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Apical Prolapse

Apical prolapse is descent of the uterus or cervix or vaginal vault. Assess the apex together with the anterior and posterior walls: loss of upper vaginal support can contribute to a visible wall defect.[1][2] Treatment depends on symptom bother, function, anatomy and patient goals.[1][2]

See POP Overview for general risk factors, staging, pelvic-floor therapy and pessary care, and Prolapse Repair Principles for the broader operative decision framework.

Terminology and Support​

TermMeaning and clinical implication
Uterine or cervical prolapseDescent of the uterus/cervix, including a retained cervical stump. Discuss uterine-preserving and hysterectomy-based options when surgery is chosen.
Vault prolapseDescent of the vaginal apex after total hysterectomy. Reconstructive repair restores apical support; an obliterative repair is another option for selected patients.
EnteroceleHerniation of a peritoneal sac, sometimes containing small bowel, into the upper posterior vaginal compartment. It may coexist with apical prolapse and is not synonymous with every rectocele.
HysteropexySuspension preserving the uterus.
ColpocleisisVaginal obliteration for a patient who accepts permanent loss of penetrative vaginal intercourse.

In DeLancey's framework, Level I support is the cardinal–uterosacral ligament complex suspending the cervix and upper vagina. Level II is the lateral attachment of the mid-vagina to the arcus tendineus fasciae pelvis and levator fascia, and Level III is the distal fusion with the perineal body and urethra. Apical descent is Level I failure, and it often drives apparent anterior and posterior wall descent. Uterosacral and cardinal tissue attaches to the cervix and vault, so it is the tissue most native-tissue suspensions recruit; the sacrospinous ligament is a lateral, more posterior anchor that changes the vaginal axis. A large genital hiatus is associated with greater prolapse on examination, but its value for predicting recurrence after apical repair is uncertain.[2] Adjusted pooled evidence has not confirmed levator avulsion as a predictor of overall objective recurrence after prolapse surgery, although an anterior native-tissue subgroup association has been reported.[25]

In DeLancey's anatomical account, these attachments form part of a continuous viscerofascial sheet in which the parametria attach the uterus and the paracolpium attaches the vagina. The cardinal ligament is described as a mesentery carrying vessels, nerves and fibrous connective tissue to the uterus and upper vagina, while the uterosacral ligament contains a distinct smooth-muscle component attached to the posterior cervix. Vaginal support has three levels: the paracolpium suspends the upper vagina from the pelvic sidewall at Level I and attaches the mid-vagina to the lateral pelvic wall and levator fascia at Level II; at Level III, the vagina fuses directly to adjacent structures without intervening paracolpium.[22][23]

In the United States, an estimated 12.6% of women undergo prolapse surgery by age 80 (20.0% for prolapse or stress incontinence surgery combined; claims-based estimate).[13] When hysterectomy is performed to treat uterine prolapse, plan the associated support procedure: removal of the uterus is not itself apical suspension. The need for additional wall repair is individualized.[1][2]

Evaluation That Changes the Plan​

Record bulge symptoms, bladder emptying and leakage, bowel symptoms, sexual goals, prior operations or mesh, medical risk, and preferences concerning the uterus and vaginal intercourse.[1][2]

Examination elementInterpretation
POP-Q CMost distal cervix or vaginal cuff.
POP-Q DPosterior fornix when the cervix is present; omit when the cervix is absent. A supracervical hysterectomy does not automatically make D inapplicable.
TVLTotal vaginal length measured with prolapse reduced.
Genital hiatus / perineal bodyDescribe the outlet and support context.
Apical reductionReassess anterior/posterior support while reducing the apex. Improvement shows an apical contribution.

Stage with an empty bladder and adequate straining; consider an upright examination if the supine findings do not reproduce symptoms. Distinguish cervical elongation from generalized apical descent. Avoid using a single study's point-C threshold as a universal indication for surgery.[2]

Additional investigations should answer a specific question:

  • Bladder assessment: measure residual urine when emptying symptoms or other findings warrant it.[2] For a prolapse-reduction cough stress test, use a bladder volume of at least 200 mL and reduce the prolapse with a speculum or pessary.[2]
  • Urodynamics: use selectively. NICE recommends multichannel filling and voiding cystometry before planned SUI surgery with anterior or apical prolapse, voiding dysfunction, unclear incontinence type or urge-predominant mixed incontinence, or previous SUI surgery.[1]
  • Imaging: dynamic imaging or defecography may help selected complex or discordant posterior or bowel presentations.
  • Retained uterus or cervix: investigate abnormal bleeding, lesions and relevant risk; confirm appropriate cervical screening.[1][2][9] Closure makes subsequent access more difficult.[1][2][9]

Choosing Treatment​

Observation, pelvic-floor therapy and pessary treatment remain options according to symptoms and preference. Offer surgical discussion when symptoms remain unacceptable or nonsurgical treatment is declined. Consider recovery burden, recurrence, urinary, bowel and sexual outcomes, material-specific harm and the possibility of future treatment.[1]

NICE NG123 frames the menu by anatomy. For vault prolapse, offer vaginal sacrospinous fixation with sutures or abdominal or laparoscopic sacrocolpopexy with mesh. For uterine prolapse when the woman has no preference about preserving the uterus, offer vaginal hysterectomy (with or without sacrospinous fixation), sacrospinous hysteropexy or Manchester repair, and include mesh sacrohysteropexy as an option subject to its mesh-counseling recommendations. Colpocleisis is to be considered when the woman does not intend penetrative vaginal sex and has a condition raising operative risk.[1]

Vaginal native-tissue suspension​

ProcedureMain considerations
Uterosacral ligament suspension (USLS)Usually bilateral support. Protect the ureters, assess the bladder and bilateral ureteral efflux cystoscopically, and investigate abnormalities. For primary uterovaginal prolapse repair with USLS, a 2026 Delphi consensus recommends repeating cystoscopy after the sutures are tied if the first check was done under tension.[27] No fixed distance from the ischial spine guarantees safe sutures.
Sacrospinous ligament fixation (SSLF)Commonly unilateral, with bilateral variants. Discuss buttock/groin/leg pain and neural or vascular injury.
Iliococcygeus suspensionAlternative support site when anatomy and the operative plan favor it; less comparative trial evidence.
McCall culdoplastyCul-de-sac closure and uterosacral support, commonly associated with vaginal hysterectomy.

See the linked technique pages below for operative anatomy and verification steps.

OPTIMAL: corrected two-year composite success was 100/155 (64.5%) after USLS versus 94/149 (63.1%) after SSLF; difference 1.4 percentage points (95% CI −9.4 to 12.2).[3] Its 374 randomized women had prolapse and SUI with planned concomitant retropubic slings.[3][30]

E-OPTIMAL: 285 women entered extended follow-up and 244 completed it. Estimated five-year first composite failure was 61.5% versus 70.3%, with substantial uncertainty around the difference. Symptoms generally remained improved.[4] An earlier anatomic or symptom failure remained counted even if a later assessment improved.[4]

Sacrocolpopexy​

Sacrocolpopexy attaches the vagina to the anterior longitudinal ligament over the sacrum using mesh. Symptoms, prior repair, anatomy, medical suitability, mesh preference and surgical expertise guide selection.[1][5]

Post-hysterectomy vault prolapse: the 2023 Cochrane review supports less recurrent prolapse and repeat prolapse surgery after sacral colpopexy than after several vaginal operations. The review included 59 trials across different comparisons, with a search ending in March 2022.[5]

ASPIRe (2024) adds a major vault-specific randomized comparison: 376 women were randomized and 360 underwent surgery. Modeled three-year composite failure was 28% with sacrocolpopexy versus 43% with native-tissue repair; adjusted HR 0.57 (99% CI 0.33–0.98).[6] The composite includes bulge, examination findings or retreatment; retreatment with a pessary or surgery through the final study visit occurred in 5/120 (4%) after sacrocolpopexy, 8/118 (7%) after native-tissue repair and 3/113 (3%) after transvaginal mesh (P = .33 across the three arms).[6] The transvaginal-mesh arm had a similar 36-month failure (29%) and was noninferior to sacrocolpopexy but not statistically superior to native tissue after adjustment; mesh exposure was 3% after sacrocolpopexy and 5% after transvaginal mesh.[6] That kit is no longer available: in April 2019 the FDA ordered manufacturers of surgical mesh for transvaginal prolapse repair (Uphold LITE, Xenform, Restorelle DirectFix Anterior) to stop selling and distributing it, and no transvaginal prolapse mesh is currently marketed in the US. The order does not address abdominally placed sacrocolpopexy mesh.[16]

Other vault comparisons. In SALTO-2 (Netherlands; 64 randomized plus a 115-woman prospective cohort), laparoscopic sacrocolpopexy and vaginal sacrospinous fixation had similar quality-of-life scores and 12-month composite success for the apical compartment (89% versus 86% in the RCT), which was a small, short trial.[15] In the UK VUE vault trial (208 women), abdominal and vaginal suspension had similar 12-month symptom scores and serious adverse events, though anterior prolapse stage 2b or greater was less frequent after abdominal repair.[14] An earlier randomized trial of 88 women with cervical prolapse to or beyond the hymen, or vault inversion of more than half its length with anterior vaginal wall descent to or beyond the hymen, compared bilateral sacrospinous suspension with paravaginal repair (n = 48) against abdominal sacral colpopexy with paravaginal repair (n = 40).[24] At a mean 2.5 years (80 evaluated), surgery was optimally effective in 29% of the vaginal and 58% of the abdominal group, and unsatisfactory with reoperation in 33% and 16%; the vaginal group had shorter operating time but more urinary infection and incontinence.[24] In CARE, women with stress continence who had sacrocolpopexy showed rising failure over seven years (anatomic failure 22–27%, composite prolapse failure 34–48% by arm) and a Kaplan-Meier mesh-erosion probability of 10.5%; modeled seven-year SUI failure was 62% with Burch urethropexy versus 77% without (risk difference −15.3 percentage points; 95% CI −26.8 to 3.0).[17]

Primary uterovaginal prolapse: September 2026 review​

The Huffman U-POP review included 24 studies (6,329 hysterectomy-plus-sacrocolpopexy patients; 681 vaginal hysterectomy-plus-native-tissue patients). It found lower pooled failure or retreatment proportions with sacrocolpopexy. Most evidence was observational and the analysis compared study-arm proportions. For patients at high risk of recurrence undergoing primary uterovaginal prolapse repair who prioritize lower failure and retreatment rates, a 2026 global consensus says minimally invasive hysterectomy with sacrocolpopexy can be recommended over total vaginal hysterectomy with native-tissue apical repair, with higher risks of mesh exposure and small-bowel injury.[29] At mean follow-up of 22.0 months after sacrocolpopexy and 18.3 months after vaginal native-tissue repair, these results inform discussion of failure and retreatment when hysterectomy is chosen.[7]

Mesh and hysterectomy counseling​

Abdominally placed sacrocolpopexy mesh differs from transvaginal mesh for prolapse. Discuss exposure, pain, infection, organ injury and possible further treatment.[5][6][8]

In e-PACT II, cumulative mesh exposure after minimally invasive total hysterectomy and sacrocolpopexy was 18/182 (9.9%) among e-PACT-eligible patients, incorporating earlier events; mean follow-up was 5.3 years among the later-extension participants. Only 82 of the original 200 participated in the later visit and 56 underwent examination.[8]

Choose uterine or cervical removal based on pathology, screening needs, anatomy and preference; retaining the cervix does not eliminate exposure. See Supracervical Hysterectomy and Sacrocolpopexy for the procedure-specific evidence.

Uterine preservation​

Offer uterine-preserving prolapse surgery to candidates without previous or current uterine or cervical pathology, using an individualized discussion of preservation and hysterectomy based on the patient's values .[19] AUGS lists uterine or cervical malignancy and abnormal uterine bleeding without workup as absolute contraindications. Postmenopausal bleeding after a negative workup, cervical dysplasia and familial cancer syndromes require individualized assessment; cervical elongation is a relative anatomic concern because of recurrence risk.[19] In a multicenter US survey of 213 women with prolapse symptoms, 36% preferred uterine preservation when outcomes were presented as equal; 21% still preferred it when hysterectomy was presented as more effective.[20] In a separate survey, 60% of 100 respondents with an intact uterus said they would decline hysterectomy if offered an equally effective alternative.[21] Counseling covers the benefit of hysterectomy for cancer detection and prevention, continued cervical cancer screening with evaluation of abnormal uterine bleeding, a later hysterectomy rate below 5% (most often for recurrent prolapse), no difference in sexual function compared with repair plus hysterectomy, and future pregnancy plans.[19] Options include native-tissue sacrospinous hysteropexy, abdominal sacrohysteropexy and Manchester repair, which includes cervical amputation. In the SAM randomized trial of first operations with POP-Q point D at or proximal to −1 cm, two-year composite success was 172/197 (87.3%) with modified Manchester repair and 151/196 (77.0%) with sacrospinous hysteropexy.[26] Success required no prolapse beyond the hymen in any compartment, no bothersome bulge and no retreatment; bulge symptoms and retreatment separately did not differ significantly.[26] No single outcome estimate applies to all routes and materials.[1][5]

Cervical elongation. For women who have completed childbearing, AUGS advises considering trachelectomy at the time of uterine-preserving surgery when the cervix is elongated (grade C). Its recommendation table defines elongation as cervical length above 4 cm; it also cites a series in which women with a preoperative cervix longer than 2 cm (point D minus point C) who had trachelectomy at the time of sacrospinous hysteropexy had higher objective and subjective cure rates. Elongation is associated with higher apical recurrence after preservation. Partial trachelectomy is favored, with caution in reproductive-age patients because it may affect future pregnancy.[19]

Ten-year SAVE-U (2026): the original trial randomized 208 women. The extended primary endpoint was available for 93 (44 hysteropexy; 49 vaginal hysterectomy with USLS), with 89 examinations. Apical failure with bothersome bulge or repeat apical surgery occurred in 3/44 versus 7/49; reported risk difference −6.6 percentage points (95% CI −19.9 to 6.7). Attrition and the inclusion of earlier failures limit the estimate. In secondary analyses, posterior-compartment failure favored hysteropexy (11.6% versus 52.2%), whereas obstructive micturition scores favored hysterectomy despite medians of zero in both groups; attrition limits both comparisons.[10]

This trial is distinct from SUPeR, which evaluated transvaginal mesh hysteropexy. In the 10-year SUPeR results, composite failure was 35/88 (40%) after mesh hysteropexy versus 46/87 (53%) after vaginal hysterectomy with USLS (aHR 0.64, 95% CI 0.41–1.00); only 64% joined the extended follow-up, patient-reported outcomes did not differ, and the expected durability advantage in years 6–10 did not appear.[18] The UK VUE uterine trial (563 women) found similar 12-month symptom scores and serious adverse events for uterine preservation versus vaginal hysterectomy.[14] See the POP overview for that distinction. Future pregnancy requires specific counseling; pregnancy-outcome data after uterine-preserving surgery are limited, and AUGS notes that among uterine-preserving operations the Manchester procedure was the one most likely to be followed by adverse pregnancy outcomes.[19] NICE excludes Manchester repair when future childbearing is planned.[1]

Colpocleisis​

Consider colpocleisis when the patient accepts permanent loss of penetrative vaginal intercourse, especially when comorbidity increases the burden of reconstructive surgery. Discuss retained organs, future access, urinary symptoms and the possibility of regret. A 2026 Delphi consensus advises against uterus- or cervix-sparing colpocleisis when cervical screening shows isolated high-risk HPV without another cervical abnormality, and advises considering hysterectomy in postmenopausal patients with unexplained vaginal bleeding despite normal preoperative investigations and no other cause.[28] Hysterectomy and concomitant continence surgery are separate decisions.[1][9]

Le Fort partial repair retains lateral epithelial channels and can also be used for a posthysterectomy vault; total colpocleisis is usually performed after hysterectomy. In a multicenter prospective cohort, 125/132 respondents were satisfied with their decision at one year, while only 103/152 had an examination.[11] Satisfaction, anatomic recurrence and reoperation are different endpoints.[9][11]

See Colpocleisis for the operative sequence and more detailed outcome and screening evidence.

Continence Planning and Follow-up​

Separate bothersome SUI, occult leakage on reduction, urgency and no incontinence. Discuss combined versus staged continence treatment and the tradeoff between postoperative leakage, catheterization, procedure-specific harm and a possible later operation. NICE NG123 recommends against surgery solely to prevent postoperative incontinence in women without incontinence.[1] The 2026 Cochrane review distinguishes these populations and finds uncertainty in prophylactic Burch evidence for stress-continent women.[1][12]

Follow symptoms, examination findings, bladder, bowel and sexual function, repeat treatment and material-related complications separately. Arrange an early recovery and emptying plan; NICE recommends a six-month postoperative review with vaginal examination and access to reassessment for recurrent symptoms or complications.[1] New bleeding, persistent discharge, pain, recurrent bulge or emptying difficulty warrants assessment.[1][8][9]

See Also​

Podcasts​

Hysteropexy vs Hysterectomy for Pelvic Organ Prolapse
BackTable OBGYN, Ep. 32 (2023) · Olivia Chang, Suzette Sutherland
backtable.com

Videos​

High Uterosacral Ligament Suspension
Dr Deeksha Pandey (2021)

References​

1. NICE. Urinary incontinence and pelvic organ prolapse in women: management (NG123). Recommendations 1.3.15–1.3.16, 1.8 and 1.9. Recommendations.

2. Barbier H, Carberry CL, Karjalainen PK, et al. International Urogynecology consultation chapter 2 committee 3: the clinical evaluation of pelvic organ prolapse including investigations into associated morbidity/pelvic floor dysfunction. Int Urogynecol J. 2023;34:2657–2688. doi:10.1007/s00192-023-05629-8.

3. Barber MD, Brubaker L, Burgio KL, et al. Comparison of 2 transvaginal surgical approaches and perioperative behavioral therapy for apical vaginal prolapse: the OPTIMAL randomized trial. JAMA. 2014;311:1023–1034. doi:10.1001/jama.2014.1719. Corrected publisher main and supplement reviewed.

4. Jelovsek JE, Barber MD, Brubaker L, et al. Effect of uterosacral ligament suspension vs sacrospinous ligament fixation with or without perioperative behavioral therapy on outcomes at 5 years in the OPTIMAL randomized clinical trial. JAMA. 2018;319:1554–1565. doi:10.1001/jama.2018.2827.

5. Maher C, Yeung E, Haya N, et al. Surgery for women with apical vaginal prolapse. Cochrane Database Syst Rev. 2023;7:CD012376. doi:10.1002/14651858.CD012376.pub2.

6. Menefee SA, Richter HE, Myers D, et al. Apical suspension repair for vaginal vault prolapse: a randomized clinical trial. JAMA Surg. 2024;159:845–855. doi:10.1001/jamasurg.2024.1206.

7. Huffman JA, Ashmore S, Kim S, et al. Hysterectomy with minimally invasive sacrocolpopexy versus native tissue repair for primary uterovaginal prolapse: a systematic review and meta-analysis. Int Urogynecol J. Published September 3, 2026. doi:10.1007/s00192-026-06863-6.

8. Bretschneider CE, Myers ER, Geller EJ, et al. Long-term mesh exposure 5 years following minimally invasive total hysterectomy and sacrocolpopexy. Int Urogynecol J. 2024;35:901–907. doi:10.1007/s00192-024-05769-5.

9. Grzybowska ME, Futyma K, Kusiak A, Wydra DG. Colpocleisis as an obliterative surgery for pelvic organ prolapse: is it still a viable option in the twenty-first century? Narrative review. Int Urogynecol J. 2022;33:31–46. doi:10.1007/s00192-021-04907-7.

10. Oegema K, et al. Sacrospinous hysteropexy versus vaginal hysterectomy in women with uterine prolapse: 10-year follow-up of a randomised controlled trial. Int Urogynecol J. 2026. doi:10.1007/s00192-026-06822-1.

11. FitzGerald MP, Richter HE, Bradley CS, et al. Pelvic support, pelvic symptoms, and patient satisfaction after colpocleisis. Int Urogynecol J Pelvic Floor Dysfunct. 2008;19:1603–1609. doi:10.1007/s00192-008-0696-6.

12. Baessler K, Christmann-Schmid C, Haya N, et al. Surgery for women with pelvic organ prolapse with or without stress urinary incontinence. Cochrane Database Syst Rev. 2026;2:CD013108. doi:10.1002/14651858.CD013108.pub2.

13. Wu JM, Matthews CA, Conover MM, et al. Lifetime risk of stress urinary incontinence or pelvic organ prolapse surgery. Obstet Gynecol. 2014;123(6):1201-1206. doi:10.1097/AOG.0000000000000286

14. Hemming C, Constable L, Goulao B, et al. Surgical interventions for uterine prolapse and for vault prolapse: the two VUE RCTs. Health Technol Assess. 2020;24(13):1-220. doi:10.3310/hta24130

15. van Oudheusden AMJ, van IJsselmuiden MN, Menge LF, et al. Laparoscopic sacrocolpopexy versus vaginal sacrospinous fixation for vaginal vault prolapse: a randomised controlled trial and prospective cohort (SALTO-2 trial). BJOG. 2023;130(12):1542-1551. doi:10.1111/1471-0528.17525

16. US Food and Drug Administration. Urogynecologic surgical mesh implants: April 16, 2019 order to stop sale and distribution of surgical mesh for transvaginal repair of pelvic organ prolapse. FDA.

17. Nygaard I, Brubaker L, Zyczynski HM, et al. Long-term outcomes following abdominal sacrocolpopexy for pelvic organ prolapse. JAMA. 2013;309(19):2016-2024. doi:10.1001/jama.2013.4919

18. Nager CW, Visco AG, Richter HE, et al. Sacrospinous hysteropexy with mesh vs vaginal hysterectomy for treatment of uterovaginal prolapse: 10-year results of a randomized clinical trial. JAMA Surg. 2026;161(8):764-774. doi:10.1001/jamasurg.2026.2263

19. Chang OH, Carter Ramirez A, Edwards A, et al. The role of uterine preservation at the time of pelvic organ prolapse surgery. Urogynecology (Phila). 2025;31(5):482–495. doi:10.1097/SPV.0000000000001667. AUGS Clinical Practice Statement.

20. Korbly NB, Kassis NC, Good MM, et al. Patient preferences for uterine preservation and hysterectomy in women with pelvic organ prolapse. Am J Obstet Gynecol. 2013;209(5):470.e1-6. doi:10.1016/j.ajog.2013.08.003

21. Frick AC, Barber MD, Paraiso MF, et al. Attitudes toward hysterectomy in women undergoing evaluation for uterovaginal prolapse. Female Pelvic Med Reconstr Surg. 2013;19(2):103-109. doi:10.1097/SPV.0b013e31827d8667

22. DeLancey JO. Anatomic aspects of vaginal eversion after hysterectomy. Am J Obstet Gynecol. 1992;166(6 Pt 1):1717-1724. doi:10.1016/0002-9378(92)91562-o

23. Kieserman-Shmokler C, Swenson CW, Chen L, Desmond LM, Ashton-Miller JA, DeLancey JO. From molecular to macro: the key role of the apical ligaments in uterovaginal support. Am J Obstet Gynecol. 2020;222(5):427-436. doi:10.1016/j.ajog.2019.10.006

24. Benson JT, Lucente V, McClellan E. Vaginal versus abdominal reconstructive surgery for the treatment of pelvic support defects: a prospective randomized study with long-term outcome evaluation. Am J Obstet Gynecol. 1996;175(6):1418-1422. doi:10.1016/S0002-9378(96)70084-4

25. Yeung E, Malacova E, Maher C. "Is levator ani avulsion a risk factor for prolapse recurrence? A systematic review and meta-analysis." Int Urogynecol J. 2022;33(7):1813–1826. doi:10.1007/s00192-022-05217-2.

26. Enklaar RA, Schulten SFM, van Eijndhoven HWF, et al. "Manchester Procedure vs Sacrospinous Hysteropexy for Treatment of Uterine Descent: A Randomized Clinical Trial." JAMA. 2023;330(7):626–635. doi:10.1001/jama.2023.13140.

27. Santis-Moya F, Wolff DT, Koven A, et al. "Management of Major Non-mesh Complications After Primary Uterovaginal Prolapse Surgery: A Systematic Review." Int Urogynecol J. 2026. doi:10.1007/s00192-026-06888-x

28. Sullivan ME, Vendramini A, Cattani L, et al. "Patient Risk Factors for Incidental Pathology After Uterovaginal Surgery for Apical Prolapse: Systematic Review and Global Expert Consensus Statements." Int Urogynecol J. 2026. doi:10.1007/s00192-026-06849-4

29. Gupta A, Grimes CL, Badlani G, et al. "A Global Consensus Conference on Surgical Management of Primary Uterovaginal Prolapse and Lower Urinary Tract Dysfunction: Combining Evidence with Expert Opinion." Int Urogynecol J. 2026. doi:10.1007/s00192-026-06758-6

30. Incorrect Outcomes Data. JAMA. 2015;313(22):2287. doi:10.1001/jama.2015.4817. OPTIMAL correction.