EURURO Vol. 72 No. 3

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Anterior colporrhaphy is performed through an anteri-
or vaginal wall incision and plication of the vaginal tissues
in the midline using absorbable sutures. Recurrence
rates are high when using anatomic outcome criteria.
However, when contemporary ‘‘functional’’ outcome
measures are used, with appropriate selection of patients,
better results can be obtained The technique
of transvaginal rectocele repair allows correction of
fascial defects, by separating the rectum and vaginal
epithelium
The relatively high recurrence and reoperation rates
(30%), especially after traditional (anterior/posterior) repair,
and the high success rates for using mesh in abdominal
hernia surgery and SUI surgery led to the quick adoption of
transvaginal mesh (TVM)-augmented pelvic floor repair
procedures. However, concerns have been raised on the
safety of TVM, with serious adverse events being reported.
The Food and Drug Administration issued a series of
statements on the safety of TVM and finally reclassified
TVM in prolapse repair into high-risk devices. The PROSPECT
multicentre RCT comparing traditional repair versus
synthetic mesh and biological grafts in >1000 women and
with 24-mo follow-up has recently been published
The results showed no benefit from TVM- or biological graft-
augmented pelvic floor repair over the traditional repair in
both patient-reported outcomes (at 2 yr) and objective
outcomes (at 1 yr). In addition, there were no significant
differences in serious adverse events, dyspareunia rates,
recurrence of prolapsed, or reoperation rates for prolapse.
However, 12% of women in the synthetic mesh group
underwent reoperations for management of mesh compli-
cations. The authors concluded that in absence of any
benefit, synthetic mesh-augmented pelvic floor repair as a
primary prolapse procedure may pose unnecessary risks;
however, they emphasised the importance of long-term
follow-up.
Depending on the patient’s individual characteristics, the
treatment of a uterine/apical prolapse can entail hyster-
opexy or colpopexy, or hysterectomy with colpopexy . A
variety of procedures exist for vault/uterine suspension for
women who are deemed fit for surgery; the two most
commonly performed procedures are sacrocolpopexy
(open/laparoscopic/robotic) and vaginal sacrospinous fixa-
tion (SSF). Other procedures include uterosacral vault
suspension and the rarely performed Infracoccygeal vaginal
sling (IVS).
Abdominal sacrocolpopexy (ASC) is the most durable
operation for advanced POP and serves as the criterion
standard with which other operations are compared
ASC involves attaching the vaginal apex to the
sacral anterior longitudinal ligament reinforced with a
graft, usually synthetic mesh . The Cochrane
review showed that compared with SSF, ASC was
associated with significantly fewer women being aware
of prolapse or requiring repeat surgery and lower rates
of postoperative dyspareunia. Long-term outcomes (7 yr)
for the well-designed CARE study reported that nearly
one-third of women who underwent ASC met their
composite definition of failure. The reoperation rate
was 16.7%—almost divided equally into one-third for
POP, one-third for SUI, and one-third for mesh-related
complications.
Colpocleisis (LeFort colpocleisis, colpectomy) is offered
to women with POP, who no longer wish to preserve
vaginal coital function. The technique consists of vaginal
closure +/– colpectomy. Colpocleisis is associated with high
success rates, and low recurrence and complication rates,
especially after the age of 80 yr
Uterine suspension using nonabsorbable sutures has
widely been reported by laparotomy or laparoscopy
. The use of strips of skin or fascia lata for
uterine and bladder suspension has also been described.
Abdominal uterosacral ligament suspension (colpopexy)
consists of suspending the vaginal apex (mainly following
concomitant hysterectomy) to the uterosacral ligaments,
using nonabsorbable or absorbable sutures, laparoscopically
or by laparotomy . It has been reported that
abdominal uterosacral ligament colpopexy (with concomi-
tant hysterectomy) was associated with an increased risk of
recurrence (6.2 times higher) when compared with ASC and
hysterectomy . The long-term anatomical and functional
outcomes, and the exact number and nature of complica-
tions, are, at this moment, not well studied for these
procedures.
4.1. Consensus view
In addition to a consensus discussion, careful consideration
of the European Commission’s Scientific Committee on
Emerging and Newly Identified Health Risks report on the
safety of surgical meshes used in urogynaecological surgery
was undertaken, and this consensus follows on from
and supports the deliberations of that panel.
A number of different types of potential materials can be
used in POP and SUI mesh surgery, which include the
following categories:
1. Allografts (eg, cadaveric fascia and dura mater)
2. Xenografts (eg, porcine and bovine)
3. Autografts (eg, fascia lata and rectus fascia)
4. Synthetic meshes (nonabsorbable, eg, PP mesh as well as
absorbable)
It is important to differentiate between the use of
synthetic MUSs for the treatment of SUI and large surface
areas of mesh for treating POP.
Based on the work with mesh in anterior abdominal
hernia repair, a classification of synthetic mesh material has
been reported A type 1 macroporous PP mesh has been
proposed as the most appropriate material for vaginal
implantation for SUI and POP, the principal characteristics
being that it should be monofilament with the pore size
being >75 microns. It is evident that a number of materials
had been evaluated in managing anterior abdominal wall
hernias until this classification was formulated. Careful
consideration needs to be given to the design and weave of
synthetic mesh materials, as these can have a significant
effect on efficacy and safety.
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