Pelvic Organ Prolapse Surgery in Academic Female Pelvic Medicine and Reconstructive Surgery Urology Practice in the Setting of the Food and Drug Administration Public Health Notifications

Specialty-Specific Trends in Surgery for Apical Pelvic Organ Prolapse Post Vaginal Mesh

IMPORTANCE

Since transvaginal mesh (VM) kits for apical pelvic organ prolapse (APOP) were labeled "high-risk" in 2016 and subsequently banned in 2019 by the U.S. Food and Drug Administration, the most common remaining surgical options include abdominal mesh-augmented sacrocolpopexy (AS) and transvaginal native tissue suspension (VN).

OBJECTIVE

The objective of this study was to determine temporal trends in APOP procedures for urologists and gynecologists.

STUDY DESIGN

Between 2011 and 2020, the American College of Surgeons National Surgical Quality Improvement Program database was queried for AS, VM, and VN.

RESULTS

There were 26,477 cases of APOP repair (32% AS, 6% VM, 62% VN) included, 9% by urologists. Urologists operated on older (65 vs 61 years) patients with more medical comorbidities. Urologists performed significantly higher proportion of AS (65% vs 29%) and VM (8% vs 6%) relative to VN (27% vs 65%) than gynecologists ( P < 0.0001). Transvaginal mesh utilization has decreased over time for both specialties ( P < 0.05); nonsignificant trends toward increasing AS ( P = 0.1646) in urologists and VN ( P = 0.0913) in gynecologists concurrently occurred. Significant independent predictors of the operating surgeon being a urologist were surgery being performed in the latter half of the cohort (2016-2020; odds ratio [OR], 1.22), non-White patient race (OR < 1 for all), a concomitant sling being placed (OR = 0.89), the surgery being VM (OR = 2.95) or AS (OR = 4.36), the patient being older (OR > 1 for each age range), and having a higher frailty index score (OR = 1.16).

CONCLUSIONS

Significant differences in APOP repair choices exist between specialties. Urologists operate on older, more medically complex patients while demonstrating a strong preference for mesh-augmented compared with transvaginal native tissue repairs.

Extracellular Matrix-Based and Electrospun Scaffolding Systems for Vaginal Reconstruction

Congenital vaginal anomalies and pelvic organ prolapse affect different age groups of women and both have significant negative impacts on patients' psychological well-being and quality of life. While surgical and non-surgical treatments are available for vaginal defects, their efficacy is limited, and they often result in long-term complications. Therefore, alternative treatment options are urgently needed. Fortunately, tissue-engineered scaffolds are promising new treatment modalities that provide an extracellular matrix (ECM)-like environment for vaginal cells to adhere, secrete ECM, and be remodeled by host cells. To this end, ECM-based scaffolds or the constructs that resemble ECM, generated by self-assembly, decellularization, or electrospinning techniques, have gained attention from both clinicians and researchers. These biomimetic scaffolds are highly similar to the native vaginal ECM and have great potential for clinical translation. This review article aims to discuss recent applications, challenges, and future perspectives of these scaffolds in vaginal reconstruction or repair strategies.

Health Care Disparities in Surgical Management of Pelvic Organ Prolapse: A Contemporary Nationwide Analysis

OBJECTIVES

Our objective was to compare the rate of native tissue repair (NTR) versus sacrocolpopexy (SCP) and reconstructive (RECON) versus obliterative repair (OBR) for the treatment of pelvic organ prolapse (POP), evaluating for health care disparities based on race, socioeconomic, and geographic factors.

METHODS

The National Inpatient Sample database was queried for patients older than 18 years undergoing POP surgery from 2008 to 2018. Baseline demographics, comorbidity index, socioeconomic, and hospital variables were extracted. The weighted t test, Wilcoxon test, and χ2 test were used to compare the rate of (1) NTR versus SCP and (2) RECON vs OBR. Multivariate weighted logistic regression was used to compare while controlling for confounders. Reference groups were White race, Medicare patients, northeast region, small hospital size, and rural location.

RESULTS

Of 71,262 patients, 67,382 (94.6%) underwent RECON. Patients undergoing OBR were older and had a higher comorbidity score. Multivariate analysis showed the following: (1) Black, Hispanic, and other races; (2) Medicaid patients; (3) patients at urban teaching hospitals are less likely to receive RECON. Patients in the midwest were more likely to receive RECON. Among 68,401 patients, 23,808 (34.8%), and 44,593 (65.19%) underwent SCP and NTR, respectively. Hysterectomy was more common in the NTR group. Multivariate analysis showed the following:(1) Black, Hispanic, and "other" races; (2) uninsured and Medicaid patients; (3) patients in the midwest, south, and west were at higher odds of receiving NTR. Patients in large and urban hospitals were less likely to undergo NTR.

CONCLUSIONS

Racial, socioeconomic, and geographic disparities exist in surgical management for POP warranting further study to seek to eliminate these disparities.

Improvement in dyspareunia after vaginal mesh removal measured by a validated questionnaire

INTRODUCTION AND HYPOTHESIS

The objective was to examine the effect of the surgical removal of vaginally placed prolapse and incontinence mesh on sexual function. We hypothesize that patients with painful complications of mesh will experience improvement in dyspareunia and sexual function after mesh removal.

METHODS

The eligible cohort consisted of 133 women who presented with a new onset of pain attributed to mesh-augmented incontinence or prolapse surgery and who elected to undergo mesh removal between 1 August 2012 and 1 July 2013. Sexual function symptoms were assessed before and after mesh removal surgery using the Pelvic Organ Prolapse and Urinary Incontinence Sexual Function Questionnaire short form (PISQ-12). Multivariate analysis was performed to identify predictors of improvement in dyspareunia.

RESULTS

Ninety-four patients undergoing mesh removal completed a pre-operative questionnaire, 63 of whom also completed a post-operative questionnaire. After mesh removal, there was a nearly 50% reduction in the proportion of women reporting always experiencing post-operative pain with intercourse among those experiencing pre-operative pain. There was a statistically significant quantitative improvement in pain with intercourse after mesh removal based on mean change score of PISQ-12 question 5 "How often do you experience pain with intercourse?". In multivariate analysis, only history of vaginal delivery was associated with symptom improvement.

CONCLUSION

Removal of transvaginal prolapse mesh is associated with improvement in self-reported dyspareunia based on a standardized question on a validated instrument in a small cohort of women. Although larger studies are needed to confirm the relationship between mesh-augmented surgeries and post-procedural dyspareunia, these data suggest that consideration of mesh removal is a reasonable step for patients with painful intercourse attributed to mesh-augmented prolapse and incontinence surgeries.

Laparoscopic sacrocolpopexy for pelvic organ prolapse: Comparison of standard versus tacker combination method

OBJECTIVE

To compare the surgical outcomes of laparoscopic sacrocolpopexy for pelvic organ prolapse between a group in which only sutures were used (standard method), and a group in which a combination of tackers and sutures were used (tacker combination method).

METHODS

A total of 77 patients who underwent laparoscopic sacrocolpopexys from June 2016 to October 2019 were divided into a suture group (36 patients) and a suture + tacker group (41 patients). We retrospectively compared operation time, amount of blood loss, postoperative length of hospital stay, incidence of perioperative complications and anatomical cure rate 1 year after surgery. Lower urinary tract symptoms were evaluated using symptom questionnaires and objective parameters.

RESULTS

Operation time in the suture + tacker group was shorter (104.9 ± 27.0 vs 147.5 ± 33.7 min; P < 0.0001). The incidence of perioperative complications in the suture group and the suture + tacker group was 2.8% and 2.4%, respectively (P = 0.9409). Anatomical cure rates at 1 year after surgery were 94.4% and 100%, respectively (P = 0.2153). Both groups showed significant improvement after 1 year for International Prostate Symptom Score total and quality of life score, Overactive Bladder Symptom Score total score, voided volume, maximum urinary flow rate and post-void residual. [Corrections added on 7 September 2021 after first online publication: the first two P-values have been updated.] CONCLUSIONS: The combined use of sutures and tackers in laparoscopic sacrocolpopexy simplifies the procedure and translates into shorter operation time. Surgical outcomes at 1 year and improvement of lower urinary tract symptoms are similar regardless of the technique.

Mesh exposure after transvaginal mesh prolapse surgery: Out of permissible range?

OBJECTIVES

To investigate the prevalence of postoperative complications after transvaginal mesh prolapse surgery, and whether modified transvaginal mesh prolapse surgery (without transobturator arms or posterior mesh) has less prevalence of mesh exposure compared with conventional transvaginal mesh prolapse surgery.

METHODS

Medical charts were retrospectively examined for 2648 patients who underwent transvaginal mesh prolapse surgery in a general hospital (2006-2017). Conventional transvaginal mesh prolapse surgery (Prolift-type, n = 2258) was used, with a shift from 2015 to modified transvaginal mesh prolapse surgery (Uphold-type, n = 330). Patients were instructed to have >2 years of follow up and to report if they had problems regarding the operation.

RESULTS

The prevalence of mesh exposure was 34 out of 2648 (1.28%); 18 vagina (0.68%), 10 bladder (0.38%), two ureter (0.08%) and four rectum (0.15%). The modified transvaginal mesh prolapse surgery group had only one case with vaginal exposure. Vaginal exposure was managed transvaginally or followed by observation. Rectal exposure was managed transvaginally without colostomy. Bladder exposure was managed by transurethral resection with saline. Open ureterocystostomy was carried out to treat ureteral exposure. In the conventional transvaginal mesh prolapse surgery group, three cases of ureteral stenosis and one case with vaginal evisceration of the small intestine were managed transvaginally. The prevalence of postoperative chronic pain was 13 out of 2648 (0.49%; with one patient in the modified transvaginal mesh prolapse surgery group). The patients underwent pharmacotherapy, and one patient underwent additional surgical treatment.

CONCLUSIONS

The reoperation rate as a result of complications after transvaginal mesh prolapse surgery seems to be low. The reoperation rate as a result of prolapse recurrence is also low. A shift from conventional transvaginal mesh prolapse surgery to modified transvaginal mesh prolapse surgery might contribute to a further decrease in the risk of complications.

A new male sling for minimal to moderate incontinence and climacturia

Erectile dysfunction (ED) and stress urinary incontinence (SUI) are known bothersome sequelae to radical prostatectomy. In recent years, additional attention has been placed on another less commonly described and reported side effect to this surgery, climacturia. While various noninvasive and surgical interventions have been described for the management of climacturia, until recently, none has provided reliable and meaningful results. In the past few years, the Mini-Jupette sling has gained popularity as an adjunct to inflatable penile prosthesis placement in patients with concomitant ED and climacturia. Recent data have also suggested its feasibility in patients with mild SUI. While the original technique described by Pr. Andrianne has shown long-term, reproducible, and safe results, innovative modifications such as the use of autologous rectus fascia, the Male Urethral Mini-Sling and the Mayo Clinic modified Mini-Jupette sling have also been suggested, proof of widespread interest amongst clinicians toward achieving the optimum surgical technique.

One-year outcomes of a suture-less laparoscopic sacral hysteropexy using polypropylene Y-mesh grafts and fibrin sealant spray: A prospective comparative study

BACKGROUND

Laparoscopic sacral hysteropexy (SH) is a minimally invasive and effective treatment for uterovaginal prolapse in women who wish to retain the uterus. However, this procedure is limited by a steep learning curve and a long operating time. In this study, we aim to evaluate the surgical outcomes of a modified laparoscopic SH procedure using innovative methods of vaginal mesh attachment, which we hypothesized to be equally effective and time-saving.

METHODS

This was a prospective, parallel, comparative study conducted at a tertiary referral hospital. A total of 34 women with advanced (POPQ [Pelvic Organ Prolapse Quantification] stages ≧ 2) uterine prolapse, who underwent a laparoscopic SH procedure using lightweight polypropylene Y-mesh grafts (ALYTE), were studied. In half (n = 17) of the cases, fibrin sealant spray (TISSEEL) was applied to the meshes fixed at the anterior and posterior vaginal wall with fewer (six vs at least ten) sutures. A detailed comparison of one-year outcomes between groups was performed.

RESULTS

Patient characteristics and perioperative results were comparable between groups with the exception of a significantly shorter total operating time (247.0 vs 292.9 minutes, p = 0.04) noted in the fibrin group. At 1 year, anatomic success (POPQ stage ≦1) rates (76.5% vs 76.5%) were not different between groups. There were eight patients, with four in each group, who had surgical failure. Notably, most (7/8; 87.5%) surgical failures were at the anterior compartment (i.e, recurrent cystocele). No vaginal mesh extrusions were noted. After statistical analysis, we found "cystocele as the dominant prolapse before operation" was a significant predisposing factor for prolapse recurrence (p = 0.019; odds ratio = 8.04).

CONCLUSION

The modified laparoscopic SH procedure using Y-mesh grafts and fibrin sealant spray with fewer vaginal sutures was equally effective as conventional methods but saved time. Laparoscopic SH using Y-mesh grafts might not be as effective in repairing a concomitant dominant cystocele.

Comparison of the vault prolapse rate after vaginal hysterectomy with or without residual uterine ligament ligations: A retrospective cohort study

PURPOSE

To evaluate the post-hysterectomy vault prolapse (PHVP) rates performed using different methods of vaginal total hysterectomy (VTH).

METHODS

A total of 251 women who underwent VTH with/without concomitant surgeries between January 1986 and December 2001 in a tertiary center. Thirty-eight women were excluded due to not only a vaginal approach. Of the remaining 213 women, 129 and 84 underwent VTH via the Tsuzi method with residual uterine ligament ligations (ligations group) and traditional VTH (without ligations group), respectively. The χ² and Mann-Whitney U tests were applied appropriately. The cumulative percentages of women without PHVP were calculated over time and compared using Kaplan-Meier curves and log-rank tests. A p value of less than 0.05 was considered statistically significant.

RESULTS

Compared to the without ligations group, women in the ligations group had longer operation time (115.9 ± 37.1 vs. 103.3 ± 41.4 min, p = 0.002) and more blood loss (217.4 ± 137.8 vs. 148.2 ± 149.0 mL, p < 0.001). When focusing on women with uterine prolapse, only operation time and grade of uterine prolapse were different between the groups (117.3 ± 24.8 vs. 107.9 ± 40.5 min, p = 0.025, and 21% vs. 41%, p = 0.018, respectively). The rate of PHVP was significantly lower in the ligation group than in the without ligations group (0 vs. 5, p = 0.005).

CONCLUSION

VTH via the Tsuzi method with residual uterine ligament ligations resulted in fewer cases of PHVP than occurred in traditional VTH. If native tissue repair is planned in pelvic reconstruction surgery, VTH with residual uterine ligament ligations should be considered.

The Management and Efficacy of Surgical Techniques Used for Erosive Mesh in the Urethra and Bladder: A Systematic Review

BACKGROUND

This study reports the re-operation and symptom resolution rates of different techniques used in surgical excision of genitourinary mesh erosions.

METHODS

A comprehensive systematic review was completed after searching electronic databases for studies involving outcomes of mesh erosion in humans that were managed surgically using a transvaginal, cystoscopic, or abdominal approach. Surgical outcomes were reported in percentages, ranges, and simple pooling to generate trends in management techniques.

RESULTS

There were 177 cases that met our inclusion criteria. Forty-one patients underwent cystoscopic removal of eroded urethral mesh while 40 cases underwent transvaginal removal of urethral mesh.

CONCLUSIONS

For mesh eroded into the urethra, a transvaginal vs. cystoscopic approach showed a trend toward resolution of symptoms and fewer interventions. For mesh eroded into the bladder, abdominal and cystoscopic approaches had similar symptom resolution, but abdominal approach required fewer interventions.

Mesenchymal stem cell-based bioengineered constructs: foreign body response, cross-talk with macrophages and impact of biomaterial design strategies for pelvic floor disorders

An excessive foreign body response (FBR) has contributed to the adverse events associated with polypropylene mesh usage for augmenting pelvic organ prolapse surgery. Consequently, current biomaterial research considers the critical role of the FBR and now focuses on developing better biocompatible biomaterials rather than using inert implants to improve the clinical outcomes of their use. Tissue engineering approaches using mesenchymal stem cells (MSCs) have improved outcomes over traditional implants in other biological systems through their interaction with macrophages, the main cellular player in the FBR. The unique angiogenic, immunomodulatory and regenerative properties of MSCs have a direct impact on the FBR following biomaterial implantation. In this review, we focus on key aspects of the FBR to tissue-engineered MSC-based implants for supporting pelvic organs and beyond. We also discuss the immunomodulatory effects of the recently discovered endometrial MSCs on the macrophage response to new biomaterials designed for use in pelvic floor reconstructive surgery. We conclude with a focus on considerations in biomaterial design that take into account the FBR and will likely influence the development of the next generation of biomaterials for gynaecological applications.

Rate of Pelvic Organ Prolapse Surgery Among Privately Insured Women in the United States, 2010-2013

OBJECTIVE

To analyze utilization of, and payments for, pelvic organ prolapse procedures after the 2011 U.S. Food and Drug Administration (FDA) communication regarding transvaginal mesh.

METHODS

This is a retrospective cohort study examining private claims from three insurance providers for inpatient and outpatient prolapse procedures from 2010 to 2013 in the Health Care Cost Institute. Primary outcomes were the change in utilization of prolapse procedures, with and without mesh, before and after the July 2011 FDA communication. Secondary outcomes were the changes in payments and reimbursements for these procedures. Utilization rates and payments were compared using generalized linear models and interrupted time-series analysis.

RESULTS

Utilization of prolapse procedures decreased from 12.3 to 9.7 per 10,000 woman-years (P=.027) with a decrease of 30.7% (3.9 in 2010 to 2.7 in 2013, P=.05) in number of mesh procedures and 16.6% (8.4 in 2010 to 7.0 in 2013, P=.011) for nonmesh procedures. Quarterly utilization of mesh procedures was increasing before the FDA communication and then significantly declined after its release (slope=0.024 vs -0.025, P=.002). Nonmesh procedures, however, were already slightly decreasing before July 2011 and continued to decline at a more rapid pace after that time, although not significantly (slope=-0.004 vs -0.022, P=.47). Inpatient utilization decreased 52.2% (P=.002), whereas outpatient utilization increased 18.5% (P=.132). Payments for individual inpatient procedures, with and without mesh, increased by 12.0% ($8,315 in 2010 to $9,315 in 2013, P=.001) and 15.6% ($7,826 in 2010 to $9,048 in 2013, P=.005), respectively, whereas those for outpatient procedures increased by 41% ($4,961 in 2010 to $6,981 in 2013, P=.006) and 30% ($3,955 in 2010 to $5,149 in 2013, P=.004), respectively.

CONCLUSION

Use of prolapse surgery declined during the study period. After the 2011 FDA communication regarding transvaginal mesh, there was a significant decrease in the utilization of procedures with mesh but not for those without mesh. A shift toward outpatient surgeries was observed, and payments for both individual inpatient and outpatient cases increased.

Trends in prolapse surgery in England

INTRODUCTION AND HYPOTHESIS

Women have a lifetime risk of undergoing pelvic organ prolapse (POP) surgery of 11-19%. Traditional native tissue repairs are associated with reoperation rates of approximately 11% after 20 years. Surgery with mesh augmentation was introduced to improve anatomic outcomes. However, the use of synthetic meshes in urogynaecological procedures has been scrutinised by the US Food and Drug Administration (FDA) and by the European Commission (SCENIHR). We aimed to review trends in pelvic organ prolapse (POP) surgery in England.

METHODS

Data were collected from the national hospital episode statistics database. Procedure and interventions-4 character tables were used to quantify POP operations. Annual reports from 2005 to 2016 were considered.

RESULTS

The total number of POP procedures increased from 2005, reaching a peak in 2014 (N = 29,228). With regard to vaginal prolapse, native tissue repairs represented more than 90% of the procedures, whereas surgical meshes were considered in a few selected cases. The number of sacrospinous ligament fixations (SSLFs) grew more than 3 times over the years, whereas sacrocolpopexy remained stable. To treat vault prolapse, transvaginal surgical meshes have been progressively abandoned. We also noted a steady increase in uterine-sparing, and obliterative procedures.

CONCLUSIONS

Following FDA and SCENIHR warnings, a positive trend for meshes has only been seen in uterine-sparing surgery. Native tissue repairs constitute the vast majority of POP operations. SSLFs have been increasingly performed to achieve apical support. Urogynaecologists' training should take into account shifts in surgical practice.

When and how to excise vaginal mesh

PURPOSE OF REVIEW

Since 2011, there has been increasing attention paid to the use of synthetic grafts (mesh) in pelvic reconstructive surgery. Although synthetic grafts are considered permanent implants to improve outcomes, the use of this material has created inadvertent complications such as erosion, chronic pain, and dyspareunia. Patient evaluation is complex and surgical techniques carry risks not yet completely understood. This review summarizes current opinions in synthetic graft excision for the treatment of mesh-related complications.

RECENT FINDINGS

Recent studies reveal excisions are being increasingly performed and graft placement is decreasing. Patients of lower-volume surgeons have a higher risk of complication and need for excisional procedures. Pain is becoming the most common indication for vaginal mesh excision and that pain is mostly elicited with palpation of the mesh arms. Explantation is technically challenging and carries significant risks.

SUMMARY

Vaginal synthetic graft complications are increasingly being managed by surgical excision. Careful evaluation of patient symptoms and objective findings should help guide management. Surgeons considering operative management should counsel patients regarding the risks of excision including but not limited to hemorrhage, nerve damage, muscular injury, and recurrent symptoms.

Trends in pelvic organ prolapse management in Latin America

AIMS

To describe practice patterns and perspectives regarding pelvic organ prolapse (POP) management among urologists, gynecologists, and urogynecologists in Latin America (LATAM).

METHODS

A cross-sectional study was conducted from April to September 2016 using a 37-item internet-based survey applied to members of urologic and gynecologic associations from 18 countries. Participants were asked about their background and practice patterns. Descriptive statistics were employed.

RESULTS

A total of 673 responses were obtained. Most came from Colombia (33.6%) and Brazil (24.7%). The number of practitioners who perform at least one POP procedure per month and were eligible to finish the survey was 529 (78.6%), out of which 323 (61.0%) were urologists, 156 (29.5%) gynecologists, and 50 (9.5%) urogynecologists. Mesh-based POP repairs were used by 57.1% of participants. Out of non-mesh users, the most frequent vaginal procedures were sacrospinous fixation (30%), colporrhaphy (25%), and uterosacral fixation (12%). Regarding the impact of FDA warnings, 75.2% participants indicated that the use of mesh has declined, and 41.9% considered this has had a negative effect in the use of incontinence tapes as well. Only two physicians reported legal disputes related to mesh procedures, and 75.8% said they would still indicate mesh repairs in certain cases.

CONCLUSIONS

This is the first report on POP practice patterns in LATAM. Preferences regarding surgical management of POP are not very different from international trends. Despite intense scrutiny and media exposure, mesh-based procedures are still largely used in LATAM.

Analysis of Complications of Pelvic Mesh Excision Surgery Using the Clavien-Dindo Classification System

PURPOSE

We describe and categorize complications using the Clavien-Dindo classification system in patients who underwent vaginal mesh excision surgery.

MATERIALS AND METHODS

With institutional review board approval we retrospectively reviewed the records of 277 patients who underwent vaginal mesh extraction between 2007 and 2015 at a single institution. Surgical complications were stratified using the Clavien-Dindo classification system. Complications were perioperative (prior to discharge) or postoperative (within 90 days). Indications for initial mesh placement, mesh revision procedure, time to resolution and medical comorbidities were assessed.

RESULTS

Of the 277 patients 47.3% had at least 1 surgical complication, including multiple complications in 7.2%. A total of 155 complications were identified, which were grade II in 49.0% of cases, grade I in 25.8%, grade IIIb in 18.7%, grade IIIa in 5.2% and grade IVa in 1.3%. No grade IVb or V complications were identified. The indication for initial mesh placement did not significantly affect complication frequency. Patients who underwent combined stress urinary incontinence and pelvic organ prolapse mesh revision surgeries had an increased frequency of complications compared to those treated with mesh revision surgery for pelvic organ prolapse or stress urinary incontinence alone (p = 0.045). Most complications occurred postoperatively and resolved by 90 days. Age, body mass index, smoking status and diabetes were not associated with increased complications.

CONCLUSIONS

Despite the complexity of mesh revision surgery most complications are minor. Serious complications may develop, emphasizing the need for proper patient counseling and surgical experience when performing these procedures.

Reasons for and Against Use of Non-absorbable, Synthetic Mesh During Pelvic Organ Prolapse Repair, According to the Prolapsed Compartment

Awareness and reporting of mesh-related complications of pelvic organ prolapse repairs have increased in recent years. As a result, deciding whether to use a mesh or not has become a difficult task for urogynecologists. Our aim was to summarize reasons for and against the use of mesh in prolapse repair based on a review of relevant literature. Scopus and PubMed databases were searched for papers reporting on the efficacy and safety of native tissue versus non-absorbable, synthetic mesh prolapse repairs. Randomized controlled trials, systematic reviews, and meta-analyses were included. Evidence is presented for each vaginal compartment separately. In the anterior compartment, mesh repairs seem to offer clearly superior efficacy and durability of results compared to native tissue repairs, but with an equally clear increase in complication rates. In the isolated posterior compartment prolapse, high-quality evidence is sparse. As far as the apical compartment is concerned, sacrocolpopexy is the most efficacious, yet the most invasive procedure. Data on the comparison of transvaginal mesh versus native tissue repairs of the apical compartment are somewhat ambiguous. Given the inevitable coexistence of advantages and disadvantages of mesh use in each of the prolapsed vaginal compartments, an individualized treatment decision, based on weighing risks against benefits for each patient, seems to be the most rational approach.