Results of Cystocele Repair: A Comparison of Traditional Anterior Colporrhaphy, Polypropylene Mesh and Porcine Dermis

Cystocele Repair by a Modified Surgical Technique of Bilateral Pubococcygeus Plication: Long-Term Surgical and Functional Results

Here we describe our modified surgical technique of bilateral pubococcygeus plication (BPCP) for cystocele repair and assess its safety and long-term outcomes. This is a prospective study of 147 consecutive women who underwent BPCP for cystocele between January 2010 to January 2018. Inclusion criteria was naïve women with symptomatic cystocele ≥ POP-Q 2nd stage. Exclusion criteria: stress urinary incontinence (SUI), urgency urinary incontinence, other associated vaginal wall prolapses ≥ stage 2, neurological diseases, previous SUI surgeries, and previous radiation/surgery of the pelvic area. BPCP was performed by obtaining the medialization of the pubococcygeus muscle fibers of the right and left sides. Statistical analysis was performed. Objective cure was POP-Q < 2nd stage. Subjective cure and functional outcomes were evaluated by validated questionnaires. Patient’s satisfaction was assessed by a Likert-type scale. Mean operative time was 64 min. At a mean follow-up of 82.4 months, objective and subjective success rates were 89.8% and 92.2% respectively. De novo urgency was 3.2%. Surgery did not alter sexual function. Complications occurred in 4.8%, and were: wrong dissection plane, hematoma, and pain lasting between 24–72 h. BPCP for correction of cystocele is safe and effective, with limited risk of complication and good long-term results.

Current Treatments for Female Pelvic Floor Dysfunctions

As global population aging, the issue of pelvic floor dysfunctions becomes increasingly. Millions of women were affected every year. The treatment of pelvic floor dysfunction has evolved in the past decade. This review aims to provide the current information on the treatment for female pelvic floor dysfunction, including pelvic organ prolapse (POP), urinary, fecal incontinence (FI), and myofascial pelvic pain among women. We used PubMed, Embase, and Web of Science to search for studies that were related to pelvic floor dysfunction regarding the POP, urinary, FI, and treatments. The development of laparoscopic surgery and synthetic and biological materials for pelvic floor reconstructive surgery were summarized. The surgical outcomes and complications of different pelvic floor reconstructive surgeries were compared. New devices for FI and the potential modified pelvic floor reconstructive surgery were also discussed here. Female pelvic medicine will continue to evolve for better treatment in the future. The pelvic floor reconstructive surgery tends to be minimally invasive approach with synthetic graft use.

Graft and Mesh Use in Transvaginal Prolapse Repair: A Systematic Review

OBJECTIVE

To update clinical practice guidelines on graft and mesh use in transvaginal pelvic organ prolapse repair based on systematic review.

DATA SOURCES

Eligible studies, published through April 2015, were retrieved through ClinicalTrials.gov, MEDLINE, and Cochrane databases and bibliography searches.

METHODS OF STUDY SELECTION

We included studies of transvaginal prolapse repair that compared graft or mesh use with either native tissue repair or use of a different graft or mesh with anatomic and symptomatic outcomes with a minimum of 12 months of follow-up.

TABULATION, INTEGRATION, AND RESULTS

Study data were extracted by one reviewer and confirmed by a second reviewer. Studies were classified by vaginal compartment (anterior, posterior, apical, or multiple), graft type (biologic, synthetic absorbable, synthetic nonabsorbable), and outcome (anatomic, symptomatic, sexual function, mesh complications, and return to the operating room). We found 66 comparative studies reported in 70 articles, including 38 randomized trials; quality of the literature has improved over time, but some outcomes still show heterogeneity and limited power. In the anterior vaginal compartment, synthetic nonabsorbable mesh consistently showed improved anatomic and bulge symptom outcomes compared with native tissue repairs based on meta-analyses. Other subjective outcomes, including urinary incontinence or dyspareunia, generally did not differ. Biologic graft or synthetic absorbable mesh use did not provide an advantage in any compartment. Synthetic mesh use in the posterior or apical compartments did not improve success. Mesh erosion rates ranged from 1.4-19% at the anterior vaginal wall, but 3-36% when mesh was placed in multiple compartments. Operative mesh revision rates ranged from 3-8%.

CONCLUSION

Synthetic mesh augmentation of anterior wall prolapse repair improves anatomic outcomes and bulge symptoms compared with native tissue repair. Biologic grafts do not improve prolapse repair outcomes in any compartment. Mesh erosion occurred in up to 36% of patients, but reoperation rates were low.

Diagnosis and Therapy of Female Pelvic Organ Prolapse. Guideline of the DGGG, SGGG and OEGGG (S2e-Level, AWMF Registry Number 015/006, April 2016)

Aims: The aim was to establish an official interdisciplinary guideline, published and coordinated by the German Society of Gynecology and Obstetrics (DGGG). The guideline was developed for use in German-speaking countries. In addition to the Germany Society of Gynecology and Obstetrics, the guideline has also been approved by the Swiss Society of Gynecology and Obstetrics (SGGG) and the Austrian Society of Gynecology and Obstetrics (OEGGG). This is a guideline published and coordinated by the DGGG. The aim is to provide evidence-based recommendations obtained by evaluating the relevant literature for the diagnostic, conservative and surgical treatment of women with female pelvic organ prolapse with or without stress incontinence. Methods: We conducted a systematic review together with a synthesis of data and meta-analyses, where feasible. MEDLINE, Embase, Cinahl, Pedro and the Cochrane Register were searched for relevant articles. Reference lists were hand-searched, as were the abstracts of the Annual Meetings of the International Continence Society and the International Urogynecological Association. We included only abstracts of randomized controlled trials that were presented and discussed in podium sessions. We assessed original data on surgical procedures published since 2008 with a minimum follow-up time of at least 12 months. If the studies included descriptions of perioperative complications, this minimum follow-up period did not apply. Recommendations: The guideline encompasses recommendations for the diagnosis and treatment of female pelvic organ prolapse. Recommendations for anterior, posterior and apical pelvic organ prolapse with or without concomitant stress urinary incontinence, uterine preservation options, and the pros and cons of mesh placements during surgery for pelvic organ prolapse are presented. The recommendations are based on an extensive and systematic review and evaluation of the current literature and include the experiences and specific conditions in Germany, Austria and Switzerland.

Simultaneous treatment of anterior vaginal wall prolapse and stress urinary incontinence by using transobturator four arms polypropylene mesh

Purpose

To evaluate the medium-term efficacy and safety of transobturator four-arm polypropylene mesh in the treatment of high-stage anterior vaginal wall prolapse and concomitant stress urinary incontinence (SUI).

Materials and Methods

Between September 2010 and August 2013, a prospective single-center trial was performed to evaluate women with stage≥3 anterior vaginal wall prolapse with or without SUI who presented to Labbafinejad Hospital, Teheran, Iran, and underwent anterior vaginal wall repair with polypropylene mesh. Pre- and postoperative evaluation included history; physical examination using the Pelvic Organ Prolapse Quantification system and cough stress test, both before and after reduction of prolapsed structures; Pelvic Floor Distress Inventory (PFDI) and Pelvic Floor Impact Questionnaire (PFIQ); urinalysis and culture; and a postvoid residual assessment. Complications were reported at a mean of 2 years of follow-up.

Results

A total of 71 patients underwent cystocele repair with the transobturator four-arm polypropylene mesh. Seven of the patients were lost to follow-up. There were no perioperative complications. The anatomical success rate was 87.5%. The subjective success rate was 92.1%. The PFDI and PFIQ were significantly improved after surgery (p<0.001). Among those with the simultaneous complaint of SUI, 82% were cured without any additional procedure. Three patients (4.6%) experienced vaginal mesh extrusion. Two patients (3.1%) reported worsening of dyspareunia after surgery.

Conclusions

The four arms polypropylene mesh is an effective device for simultaneous correction of anterior vaginal wall prolapse and SUI with a low complication rate at a medium-term follow-up. The majority of the subgroup with concomitant SUI were cured without a second simultaneous procedure.

To mesh or not to mesh: a review of pelvic organ reconstructive surgery

Pelvic organ prolapse (POP) is a major health issue with a lifetime risk of undergoing at least one surgical intervention estimated at close to 10%. In the 1990s, the risk of reoperation after primary standard vaginal procedure was estimated to be as high as 30% to 50%. In order to reduce the risk of relapse, gynecological surgeons started to use mesh implants in pelvic organ reconstructive surgery with the emergence of new complications. Recent studies have nevertheless shown that the risk of POP recurrence requiring reoperation is lower than previously estimated, being closer to 10% rather than 30%. The development of mesh surgery - actively promoted by the marketing industry - was tremendous during the past decade, and preceded any studies supporting its benefit for our patients. Randomized trials comparing the use of mesh to native tissue repair in POP surgery have now shown better anatomical but similar functional outcomes, and meshes are associated with more complications, in particular for transvaginal mesh implants. POP is not a life-threatening condition, but a functional problem that impairs quality of life for women. The old adage "primum non nocere" is particularly appropriate when dealing with this condition which requires no treatment when asymptomatic. It is currently admitted that a certain degree of POP is physiological with aging when situated above the landmark of the hymen. Treatment should be individualized and the use of mesh needs to be selective and appropriate. Mesh implants are probably an important tool in pelvic reconstructive surgery, but the ideal implant has yet to be found. The indications for its use still require caution and discernment. This review explores the reasons behind the introduction of mesh augmentation in POP surgery, and aims to clarify the risks, benefits, and the recognized indications for its use.

Efficacy of Pelvisoft® Biomesh for cystocele repair: assessment of long-term results

INTRODUCTION AND HYPOTHESIS

To our knowledge a study regarding the efficacy of Pelvisoft® Biomesh for cystocele repair has not previously been reported in the literature. The aim of our study was to assess the long-term efficacy, subjective outcomes and complications in the use of a non-synthetic porcine skin mesh graft (Pelvisoft® Biomesh) associated with transvaginal anterior colporrhaphy in the treatment of cystocele prolapse.

MATERIALS AND METHODS

A retrospective study was performed at a single centre. Thirty-three women aged 35-77 years underwent cystocele repair using Pelvisoft® graft between December 2005 and June 2009. Twenty-nine women who underwent transvaginal cystocele repair with Pelvisoft® Biomesh for over a 2 years period were assessed. Four patients were lost to follow-up. Cystocele repair was performed via the vaginal route using Pelvisoft® Biomesh implant by inserting it in the anterior vaginal wall.

RESULTS

The median follow-up time was 54.0 months. The rate of recurrence was 17.3%. A total of 6.9% of patients presented early mesh exposure treated by conservative treatment. The mean PFDI-20 score was 72.2. Among sexually active women, the mean PISQ 12 was 33.9 but 56.2% had dyspareunia. After surgery, 6 patients had de novo intercourse.

CONCLUSIONS

Our results show that the use of Pelvisoft® biomaterial associated with anterior colporrhaphy for cystocele repair appears to be safe with acceptable failure and complication rates at long term. Nevertheless, an adverse impact on sexual function was reported by the majority of patients.

The outcome of transobturator anterior vaginal wall prolapse repair using porcine dermis graft: intermediate term follow-up

INTRODUCTION AND HYPOTHESIS

We evaluated the anatomical success and complications of Perigee® with porcine dermis Graft in the repair of anterior vaginal wall prolapse (AVWP) MATERIALS AND METHODS: After Institutional Review Board (IRB) approval, the charts of all patients who underwent AVWP repair using the Perigee/InteXen® kit from July 2005 to July 2009 were reviewed. Patients who had less than 6-month follow-up were excluded. Preoperative data including patient age, previous AVWP repairs, hysterectomy status, preoperative dyspareunia and pertinent physical findings were collected and recorded. Postoperative success was defined as anatomical stage 0 or I using the Pelvic Organ Prolapse Quantification (POP-Q) scoring system. Graft related complications were also recorded.

RESULTS

Out of 89 patients, 69 completed at least 6-month follow-up. Median follow-up was 13 (6-48) months. Seventeen patients (25%) had previous AVWP repair and 32 (46%) had previous hysterectomy. Preoperatively, AVWP stage II was found in 9 (13%), stage III in 27 (39%) and stage IV in 33 (48%) patients. Anatomic success was found in 48 (69%) patients, with 23 (33%) having stage 0 and 25 (36%) stage I AVWP. Intraoperative complications included incidental cystotomy in one patient and bladder perforation in one. Postoperative complications included vaginal exposure and dyspareunia in one case, wound dehiscence in one and tenderness over the graft arm with dyspareunia in one.

CONCLUSIONS

The use of porcine dermis in AVWP repair is safe with minimal graft related complications; however, anatomical success is lower than that reported with the use of synthetic grafts.

Outcomes of vaginal prolapse surgery among female Medicare beneficiaries: the role of apical support

OBJECTIVE

Recurrent pelvic organ prolapse (POP) has been attributed to many factors, one of which is lack of vaginal apical support. To assess the role of vaginal apical support and POP, we analyzed a national dataset to compare long-term reoperation rates after prolapse surgery performed with and without apical support.

METHODS

Public use file data on a 5% random national sample of female Medicare beneficiaries were obtained from the Centers for Medicare and Medicaid Services. Women with POP who underwent surgery during 1999 were identified by relevant International Classification of Diseases, 9th Revision, Clinical Modification, and Current Procedural Terminology, Fourth Edition codes. Individual patients were followed-up through 2009. Prolapse repair was categorized as anterior, posterior, or anterior-posterior with or without a concomitant apical suspension procedure. The primary outcome was the rate of retreatment for POP.

RESULTS

In 1999, 21,245 women had a diagnosis of POP. Of these, 3,244 (15.3%) underwent prolapse surgery that year. There were 2,756 women who underwent an anterior colporrhaphy, posterior colporrhaphy, or both with or without apical suspension. After 10 years, cumulative reoperation rates were highest among women who had an isolated anterior repair (20.2%) and significantly exceeded reoperation rates among women who had a concomitant apical support procedure (11.6%; P<.01).

CONCLUSION

Ten years after surgery for POP, the reoperation rate was significantly reduced when a concomitant apical suspension procedure was performed. This analysis of a national cohort suggests that the appropriate use of a vaginal apical support procedure at the time of surgical treatment of POP might reduce the long-term risk of prolapse recurrence.

LEVEL OF EVIDENCE

II.

The use of biological materials in urogynecologic reconstruction: a systematic review

There are numerous randomized controlled trials examining biological materials in urogynecologic surgery. For prolapse surgery, the addition of a biological graft adds no benefit compared with native tissue repairs for rectocele repair. Conflicting data exist regarding cystocele repair. Synthetic mesh repairs provide superior anatomical support for sacral colpopexy and cystocele repair compared with biologic grafts. However, biological and synthetic mesh slings have equivalent success rates for the treatment of stress urinary incontinence. Contrary to prior assumptions that biologic grafts add tissue strength without graft-related complications, there appears to be no benefit to the use of biological materials for prolapse and incontinence surgery.

The use of synthetic mesh and the management of mesh extrusion in vaginal surgery

The authors present a review of the literature regarding the management of mesh extrusion in vaginal surgery. As used in traditional surgical techniques, the use of mesh theoretically allows for a broader base of support and eliminates the need to rely on pre-existing weakened fascia. In this article, the different physical properties and types of synthetic mesh used, and their respective advantages and disadvantages in terms of mesh extrusion, are reviewed.

[Rectocele repair with porcine dermal collagen implant associated with infracoccygeal sacropexy]

OBJECTIVES

To evaluate an infracoccygeal colpopexy procedure by tension-free synthetic tape for vaginal apical prolapse associated with a posterior mesh procedure using porcine dermal graft for rectocele repair.

METHODS

A retrospective study concerning 35 women. The surgical procedure included rectocele repair with porcine dermal collagen implant (porcine dermal matrix, native) associated with transgluteal infracoccygeal sacropexy using a polypropylene sling.

RESULTS

Median follow up was 48 months (42-54). A vaginal hysterectomy was associated in 43% and a cure of cystocele was associated in 63% of cases. No intra-operative complication was noted. The prevalence of dyschesia decreased from 25% (eight patients) preoperatively to 3% (one patient) postoperatively. No cases of de novo dyspareunia was noted. Five (14%) patients had a recurrent prolapse (two cases of rectocele stage 2, one case of grade 3 rectocele associated with a cystocele, a case of uterine prolapse associated with cystocele and one case of recurrent isolated uterine prolapse). Among them, three patients (9%) required a re-intervention for prolapse recurrence. No vaginal mesh exposure was observed. Perineal pain was reported by 12 (33%) patients at one month follow-up, but no patient complained with perineal pain one year follow-up.

CONCLUSION

Infracoccygeal sacropexy associated with rectocele repair using porcine dermal collagen implant was associated with satisfactory results at medium term follow-up.

A multicenter prospective trial evaluating fetal bovine dermal graft (Xenform® Matrix) for pelvic reconstructive surgery

Background

A prospective multicenter clinical study was performed to evaluate the safety and efficacy of a bovine dermal graft (Xenform^® Matrix, Boston Scientific, Natick, MA, USA) during vaginal reconstructive surgery.

Methods

Forty-five women with ICS stage 2 or higher pelvic organ prolapse (POP) were enrolled at 4 centers. POP-Q, pelvic floor function (PFDI-20), sexual function (PISQ-12), and patient satisfaction tools were used to assess subjects at baseline, and at 2 and 6 weeks, and 3, 6 and 12 months post surgery. The significance of symptom score changes at 6 months and 1 year were determined by the t-test for paired data. Forty-three of the 45 patients completed the 12 month study.

Results

The majority of the subjects had cystocele (98%) and/or rectocele (84%) defects at study entry. At 12 months, 74% of the defects had improved to a stage 0 or 1. Mean PFDI-20 scores improved by 72% (p < 0.001) at 12 months, and PISQ-12 scores were maintained during the follow-up period indicating no decline in sexual function. Three subjects experienced one serious adverse event each; one of the adverse events (constipation) was deemed by the study physician to be unrelated to Xenform^®. One subject had severe pyelonephritis resulting in dialysis. This subject had a previous history of pyelonephritis, sepsis and acute renal failure. The third subject had a reported recurrent cystocele of moderate severity, possibly related to the device. No graft related erosions or pain lasting more than 30 days were reported. No subjects withdrew due to an adverse event.

Conclusion

This study is the first to investigate the use of Xenform^® Matrix in vaginal reconstructive surgery among patients with POP. Significant improvement was maintained at 12 months utilizing both objective and subjective assessment tools, confirming the safety and efficacy of this material in vaginal surgery.

Trial Registration

ClinicalTrials.gov NCT01244165

Biological Mesh in Hernia Repair, Abdominal Wall Defects, and Reconstruction and Treatment of Pelvic Organ Prolapse: A Review of the Clinical Evidence

The use of biological meshes seems to be an innovation that influences all surgical fields. The existing evidence indicates that biological meshes cannot only be applied on the area of hernia repair, but also on cases of abdominal reconstruction and pelvic organ prolapse treatment, especially in the presence of contaminated or potentially contaminated surgical fields. Low risks of graft rejection, complications, and infection seem to be the main advantages of biological meshes in comparison with the synthetic nonabsorbable ones. Nevertheless, the elevated costs suggest that biological mesh implantation should be evaluated in correlation to the needs of each clinical case.

Efficacy and Safety of "Tension-free" Placement of Gynemesh PS for the Treatment of Anterior Vaginal Wall Prolapse

PURPOSE

To evaluate the efficacy and safety of the tension-free placement of a monofilament polypropylene mesh for the repair of an anterior vaginal wall prolapse (AVWP).

MATERIALS AND METHODS

Women aged ≥ 30 years with an AVWP stage of II or greater were included. Forty-nine women underwent trans-vaginal repair using a Gynemesh™ PS. Forty-six women who had symptomatic stress urinary incontinence received a midurethral sling (MUS). At the 12-month follow-up, evaluations were made for changes in the Pelvic Organ Prolapse Quantification (POP-Q) stage and Pelvic Floor Distress Inventory. Cure was defined as a POP-Q stage of 0 and improvement as a stage of I. Complications were also evaluated.

RESULTS

The cure rate was 71.4%, and the improvement rate was 18.4%. Obstructive/discomfort, irritative, and stress subscale scores of the Urinary Distress Inventory anterior and posterior subscale scores of the POP Distress Inventory and the obstructive subscale score of the Colo-Rectal-Anal Distress Inventory were significantly improved. Thirty-two of the 46 women (69.6%) who received MUS procedures reported no leakage after surgery. Complications were 2 cases of increased intraoperative bleeding and 1 case of vaginal erosion.

CONCLUSIONS

Trans-vaginal repair using a Gynemesh™ PS is a feasible and effective procedure for the treatment of AVWP with no significant complications.

Long-term results of vaginal repairs with and without xenograft reinforcement

INTRODUCTION AND HYPOTHESIS

The aim of this paper is to study if xenograft reinforcement of vaginal repair reduces recurrence of prolapse.

METHODS

Results 1-5 years after vaginal repair were studied in 41 cases with xenograft and in 82 matched controls without. Symptoms were evaluated by a validated questionnaire and anatomy by pelvic organ prolapse quantification (POPQ).

RESULTS

Significant more cases, 97% versus 81% controls, felt cured or much improved (p = 0.02); 11% of cases and 19% of controls had POP symptoms, POPQ > -1 was found in 31% cases and 24% controls. Defining recurrence as POPQ > -1 plus symptoms revealed recurrence in 3% of cases and 12% controls. None of the recurrence rates was significantly different for cases versus controls. No vaginal erosions were seen. Previous surgery was a significant risk factor with odds ratio 7.3 for another recurrence.

CONCLUSIONS

Recurrence rates defined by POPQ plus symptoms were low compared to literature. Xenograft reinforcement might improve results.

Advances in managing pelvic floor disorders

The last 10-12 years have seen an avalanche of changes in both the management of incontinence and genital prolapse. So many new procedures continue to appear that often the clinician is confused as to which approach to adopt. Complications are now being reported, creating a need to reappraise the situation.

Improvements in overactive bladder syndrome after polypropylene mesh surgery for cystocele

BACKGROUND

The International Continence Society has defined overactive bladder syndrome (OABS) by the following set of symptoms: 'urgency, with or without urge incontinence, usually with urinary frequency and nocturia'. OABS and cystocele often coexist.

AIM

This study aimed to analyse the changes in the overactive bladder symptom score (OABSS) of women followed up for one year after anterior repair surgery performed using a polypropylene mesh. In this surgery, a tape with four straps designed for optimum tissue holding capacity was fixed to the obturator foramen.

MATERIAL AND METHODS

Thirty-four women were operated using the abovementioned mesh. The OABSS, maximal urinary flow rate (Qmax) and postvoid residual (PVR) volume were evaluated pre- and post-surgery.

RESULTS

We observed significant improvements in the OABSS and quality of life scores before and after one year of surgery. The surgery was significantly effective in improving urgency, daytime frequency, incontinence, the Qmax and the PVR volume. No significant change in nocturia was observed post-surgery.

CONCLUSIONS

Our study confirmed the efficacy of the propylene mesh introduction surgery for cystocele for the improvement of OABS symptoms.

Complex pelvic floor failure and associated problems

The pelvic floor is a highly complex structure made up of skeletal and striated muscles, support and suspensory ligaments, fascial coverings and an intricate neural network. Its dual role is to provide support for the pelvic viscera (bladder, bowel and uterus) and maintain functional integrity of these organs. In order to maintain good pelvic floor function, this elaborate system must work in a highly integrated manner. When this system if damaged, pelvic floor failure ensues. The aetiology is inevitably multi-factorial, and seldom as a consequence of a single aetiological factor. It can affect one or all the three compartments of the pelvic floor, often resulting in prolapse and functional disturbance of the bladder (urinary incontinence and voiding dysfunction), rectum (faecal incontinence), vagina and/or uterus (sexual dysfunction). This compartmentalisation of the pelvic floor has resulted in the partitioning of patients into urology, colo-rectal surgery or gynaecology, respectively, depending on the patients presenting symptoms. In complete pelvic floor failure, all three compartments are inevitably damaged resulting in apical prolapse, with associated organ dysfunction. It is clear that in this state, the patient needs the clinical input of at least two of the three pelvic floor clinical specialities. Whilst the primary clinical aim is to correct the anatomy, it must also be to preserve or restore pelvic floor function. As a consequence, these patients need careful clinical assessment, appropriate investigations, and counselling before embarking on a well-defined management pathway. The latter includes behavioural and lifestyle changes, conservative treatments (pelvic support pessaries, physiotherapy and biofeedback), pharmacotherapy, minimally invasive surgery (intravaginal slingoplasty, sacrospinous fixation and mid-urethral tapes) and radical specialised surgery (open or laparoscopic sacrocolpopexy). It is not surprising that in this complex group of patients, a multi-disciplinary approach is not only essential, but also critical, if good clinical care and governance is to be ensured.

[What about transvaginal mesh repair of pelvic organ prolapse? Review of the literature since the HAS (French Health Authorities) report]

The French Health Authorities' (HAS) report of November 2006 concluded that the use of mesh at the time of transvaginal repair of pelvic organ prolapse (POP) should be limited to clinical research. This review intends to analyse and comment the recent data on this topic. A review on PubMed, on a personal database and actualisation until May 2008 has been performed choosing French or English language series concerning prolapse surgery with mesh disposed by the vaginal route. It includes six randomised controlled trials comparing transvaginal repair of POP with or without mesh: four about cystocele, one about rectocele and one about apical prolapse. Both surgical techniques and recurrence criteria are poorly standardised. The four randomised trials focusing on cystocele repair support the anatomical superiority of techniques using mesh, with similar functional results with or without mesh reinforcement. In the other indications, the results remain unclear or controversial. According to the randomised trials, the complications rate, except mesh exposure, is similar with and without mesh. However there are some specific complications when using mesh, such as mesh infection, mesh exposure or shrinkage and visceral extrusion. We recommend using vaginal reinforcement mesh with specific care in selected patients and we suggest some guidelines to be proposed for consensus at concerned French scientific societies.