Introduction and hypothesis The aim was to review the economic costs associated with pelvic organ prolapse surgery. Methods Every 4 years and as part of the Fifth International Collaboration on Incontinence we reviewed the English-language scientific literature after searching PubMed, Medline, Cochrane library and Cochrane database of systematic reviews, published up to January 2012. Publications were classified as level 1 evidence (randomised controlled trials [RCT] or systematic reviews), level 2 (poor quality RCT, prospective cohort studies), level 3 (case series or retrospective studies) and level 4 (case reports). The highest level of evidence was utilised by the committee to make evidence based recommendations based upon the Oxford grading system. Grade A recommendation usually depends on consistent level 1 evidence. Grade B recommendation usually depends on consistent level 2 and/or 3 studies, or “majority evidence” from RCTs. Grade C recommendation usually depends on level 4 studies or “majority evidence” from level 2/3 studies or Delphi processed expert opinion. Grade D “no recommendation possible” would be used where the evidence is inadequate or conflicting and when expert opinion is delivered without a formal analytical process, such as by Delphi. Results The annual economic costs of pelvic organ prolapse surgeries are significant and over the next decades will grow at twice the rate of population growth because of our aging population. In a single institution study vaginal reconstructive surgery and pessary use were more cost-effective than expectant management, traditional abdominal sacral colpopexy (ASC) or robot-assisted sacral colpopexy (RSC; grade C). Two studies have demonstrated that ASC incurs lower inpatient costs than LSC or RSC (grade C). Data from a single RCT demonstrated the LSC to incur lower inpatient costs than RSC specifically relating to shorter operating times in the LSC group (grade B). Data from a single RCT demonstrated LSC to be a more effective cost-minimising surgery than total vaginal mesh for vaginal vault prolapse (grade B). Data from a meta-analysis of anterior vaginal compartment prolapse operations demonstrated that commercial mesh kits for anterior repair are less cost-effective than non-kit mesh and anterior colporrhaphy (grade B). Conclusions There is a paucity of good economic data relating to pelvic organ prolapse surgery. Transvaginal mesh surgeries have not been proven to be cost-effective. It is recommended that all randomised controlled trials relating to prolapse surgery include a formal cost analysis.