Traditional native tissue versus mesh-augmented pelvic organ prolapse repairs: providing an accurate interpretation of current literature

The double-edged sword of mesh use in pelvic organ prolapse surgery: a case report

Introduction

Pelvic organ prolapse (POP) is a prevalent condition among parous women, often warranting surgical intervention. This case accentuates the complications associated with mesh in POP surgeries, iterating the imperative need for an evidence-based approach towards its utilization and exhaustive patient counselling.

Case presentation

A 60-year-old female, post-mesh-augmented POP repair, embarked on a 13-year journey characterized by persistent pelvic pain and multiple interventions. Despite undergoing several surgeries across different countries, involving mesh and stone removals, her symptoms, notably pelvic pain and dyspareunia, persisted. Clinical examinations revealed mesh erosion into the perivesical tissue, bladder, and associated stones, which were addressed through multiple interventions, albeit with transient success.

Discussion

The complex journey of this patient exemplifies the intricate challenges mesh poses in POP surgeries. While mesh application offers a minimally invasive approach and has proven successful in numerous cases, it simultaneously opens a Pandora's box of potential severe complications, necessitating thorough patient counselling and post-surgery management.

Conclusion

The case delineates the challenging path that clinicians and patients tread when navigating through mesh-associated complications post-POP repair. Although mesh has been heralded as a revolutionary approach in POP surgeries, its potential drawbacks necessitate judicious application, ensuring clinicians are well-versed with its associated risks and are adept in managing ensuing complications.

Mesenchymal stem cell transplantation for vaginal repair in an ovariectomized rhesus macaque model

BACKGROUND

Current surgical therapies for pelvic organ prolapse (POP) do not repair weak vaginal tissue and just provide support; these therapies may trigger severe complications. Stem cell-based regenerative therapy, due to its ability to reconstruct damaged tissue, may be a promising therapeutic strategy for POP. The objective of this study is to evaluate whether mesenchymal stem cell (MSC) therapy can repair weak vaginal tissue in an ovariectomized rhesus macaque model.

METHODS

A bilateral ovariectomy model was established in rhesus macaques to induce menopause-related vaginal injury. Ten bilaterally ovariectomized rhesus macaques were divided into two groups (n=5/group): the saline group and the MSC group. Three months after ovariectomy, saline or MSCs were injected in situ into the injured vaginal wall. The vaginal tissue was harvested 12 weeks after injection for histological and biochemical analyses to evaluate changes of extracellular matrix, microvascular density, and smooth muscle in the vaginal tissue. Biomechanical properties of the vaginal tissue were assessed by uniaxial tensile testing. Data analysis was performed with unpaired Student's t test or Mann-Whitney.

RESULTS

Twelve weeks after MSC transplantation, histological and biochemical analyses revealed that the content of collagen I, elastin, and microvascular density in the lamina propria of the vagina increased significantly in the MSC group compared with the saline group. And the fraction of smooth muscle in the muscularis of vagina increased significantly in the MSC group. In addition, MSC transplantation improved the biomechanical properties of the vagina by enhancing the elastic modulus.

CONCLUSION

Vaginal MSC transplantation could repair the weak vaginal tissue by promoting extracellular matrix ingrowth, neovascularization, and smooth muscle formation and improve the biomechanical properties of the vagina, providing a new prospective treatment for POP.

Motion of the vaginal apex during strain and defecation

INTRODUCTION AND HYPOTHESIS

Although the main function of the suspensory ligaments of the vaginal apex is to prevent its descent toward the vaginal introitus, there remains limited information regarding its normal physiological motion. This study was aimed at quantifying the motion of the non-prolapsed vaginal apex during strain and defecation maneuvers.

METHODS

This study represents a sub-analysis of a parent study that was aimed at evaluating rectal mobility with regard to obstructed defecation symptoms. Patients with normal apical vaginal support who had undergone MR defecography were entered into the study. For each patient, midsagittal images at rest, maximum strain, and maximum evacuation were utilized. The location of the cervicovaginal junction, S4-S5 intervertebral disc, sacral promontory, and hymen were identified. Vectors were calculated from each of these landmarks to the vaginal apex to compare vector angles and magnitudes across subjects.

RESULTS

Twelve patients were included in this study. At rest, the vagina extends from the hymen, which is inferior and posterior to the inferior symphysis pubis, to the vaginal apex at an angle of 45.2° ± 14.5° relative to the pubococcygeal line. This angle became more acute with strain and even more so during maximum evacuation (14.1° ± 9.0°, p < 0.001). Differences in the vector magnitude, although not statistically significant, showed a trend indicating shorter lengths with maximum evacuation.

CONCLUSIONS

The vaginal apex is a highly mobile structure demonstrating significantly more mobility during defecation compared with strain. The data obtained contradict the general perception that the vaginal apex is relatively fixed within the pelvis of normally supported women.

Pelvic floor muscle weakness: a risk factor for anterior vaginal wall prolapse recurrence

INTRODUCTION AND HYPOTHESIS

Native tissue vaginal repairs are associated with relatively high levels of recurrence. Systematic reviews have noted that preoperative pelvic floor muscle strength was associated with increased risk of recurrence in the short term.

METHODS

This is a retrospective review of patients who underwent a primary reconstructive surgery for anterior compartment vaginal prolapse between 2001 and 2015. Patients were divided into "absent," "weak" and "good" preoperative PFM strength (aPFM, wPFM and gPFM, respectively) based on a modified Oxford scale. Failure rates were determined by a composite of subjective and objective anatomic outcomes. Subjects who underwent re-operations or procedures for recurrent prolapse of the anterior compartment were considered failures. A p value < 0.05 was considered statistically significant.

RESULTS

Two hundred ninety-nine patients were included. The aPFM (n = 36), wPFM (n = 115) and gPFM (n = 148) groups had similar descriptive statistics, except subjects in the aPFM and wPFM groups were significantly older than the gPFM group (p = 0.008). All groups underwent similar reconstructive surgeries. Average length of follow-up of 143.9 weeks (41 to 717 weeks) was similar among the three groups (p = 0.472). For the primary outcome of composite failure, aPFM had significantly more anterior vaginal wall recurrences than both the wPFM and gPFM groups, 13.89% vs. 3.48% and 4.05%, respectively (p = 0.033).

CONCLUSIONS

Patients with preoperative absent pelvic floor muscle strength (nonfunctioning PFM) had a significantly higher anterior vaginal wall recurrence rate than those with weak or good pelvic floor muscle strength.

Pelvic floor muscle function and quality of life in postmenopausal women with and without pelvic floor dysfunction

INTRODUCTION

This study aims to compare pelvic floor muscle (PFM) function in postmenopausal women with and without pelvic floor dysfunction (PFD) and the relation between PFM function and quality of life.

MATERIAL AND METHODS

A case-control study with 216 postmenopausal women with (n = 126) and without (n = 90) PFD. PFM function was assessed by digital vaginal palpation using the PERFECT scale. Specific quality of life was evaluated using the King's Health Questionnaire for women with urinary incontinence and the Prolapse Quality-of-Life Questionnaire for women with pelvic organ prolapse. We analyzed women with PFD into two categories: Oxford's grade ≤2 or ≥3 using a chi-squared test.

RESULTS

Out of 126 womem with PFD 44 (34.9%) presented stress urinary incontinence, 21 (16.6%) had pelvic organ prolapse and 61 (48.4%) had urinary incontinence + pelvic organ prolapse. Strength had a median value 2 (0-5) in all women studied and most of them had insufficient strength, reduced endurance and repetition without statistical difference between groups. Incontinent women with strength ≤2 had worse perception of general health domain of King's Health Questionnaire (p = 0.007). No association was found between PFM function and Prolapse Quality-of-Life Questionnaire.

CONCLUSIONS

PFM function assessed by bidigital palpation in postmenopausal women was not sufficiently sensitive to differentiate between women with vs. women without PFM dysfunction and was not related with specific quality of life in women with urinary incontinence and pelvic organ prolapse, respectively. These data should be used to reinforce the widespread recommendation that PFM training is essencial in PFD treatment.

Host inflammatory response to polypropylene implants: insights from a quantitative immunohistochemical and birefringence analysis in a rat subcutaneous model

Objectives

To describe acute and sub acute aspects of histological and immunohistochemical response to PP implant in a rat subcutaneous model based on objective methods.

Materials and Methods

Thirty rats had a PP mesh subcutaneously implanted and the same dissection on the other side of abdomen but without mesh (sham). The animals were euthanized after 4 and 30 days. Six slides were prepared using the tissue removed: one stained with hematoxylin-eosin (inflammation assessment); one unstained (birefringence evaluation) and four slides for immunohistochemical processing: IL-1 and TNF-α (pro-inflammatory cytokines), MMP-2 (collagen metabolism) and CD-31 (angiogenesis). The area of inflammation, the birefringence index, the area of immunoreactivity and the number of vessels were objectively measured.

Results

A larger area of inflammatory reaction was observed in PP compared to sham on the 4th and on the 30^th day (p=0.0002). After 4 days, PP presented higher TNF (p=0.0001) immunoreactivity than sham and no differences were observed in MMP-2 (p=0.06) and IL-1 (p=0.08). After 30 days, a reduction of IL-1 (p=0.010) and TNF (p=0.016) for PP and of IL-1 (p=0.010) for sham were observed. Moreover, area of MMP-2 immunoreactivity decreased over time for PP group (p=0.018). Birefringence index and vessel counting showed no differences between PP and sham (p=0.27 and p=0.58, respectively).

Conclusions

The implantation of monofilament and macroporous polypropylene in the subcutaneous of rats resulted in increased inflammatory activity and higher TNF production in the early post implant phase. After 30 days, PP has similar cytokines immunoreactivity, vessel density and extracellular matrix organization.

A preclinical evaluation of polypropylene/polylacticacid hybrid meshes for fascial defect repair using a rat abdominal hernia model

OBJECTIVES

Synthetic mesh surgery for both abdominal and urogenital hernia repair is often unsatisfactory in the long-term due to postoperative complications. We hypothesized that a semi-degradable mesh hybrid may provide more appropriate biocompatibility with comparable mechanical properties. The aim was to compare its in vivo biocompatibility with a commercial polypropylene (PP) mesh.

METHODS

72 rats were randomly allocated to either our new composite mesh (monofilament PP mesh knitted with polylactic-acid-fibers (PLA)) or to a commercially available PP mesh that was used as a control. 15, 90, and 180 days after implantation into the rat abdomen mesh tissue complexes were analysed for erosion, contraction, foreign body reaction, tissue integration and biomechanical properties.

RESULTS

No differences were seen in regard to clinical parameters including erosion, contraction or infection rates between the two groups. Biomechanical properties including breaking load, stiffness and deformation did not show any significant differences between the different materials at any timepoint. Macrophage staining did not reveal any significant differences between the two groups or between timepoints either. In regard to collagen I there was significantly less collagen I in the PP group compared to the PP/ PLA group at day 180. Collagen III did not show any significant differences at any timepoint between the two groups.

CONCLUSION

A PP/PLA hybrid mesh, leaving a low amount of PP after PLA degradation seems to have comparable biomechanical properties like PP at 180 days due to enhanced collagen production without significant differences in erosion, contraction, herniation or infection rates.

Endometrial mesenchymal stem cells as a cell based therapy for pelvic organ prolapse

Pelvic organ prolapse (POP) occurs when the pelvic organs (bladder, bowel or uterus) herniate into the vagina, causing incontinence, voiding, bowel and sexual dysfunction, negatively impacting upon a woman’s quality of life. POP affects 25% of all women and results from childbirth injury. For 19% of all women, surgical reconstructive surgery is required for treatment, often augmented with surgical mesh. The surgical treatment fails in up to 30% of cases or results in adverse effects, such as pain and mesh erosion into the bladder, bowel or vagina. Due to these complications the Food and Drug Administration cautioned against the use of vaginal mesh and several major brands have been recently been withdrawn from market. In this review we will discuss new cell-based approaches being developed for the treatment of POP. Several cell types have been investigated in animal models, including a new source of mesenchymal stem/stromal cells (MSC) derived from human endometrium. The unique characteristics of endometrial MSC, methods for their isolation and purification and steps towards their development for good manufacturing practice production will be described. Animal models that could be used to examine the potential for this approach will also be discussed as will a rodent model showing promise in developing an endometrial MSC-based therapy for POP. The development of a preclinical large animal model for assessing tissue engineering constructs for treating POP will also be mentioned.

In vivo response to polypropylene following implantation in animal models: a review of biocompatibility

INTRODUCTION AND HYPOTHESIS

Polypropylene is a material that is commonly used to treat pelvic floor conditions such as pelvic organ prolapse (POP) and stress urinary incontinence (SUI). Owing to the nature of complications experienced by some patients implanted with either incontinence or prolapse meshes, the biocompatibility of polypropylene has recently been questioned. This literature review considers the in vivo response to polypropylene following implantation in animal models. The specific areas explored in this review are material selection, impact of anatomical location, and the structure, weight and size of polypropylene mesh types.

METHODS

All relevant abstracts from original articles investigating the host response of mesh in vivo were reviewed. Papers were obtained and categorised into various mesh material types: polypropylene, polypropylene composites, and other synthetic and biologically derived mesh.

RESULTS

Polypropylene mesh fared well in comparison with other material types in terms of host response. It was found that a lightweight, large-pore mesh is the most appropriate structure.

CONCLUSION

The evidence reviewed shows that polypropylene evokes a less inflammatory or similar host response when compared with other materials used in mesh devices.

The natural history of cystocele recurrence

INTRODUCTION AND HYPOTHESIS

Female pelvic organ prolapse is a common condition, and recurrence after surgery is considered a significant clinical issue, especially in the anterior compartment. To the best of our knowledge, there are currently no published data in the literature on the timing of recurrence. We used data obtained in clinical audit projects and a prospective surgical trial to define the natural history of cystocele recurrence.

METHODS

This is an observational retrospective study utilising data of 166 patients seen at least twice after anterior colporrhaphy, obtained from four clinical audit projects and one prospective surgical trial.

RESULTS

We identified a total of 481 postoperative visits at a mean follow-up of 1.11 years in 166 individuals. At last available follow-up, 80 (48%) had evidence of cystocele recurrence (ICS POP-Q stage 2+), and 44 (27%) reported symptoms of prolapse. Ultrasound evidence of cystocele recurrence was seen in 74 women (45%). Regression modelling demonstrated that the likelihood of recurrence was highest between 1 and 2 years' follow-up.

CONCLUSIONS

Cystocele recurrence after anterior colporrhaphy seems to be a relatively early phenomenon, with maximum prevalence reached at 18-24 months.

Human endometrial mesenchymal stem cells modulate the tissue response and mechanical behavior of polyamide mesh implants for pelvic organ prolapse repair

BACKGROUND

Pelvic organ prolapse (POP) is defined as the descent of one or more of the pelvic structures into the vagina and includes uterine, vaginal vault, and anterior or posterior vaginal wall prolapse. The treatment of POP may include implantation of a synthetic mesh. However, the long-term benefit of mesh surgery is controversial due to complications such as mesh exposure or pain. The aim of this study was to use a tissue engineering (TE) approach to assess the in vivo biological and biomechanical behavior of a new gelatin/polyamide mesh, seeded with a novel source of mesenchymal stem cells in a subcutaneous rat model of wound repair.

METHODS

W5C5-enriched human endometrial mesenchymal stem cells (eMSC) were seeded onto meshes (gelatin-coated polyamide knit) at 100,000 cells/cm². Meshes, with or without cells were subcutaneously implanted dorsally in immunocompromised rats for 7, 30, 60, and 90 days. Flow cytometry was used to detect DiO labeled cells after explantation. Immunohistochemical assessment of foreign body reaction and tissue integration were conducted. Total collagen and the levels of collagens type III and type I were determined. Uniaxial tensiometry was performed on explanted meshes, originally seeded with and without cells, at days 7 and 90.

RESULTS

Implanted meshes were well tolerated, with labeled cells detected on the mesh up to 14 days postimplantation. Meshes with cells promoted significantly more neovascularization at 7 days (p<0.05) and attracted fewer macrophages at 90 days (p<0.05). Similarly, leukocyte infiltration was significantly lower in the cell-seeded meshes at 90 days (p<0.05). Meshes with cells were generally less stiff than those without cells, after 7 and 90 days implantation.

CONCLUSION

The TE approach used in this study significantly reduced the number of inflammatory cells around the implanted mesh and promoted neovascularization. Seeding with eMSC exerts an anti-inflammatory effect and promotes wound repair with new tissue growth and minimal fibrosis, and produces mesh with greater extensibility. Cell seeding onto polyamide/gelatin mesh improves mesh biocompatibility and may be an alternative option for future treatment of POP.

Surgical repair of pelvic organ prolapse and follow-up: An institutional multi-center experience

AIM: To investigate the effects of the Elevate Anterior and Posterior transvaginal mesh procedure on 30 patients affected by pelvic organ prolapse (POP) at 12 mo follow-up.

METHODS: Between September 2011 and September 2012, a prospective multicenter observational study enrolled 30 consecutive patients with POP-Q ≥ stage II. After a preoperative evaluation, patients underwent prolapse repair utilizing the Elevate Anterior and Posterior Prolapse Repair System (American Medical Systems, Minnetonka, MN, United States). Operative technique was standardized and performed by the same surgical team under spinal or general anesthesia. Patients were evaluated postoperatively at 1, 3, 6 and 12 mo.

RESULTS: All 30 patients completed the 12 mo follow-up. The mean age was 65.3 years (range 49-81 years) and average hospital stay was 4.5 d. The mean operative time was 65 min (range 40-120 min). Related adverse events reported were mesh extrusions (6.7%) and post void residual urine volume (13.3%). There were no visceral injuries, no infection of the mesh, and no symptoms of recurrent prolapse. All quality-of-life scores significantly improved from baseline.

CONCLUSION: One year’s follow-up of our 30 patients confirms the safety and the efficacy of the Elevate Anterior and Posterior transvaginal mesh procedure for POP treatment. Our final results are comforting but longer term follow-up is ongoing.

Laparoscopic hysteropexy: 1- to 4-year follow-up of women postoperatively

INTRODUCTION AND HYPOTHESIS

Uterine conserving re-suspension surgery has become more popular in recent years. Such surgery may allow preservation of fertility in younger women, but may also have the added benefit of augmenting weak connective tissue and possibly providing stronger apical support than the conventional hysterectomy. Our goal was to evaluate the 1- to 4-year outcome of laparoscopic hysteropexy for the surgical management of uterine prolapse.

METHODS

This study was a prospective observational study of 182 consecutive women who underwent laparoscopic hysteropexy, with or without additional vaginal repair, from the beginning of 2007 until the end of 2010. Women were invited to attend a dedicated clinic for interview and their prolapse was assessed using the Patient Global Impression of Improvement (PGI-I), the International Consultation on Incontinence Questionnaire for Vaginal Symptoms (ICIQ-VS) and the pelvic organ prolapse quantification (POP-Q) scale. Wilcoxon signed-rank test was used to compare pre-operative with postoperative data. Complications and women's satisfaction were also noted.

RESULTS

One hundred and forty women agreed to participate; the mean interval from operation was 2.1 years (range 1-4.4). Eighty-nine percent of women felt that their prolapse is "very much" or "much" better using PGI-I subjective outcome measure. There was significant improvement for all parameters of ICIQ-VS and POP-Q scoring post-surgery (p < 0.001). Six women (4 %) had further apical prolapse; of these, 3 underwent further prolapse surgery. None of the participants had any mesh exposure. Ninety two percent of participants would recommend the operation.

CONCLUSIONS

Laparoscopic hysteropexy is a safe and effective treatment. The 1- to 4-year outcome suggests high patient satisfaction and low rates of apical prolapse recurrence. Longer term follow-up and randomized controlled studies are required.

Where to for pelvic organ prolapse treatment after the FDA pronouncements? A systematic review of the recent literature

INTRODUCTION

With the publication of the updated US Food and Drug Administration (FDA) communication in 2011 on the use of transvaginal placement of mesh for pelvic organ prolapse (POP) it is appropriate to now review recent studies of good quality on POP to assess the safety and effectiveness of treatment options and determine their place in management.

METHODS

A systematic search for studies on the conservative and surgical management of POP published in the English literature between January 2002 and October 2012 was performed. Studies included were review articles, randomized controlled trials, prospective and relevant retrospective studies as well as conference abstracts. Selected articles were appraised by the authors regarding clinical relevance.

RESULTS

Prospective comparative studies show that vaginal pessaries constitute an effective and safe treatment for POP and should be offered as first treatment of choice in women with symptomatic POP. However, a pessary will have to be used for the patient's lifetime. Abdominal sacral colpopexy is effective in treating apical prolapse with an acceptable benefit-risk ratio. This procedure should be balanced against the low but non-negligible risk of serious complications. The results of native tissue vaginal POP repair are better than previously thought with high patient satisfaction and acceptable reoperation rates. The insertion of mesh at the time of anterior vaginal wall repair reduces the awareness of prolapse as well as the risk of recurrent anterior prolapse. There is no difference in anatomic and subjective outcome when native tissue vaginal repairs are compared with multicompartment vaginal mesh. Mesh exposure is still a significant problem requiring surgical excision in approximately ≥ 10 % of cases. The ideal mesh has not yet been found necessitating more basic research into mesh properties and host response. Several studies indicate that greater surgical experience is correlated with fewer mesh complications. In women with uterovaginal prolapse uterine preservation is a feasible option which women should be offered. Randomized studies with long-term follow-up are advisable to establish the place of uterine preservation in POP surgery.

CONCLUSION

Over the last decade treatment of POP has been dominated by the use of mesh. Conservative treatment is the first option in women with POP. Surgical repair with or without mesh generally results in good short-term objective and functional outcomes. However, basic research into mesh properties with host response and comparative studies with long-term follow-up are urgently needed.

A preclinical evaluation of alternative synthetic biomaterials for fascial defect repair using a rat abdominal hernia model

INTRODUCTION

Fascial defects are a common problem in the abdominal wall and in the vagina leading to hernia or pelvic organ prolapse that requires mesh enhancement to reduce operation failure. However, the long-term outcome of synthetic mesh surgery may be unsatisfactory due to post-surgical complications. We hypothesized that mesh fabricated from alternative synthetic polymers may evoke a different tissue response, and provide more appropriate mechanical properties for hernia repair. Our aim was to compare the in vivo biocompatibility of new synthetic meshes with a commercial mesh.

METHODS

We have fabricated 3 new warp-knitted synthetic meshes from different polymers with different tensile properties polyetheretherketone (PEEK), polyamide (PA) and a composite, gelatin coated PA (PA+G). The rat abdominal hernia model was used to implant the meshes (25 × 35 mm, n = 24/ group). After 7, 30, 60, 90 days tissues were explanted for immunohistochemical assessment of foreign body reaction and tissue integration, using CD31, CD45, CD68, alpha-SMA antibodies. The images were analysed using an image analysis software program. Biomechanical properties were uniaxially evaluated using an Instron Tensile® Tester.

RESULTS

This study showed that the new meshes induced complex differences in the type of foreign body reaction over the time course of implantation. The PA, and particularly the composite PA+G meshes, evoked a milder early inflammatory response, and macrophages were apparent throughout the time course. Our meshes led to better tissue integration and new collagen deposition, particularly with the PA+G meshes, as well as greater and sustained neovascularisation compared with the PP meshes.

CONCLUSION

PA, PA+G and PEEK appear to be well tolerated and are biocompatible, evoking an overlapping and different host tissue response with time that might convey mechanical variations in the healing tissue. These new meshes comprising different polymers may provide an alternative option for future treatment of fascial defects.

Outcomes after anterior vaginal wall repair with mesh: a randomized, controlled trial with a 3 year follow-up

Introduction and hypothesis

The aim of the study was to compare the efficacy and safety of transvaginal trocar-guided polypropylene mesh insertion with traditional colporrhaphy for treatment of anterior vaginal wall prolapse.

Methods

This is a randomized controlled trial in which women with advanced anterior vaginal wall prolapse, at least stage II with Ba ≥ +1 cm according to the Pelvic Organ Prolapse Quantification (POP-Q) classification, were randomly assigned to have either anterior colporrhaphy (n = 39) or repair using trocar-guided transvaginal mesh (n = 40). The primary outcome was objective cure rate of the anterior compartment (point Ba) assessed at the 12-month follow-up visit, with stages 0 and I defined as anatomical success. Secondary outcomes included quantification of other vaginal compartments (POP-Q points), comparison of quality of life by the prolapse quality of life (P-QOL) questionnaire, and complication rate between the groups after 1 year. Study power was fixed as 80 % with 5 % cutoff point (p < 0.05) for statistical significance.

Results

The groups were similar regarding demographic and clinical preoperative parameters. Anatomical success rates for colporrhaphy and repair with mesh placement groups were 56.4 vs 82.5 % (95 % confidence interval 0.068–0.54), respectively, and the difference between the groups was statistically significant (p = 0.018). Similar total complication rates were observed in both groups, with tape exposure observed in 5 % of the patients. There was a significant improvement in all P-QOL domains as a result of both procedures (p < 0.001), but they were not distinct between groups (p > 0.05).

Conclusions

Trocar-guided transvaginal synthetic mesh for advanced anterior POP repair is associated with a higher anatomical success rate for the anterior compartment compared with traditional colporrhaphy. Quality of life equally improved after both techniques. However, the trial failed to detect differences in P-QOL scores and complication rates between the groups.