MRI-Based Evaluation of Vaginal Axis After Mesh Versus Wire Pectopexy: A Prospective Comparative Study

Background: Restoration of apical support is a primary objective in pelvic organ prolapse surgery; however, postoperative pelvic floor biomechanics and vaginal axis orientation are increasingly recognized as relevant determinants of clinical outcome. Laparoscopic pectopexy may be performed using synthetic mesh or non-absorbable sutures (wire), yet the influence of fixation material on postoperative vaginal axis remains insufficiently explored. This study aimed to evaluate vaginal axis orientation after mesh versus wire pectopexy using magnetic resonance imaging (MRI). Methods: A prospective non-randomized comparative cohort study included 100 women with symptomatic apical pelvic organ prolapse (POP-Q stage ≥ II). Fifty patients underwent mesh pectopexy and fifty wire pectopexy. All patients underwent standardized postoperative pelvic MRI at one-year follow-up using a 1.5 Tesla scanner with dynamic Valsalva sequences. MRI measurements included vaginal PS3L axis angle, H-line, and M-line. Clinical outcomes were assessed by gynecological examination. Statistical analysis included ANOVA, logistic regression, and ROC curve evaluation. Results: No cases of apical prolapse recurrence were observed. Vaginal axis orientation was significantly associated with postoperative clinical findings (F = 3.867, p = 0.019). Logistic regression identified vaginal axis angle as an independent predictor of normal clinical outcome (β = −0.257, p = 0.008; AUC = 0.819). A more physiological vaginal axis was more frequently observed following wire pectopexy Conclusions: Postoperative vaginal axis orientation assessed by MRI represents a relevant parameter after apical prolapse repair. Wire pectopexy was associated with a more physiological vaginal axis alignment, suggesting potential biomechanical advantages that may influence postoperative pelvic floor stability.