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Introduction and Hypothesis: The high recurrence rate (up to 40%) of native tissue surgery for pelvic organ prolapse (POP) is concerning and a better understanding of the effect of surgery is essential in optimizing treatment. As physical examination (Pelvic Organ Prolapse-Quantification, POP-Q) underestimates the degree of prolapse, upright assessment may provide new insights. Therefore, we compared supine POP-Q with upright magnetic resonance imaging (MRI) examination of the anatomical effect of native tissue POP surgery on the pelvic anatomy., Methods: This prospective study included 59 women with stage ≥ 2 anterior compartment prolapse undergoing solely anterior colporrhaphy (AC) or in combination with posterior colporrhaphy (PC), sacrospinous hysteropexy (SSH) or Manchester Fothergill (MF). Preoperatively and 6 weeks postoperatively, anatomical measurements were obtained: POP-Q and upright MRI. The Patient Global Impression of Improvement (PGI-I) questionnaire was completed 6 weeks postoperatively., Results: Significant lift of the lowest point of the bladder was observed on both POP-Q (37 ± 18 mm) and upright MRI (26 ± 22 mm), which was 10 ± 17 mm (p < 0.001) larger on POP-Q than on upright MRI. Symptomatic improvement (PGI-I) was reported by 93.2% of the patients, which showed a weak correlation with the bladder lift on upright MRI (Spearman's ρ -0.301, p = 0.021), but no correlation with the bladder lift on POP-Q (Spearman's ρ -0.078, p = 0.565)., Conclusions: The POP-Q examination overestimates the anatomical result of native tissue POP repair on the anterior vaginal wall by 1 cm compared with upright MRI examination upon 6 weeks' follow-up. Upright MRI examination is suggested to relate better to symptomatic outcome than does POP-Q examination., Competing Interests: Declarations. Ethical Approval: The medical ethics committee “Commissie Mensgebonden Onderzoek Arnhem-Nijmegen” and the institution’s board of directors approved this “Twents Onderzoek naar Recidieven na Bekkenbodem Operaties” (TORBO) study, reference number NL79717.091.21. Conflicts of Interest: None., (© 2024. The International Urogynecological Association.)