopexy","volume":"3","author":"Kato","year":"2020","journal-title":"IJU Case Rep."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"3089","DOI":"10.1007\/s00192-021-04791-1","article-title":"A new method of adjusting mesh tension using cystoscopy during laparoscopic sacrocolpopexy","volume":"32","author":"Nomura","year":"2021","journal-title":"Int. Urogynecol. J."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"501","DOI":"10.1016\/S0029-7844(97)00058-6","article-title":"Epidemiology of surgically managed pelvic organ prolapse and urinary incontinence","volume":"89","author":"Olsen","year":"1997","journal-title":"Obstet. Gynecol."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"437","DOI":"10.1007\/s00192-007-0459-9","article-title":"Lifetime risk of surgical management for pelvic organ prolapse or urinary incontinence","volume":"19","author":"Fialkow","year":"2008","journal-title":"Int. Urogynecol. J. Pelvic Floor Dysfunct."},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"407","DOI":"10.1007\/s00192-012-1882-0","article-title":"Predictor of de novo stress urinary incontinence following TVM procedure: A further analysis of preoperative voiding function","volume":"24","author":"Kuribayashi","year":"2013","journal-title":"Int. Urogynecol. J."},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"607","DOI":"10.1007\/s00192-007-0498-2","article-title":"The role of preoperative urodynamic testing in stress-continent women undergoing sacrocolpopexy: The Colpopexy and Urinary Reduction Efforts (CARE) randomized surgical trial","volume":"19","author":"Visco","year":"2008","journal-title":"Int. Urogynecol. J. Pelvic Floor Dysfunct."},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"124","DOI":"10.1002\/uog.19165","article-title":"Changes in urethral mobility and configuration after prolapse repair","volume":"53","author":"Wen","year":"2019","journal-title":"Ultrasound Obstet. Gynecol."},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"583","DOI":"10.1007\/s00192-016-3149-7","article-title":"De novo stress urinary incontinence after pelvic organ prolapse surgery in women without occult incontinence","volume":"28","author":"Alas","year":"2017","journal-title":"Int. Urogynecol. J."},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"1041","DOI":"10.1007\/s00192-015-2641-9","article-title":"New onset stress urinary incontinence following laparoscopic sacrocolpopexy and its relation to anatomical outcomes","volume":"26","author":"Fayyad","year":"2015","journal-title":"Int. Urogynecol. J."},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"175","DOI":"10.1016\/j.ejogrb.2017.06.022","article-title":"Hysterectomy is not associated with de-novo urinary incontinence: A ten-year cohort study","volume":"215","author":"Christiansen","year":"2017","journal-title":"Eur. J. Obstet. Gynecol. Reprod. Biol."},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"1313","DOI":"10.1007\/s00192-015-2685-x","article-title":"Predictors for de novo stress urinary incontinence following extensive pelvic reconstructive surgery","volume":"26","author":"Lo","year":"2015","journal-title":"Int. Urogynecol. J."},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"1599","DOI":"10.1007\/s00192-022-05434-9","article-title":"Incidence of de novo stress urinary incontinence following minimally invasive sacrocolpopexy","volume":"34","author":"Kim","year":"2023","journal-title":"Int. Urogynecol. J."},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"292","DOI":"10.1097\/SPV.0000000000000487","article-title":"Does the Degree of Cystocele Predict De Novo Stress Urinary Incontinence After Prolapse Repair? Further Analysis of the Colpopexy and Urinary Reduction Efforts Trial","volume":"24","author":"Davenport","year":"2018","journal-title":"Female Pelvic Med. Reconstr. Surg."},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"2358","DOI":"10.1056\/NEJMoa1111967","article-title":"A midurethral sling to reduce incontinence after vaginal prolapse repair","volume":"366","author":"Wei","year":"2012","journal-title":"N. Engl. J. Med."},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"909","DOI":"10.1007\/s00192-024-05760-0","article-title":"Changes in Stress Urinary Incontinence Symptoms after Pelvic Organ Prolapse Surgery: A Nationwide Cohort Study (FINPOP)","volume":"35","author":"Karjalainen","year":"2024","journal-title":"Int. Urogynecol. J."},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"10","DOI":"10.1016\/j.ejogrb.2017.10.002","article-title":"Retrospective study on de novo postoperative urinary incontinence after pelvic organ prolapse surgery","volume":"219","author":"Ugianskiene","year":"2017","journal-title":"Eur. J. Obstet. Gynecol. Reprod. Biol."},{"key":"ref_43","doi-asserted-by":"crossref","first-page":"227","DOI":"10.1016\/j.ejogrb.2012.12.029","article-title":"De novo stress urinary incontinence after vaginal repair for pelvic organ prolapse: One-year follow-up","volume":"168","author":"Hafidh","year":"2013","journal-title":"Eur. J. Obstet. Gynecol. Reprod. Biol."},{"key":"ref_44","doi-asserted-by":"crossref","first-page":"172","DOI":"10.1111\/aogs.12045","article-title":"Sequential urodynamic assessment before and after laparoscopic sacrocolpopexy","volume":"92","author":"Kummeling","year":"2013","journal-title":"Acta Obstet. Gynecol. Scand."},{"key":"ref_45","doi-asserted-by":"crossref","first-page":"807","DOI":"10.1016\/j.jmig.2025.05.009","article-title":"Does Concurrent Burch Colposuspension Reduce Postoperative Stress Urinary Incontinence in Laparoscopic Sacrocolpopexy? An Interim Analysis","volume":"32","author":"Oyama","year":"2025","journal-title":"J. Minim. Invasive Gynecol."},{"key":"ref_46","doi-asserted-by":"crossref","first-page":"978","DOI":"10.3906\/sag-2005-117","article-title":"The effect of sacrospinous ligament fixation during vaginal hysterectomy on postoperative de novo stress incontinence occurrence: A prospective study with 2-year follow-up","volume":"50","author":"Kiyak","year":"2020","journal-title":"Turk. J. Med. Sci."}],"container-title":["Journal of Clinical Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2077-0383\/14\/22\/8153\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,11,19]],"date-time":"2025-11-19T13:24:00Z","timestamp":1763558640000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2077-0383\/14\/22\/8153"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,11,17]]},"references-count":46,"journal-issue":{"issue":"22","published-online":{"date-parts":[[2025,11]]}},"alternative-id":["jcm14228153"],"URL":"https:\/\/doi.org\/10.3390\/jcm14228153","relation":{},"ISSN":["2077-0383"],"issn-type":[{"value":"2077-0383","type":"electronic"}],"subject":[],"published":{"date-parts":[[2025,11,17]]}}}