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Almost 400,000 female pelvic reconstructive operations were performed in 2010 for urinary incontinence and pelvic organ prolapse in the United States, and it is likely that this will continue to increase each year. There is a lack of population-based data evaluating the risk of blood transfusion after urogynecologic procedures.We sought to assess the incidence of blood transfusion related to pelvic reconstructive surgery in a large national surgical quality database and to identify transfusion-associated risk factors.This retrospective cohort study was performed using the National Surgical Quality Improvement Program database from the years 2010 through 2014. All women undergoing surgery for pelvic floor disorders were identified by Current Procedural Terminology code. Demographic and clinical variables were abstracted. The incidence of blood transfusion was determined. A multivariate logistic regression analysis was performed to identify clinical factors independently associated with blood transfusion.A total of 54,387 women underwent pelvic reconstructive surgery from 2010 through 2014 in the National Surgical Quality Improvement Program database. Of these subjects, 686 (1.26%) received a blood transfusion. The median age was 57 (range 28-89) years. Of the population, 0.81% was underweight (body mass index <18.5), 27.0% was normal weight (body mass index 18.5-24.9), 35.6% was overweight (body mass index 25-29.9), and 36.7% was obese (body mass index ≥30). The majority of subjects in the study cohort were Caucasian (91.4%) followed by African Americans (4.6%); the remainder included Asian, American Indian/Alaska Native, and Native Hawaiian/Pacific Islander. Hispanic ethnicity was reported in 9.3% of the population. American Society of Anesthesiologists class 1 and 2 represented a majority of the sample (76.5%). Concomitant hysterectomy was performed in 20,735 (38.1%) of the population. In the multivariate analysis, preoperative hematocrit <30% (odds ratio, 13.68; 95% confidence interval, 10.65–17.59), history of coagulopathy (odds ratio, 3.74; 95% confidence interval, 2.50–5.60), and concomitant hysterectomy (odds ratio, 1.77; 95% confidence interval, 1.49–2.12) were factors independently associated with receiving blood transfusion (all P < .05). When compared to American Society of Anesthesiologists class 1, patients who were class 3 (odds ratio, 2.82, P < .01; 95% confidence interval, 2.02–3.93) or class 4 (odds ratio, 6.56, P < .01; 95% confidence interval, 3.65–11.78) were more likely to require a transfusion. When compared to Caucasians, African Americans (odds ratio, 1.73, P < .01; 95% confidence interval, 1.27–2.36) and Hispanics (odds ratio, 1.92, P < .01; 95% confidence interval, 1.54–2.40) were more likely to require a transfusion. In this cohort, overweight (odds ratio, 0.75; 95% confidence interval, 0.62–0.93) and obese (odds ratio, 0.61; 95% confidence interval, 0.49–0.75) subjects were less likely to receive a transfusion. When compared to a vaginal approach, patients who had a minimally invasive approach (odds ratio, 0.63; 95% confidence interval, 0.49–0.83) were less likely to receive a transfusion, while those with an open approach were more likely to receive a transfusion (odds ratio, 5.43; 95% confidence interval, 4.49–6.56). Age was not a risk factor for transfusion.Transfusion after pelvic reconstructive surgery is uncommon. The variables associated with transfusion are preoperative hematocrit <30%, American Society of Anesthesiologists class, bleeding disorders, nonwhite race, Hispanic ethnicity, and concomitant hysterectomy. Recognition of these factors can help guide preoperative counseling regarding transfusion risk after pelvic reconstructive surgery and individualize preoperative preparation.