Review The role of synthetic mesh in the treatment of pelvic organ prolapse

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1 /toag The role of synthetic mesh in the treatment of pelvic organ prolapse Authors Priscilla Devaseelan / Paul Fogarty Key content: Genital prolapse is a common indication for surgery and 30% of women treated with conventional surgery will develop recurrence of symptoms. Innovative surgical repair techniques and systems are emerging but the search continues for the ideal procedure with guaranteed permanent success. There is a general paucity of evidence to assist the surgeon in selecting the optimal approach. This article addresses the role of different approaches to synthetic mesh repair in pelvic organ prolapse, their success rate and their short- and long-term morbidity. Learning objectives: To understand the properties of synthetic mesh and the body s response. To understand the possible roles of synthetic mesh in pelvic organ prolapse. To be aware of the indications for use and the limitations and complications of the uses of mesh in pelvic organ prolapse. Ethical issues: The use of synthetic mesh has not been fully evaluated in randomised controlled trials but has been widely adopted into clinical practice. Is this an example of novelty triumphing over clinical evidence? Keywords erosion / pelvic floor surgery / pelvic organ prolapse / repair / synthetic mesh Please cite this article as: Devaseelan P, Fogarty P. The role of synthetic mesh in the treatment of pelvic organ prolapse. The Obstetrician & Gynaecologist 177. Author details Priscilla Devaseelan MD DNB MRCOG Specialist Registrar Royal Jubilee Maternity Service, Grosvenor Road, Belfast BT12 6BA, Northern Ireland, UK priscilla.devaseelan@gmail.com (corresponding author) Paul Fogarty MD FRCOG Consultant Obstetrician and Gynaecologist Ulster Hospital, South Eastern Health and Social Care Trust, Upper Newtownards Road, Dundonald, Belfast BT16 1RH, Northern Ireland, UK (1 of 9) 169

2 The Obstetrician & Gynaecologist Box 1 Aims of surgery for pelvic organ prolapse (2 of 9) Introduction Pelvic organ prolapse is an increasingly common indication for surgery. The lifetime risk of surgery for prolapse is 11%. 1 Unfortunately, surgery has a significant failure rate and in the longer term is associated with a recurrence rate of 25 30%. 2 The ideal procedure should be safe, effective, long lasting, free of any morbidity, cost-effective and provide normalisation of function with patient satisfaction (Box 1). There has been a recent surge in the use of synthetic mesh for prolapse, driven, at least in part, by new materials being promoted by industry. This article reviews the uses and limitations of synthetic mesh and its applications in prolapse surgery. It is based on a review of articles identified on MEDLINE ( ) using a combination of the search terms synthetic mesh, pelvic organ prolapse, repair and erosion. The connective tissues of the vagina and supportive tissues are in a constant state of flux. Active remodelling occurs in pregnancy, menopause and with the use of hormone replacement therapy. 3 Childbirth is a common cause of trauma to the pelvic floor. In addition to pudendal nerve injury, it has also been shown to cause damage to levator ani and fascial supports such as the rectovaginal septum. 4 Hence, the rate of vaginal prolapse increases with ageing and is compounded by a lack of estrogen and any previous trauma. Why use mesh? The use of mesh in prolapse surgery is increasing despite a lack of clinical safety data or compelling clinical evidence demonstrating an improved outcome compared with traditional suturing techniques. 5 Nevertheless, a wide range of mesh materials is now available and marketed. Although the idea of incorporating mesh in prolapse repairs was borrowed from general surgeons who use mesh for hernia repair, there are important differences. The mesh of a ventral hernia is not subject to the same external stress as a vaginal mesh, particularly during intercourse. Furthermore, the mesh used in hernia repair is completely covered by the full thickness of the abdominal wall, whereas vaginal mesh, lying in a nonsterile environment, is only covered by thin, often postmenopausal, Relief from prolapse symptoms Long-term restoration of normal anatomy and function Maintenance or improvement of bladder and bowel function Maintenance of sexual function Prevention of surgery-related bladder, bowel and sexual problems vaginal mucosa. 6 The aim of using mesh in prolapse repair surgery is to provide additional support and reduce risk of recurrence, especially in women with recurrent prolapse or those with connective tissue disorders. 7 The ideal mesh should be biocompatible, inert, inexpensive, induce minimal inflammatory response and, at the same time, act as a scaffold to facilitate fibrous tissue ingrowth, be resistant to infection, avoid shrinkage and be easy to handle. 2 Classification and selection of mesh The response of the body to synthetic mesh varies depending on the route of insertion (abdominal or vaginal), the properties of the mesh and the woman s age and the efficiency of her immune system. The immune system seems to respond to synthetic meshes by a chronic inflammatory process with the production of foreign body giant cells, macrophages and lymphocytes. Meshes removed surgically because of complications show acute and chronic inflammatory responses with neutrophils and lymphocytes, in contrast to meshes without complications, which only show chronic inflammation. 2 In fact, all complications of mesh such as poor healing, infection, extrusion and rejection, can be viewed as an acute-on-chronic reaction of the immune system to a foreign graft. More research into the body s response to synthetic mesh will aid in the development of the ideal mesh. Prosthetic materials for prolapse repair can be biological, synthetic or combined. Biological mesh Biological materials are either autologous grafts from the patient (rectus fascia, fascia lata or vaginal mucosa), allografts (dura mater, fascia lata and dermis from harvested human cadavers) or xenografts (porcine or bovine dermis or small intestinal submucosa). 8 Although the risk of mesh extrusion or exposure (previously described as erosion but, as there is no consensus as to whether aetiology is actually infective or erosive, it is referred to as extrusion in this article) is lower with biological materials, there are problems with infection, graft versus host reaction and higher failure rates. Synthetic mesh Synthetic mesh has the advantages of high tensile strength, decreased potential for disease transmission, ready availability and cost-effectiveness. 9 A variety of prosthetic materials are available for transvaginal prolapse surgery. Synthetic meshes are broadly divided into absorbable, nonabsorbable and mixed. Absorbable meshes have the advantage of being less susceptible

3 to infection or rejection but have the distinct disadvantage of losing tensile strength once absorbed. Most absorbable meshes are made of polyglycolic acid and polyglactin 910. Absorbable meshes, as evaluated in randomised trials, were found to be associated with high recurrence rates in prolapse surgery and are not popular. Nonabsorbable synthetic meshes include nylon, silicone, polytetrafluoroethylene, polyester and polypropylene forms. Boulanger et al. 10 showed that tissue integration was best with polypropylene meshes, which allowed the formation of mature, well-organised connective tissue. The mechanical properties of the synthetic mesh depend on the structure of the fabric and the thread. The tensile strength of permanent synthetic mesh is highly variable, depending on fibre type, weight:area ratio and weave. To increase versatility, materials can be structured from monofilament or multifilament fibres, which can be twisted, coated, braided or double-braided. Furthermore, implants can have perforations and be moulded into various shapes. These materials can be woven, knitted, or unwoven. The advantages of woven materials include strength and good memory, whereas the disadvantages include fraying and poor conformity. The advantages of knitted materials include flexibility, versatility and high conformity. Unwoven materials are well absorbed but have the disadvantages of nonconformity and poor visibility. 11 Both absorbable and nonabsorbable meshes can be multifilament or monofilament. Multifilament meshes have interstices within the filaments, measuring 10 m, which can allow bacteria but not the host immune cells, to pass through, thereby restricting the host s ability to combat infection within the mesh. It has been shown that multifilament mesh produces more fibrosis and acute inflammation than their monofilament counterparts. 12 Synthetic meshes can be further classified according to their pore size, which denotes the size of the perforations between the threads, into macroporous ( 75 m pore size) and microporous ( 10 m). Pore size determines which cells enter the mesh and can be an important mesh characteristic. Macroporous mesh allows not only bacteria to enter but also macrophages, fibroblasts and blood vessels, thereby preventing mesh infection and allowing fibrous ingrowth. They are also more flexible. revealed no studies to demonstrate its superiority over the other mesh types. Amid 11 classified synthetic meshes according to their pore size and fibre type. Type I: knitted monofilament type with large pores and good elasticity hence they are easier to work with (Figure 1). They allow macrophages, fibroblasts (which are 75 m) and bacteria (1 2 m) to enter. Thus infection and adhesions are a problem but infections can be treated without removal of mesh. 13 Theoretically, this is the best implant as it promotes host defences. Type II: knitted multifilament mesh with small interstices ( 75 m) and reduced elasticity. They prevent adhesions but infections are difficult to treat as antibiotics and white blood cells cannot penetrate, thus necessitating removal of the mesh. Type III: nonknitted, nonwoven multifilament type with large pores, small interstices and restricted elasticity. They allow bacteria to infiltrate but not macrophages; infection can be a problem. Type II and III meshes result in a greater foreign body reaction than Type I. Type IV: coated biomaterial that contains pores of 1 m. Often used for adhesion prevention in abdominal surgery; not used in gynaecological surgery. Comparative studies or case series with results beyond 1 2 years have not demonstrated the superiority of one type of mesh over another. Debodinance et al. 14 studied the efficacy and morbidity of various synthetic meshes and concluded that there was insufficient evidence to draw any definite conclusions regarding choice of mesh. De Tayrac et al., 15 in their prospective multicentre trial using synthetic polypropylene mesh protected by a hydrophilic absorbable film for vaginal repair, reported less vaginal mesh extrusion and fewer cases of dyspareunia at 1 year but long-term data are awaited. Figure 1 Types of meshes and their properties. Original picture kindly supplied by Dr Kaven Baessler, Charité Universitätsmedizin Berlin, Germany Combined mesh In an attempt to reduce the complications of synthetic mesh and to maximise the advantages of both types, biosynthetic meshes have now been developed. However, a review of the literature has (3 of 9)

4 The Obstetrician & Gynaecologist Figure 2 Abdominal sacrocolpopexy showing mesh attachment from the sacrum to the vaginal vault Figure 3 Position of mesh in laparoscopic sacrocolpopexy. Copyright Miklos/Moore, Atlanta Urogynaecology Associates; from Reproduced with permission Use of mesh in abdominal surgery Abdominal sacrocolpopexy In this operation a piece of fascia or Y-shaped mesh is attached from the anterior longitudinal ligament overlying the sacral promontory to the vaginal vault and for a variable distance down the anterior and posterior vaginal walls (Figure 2). Some surgeons prefer to attach the mesh to the anterior abdominal wall. Excellent long-term data exist for the use of synthetic mesh in sacrocolpopexy. The abdominal approach seems best when the vagina has been shortened as a result of previous repairs or when there is obvious failure of compensatory support mechanisms of the pelvis, as in prolapse in the very young woman. 16 In a comprehensive review of 98 articles, Nygaard et al. 17 reported success rates ranging from % with an extrusion rate of 3.4%. This procedure is considered to be the gold standard in vault (apical) prolapse repair. In a Cochrane review on surgical management of pelvic organ prolapse, Maher et al. 18 concluded that abdominal sacrocolpopexy was more effective than vaginal sacrospinous colpopexy in reducing recurrent vault prolapse (4% versus 15%) and in preventing postoperative dyspareunia and stress incontinence. Abdominal sacrocolpopexy, however, does require a longer operating time with a delayed return to normal activities. In a randomised controlled trial 19 comparing autologous fascia with synthetic mesh, objective failure was reported in 32% in the fascia group compared with 9% in the mesh group at 12 months. In another study 20 comparing xenograft with synthetic mesh, 29% had recurrent prolapse in the xenograft group at 7 months compared with 24% in the synthetic mesh group (P 0.4). The adverse effects included mesh extrusion and infection, bowel obstruction, bleeding from presacral vessels and bowel and bladder perforation. Rates of mesh extrusion increased if the mesh was introduced through the vaginal route. Long-term data on the efficacy and complications of different types of mesh would be useful, although biological meshes seem to be less effective than synthetic ones. 8 Sacrohysteropexy This is an option for uterovaginal prolapse in young women who wish to retain their uterus. It involves attaching a piece of mesh from the uterine isthmus to the anterior longitudinal ligament of the first or second sacral vertebra in a tension-free manner. The mesh can be extended to correct concurrent cystocele or rectocele. Another technique involves attaching the mesh to the front of the cervix and to the ileopectineal ligaments. Barranger et al. 21 followed up 30 women who underwent sacrohysteropexy for a mean period of 44 months and found this to be a safe and effective option for women of childbearing age, with a 6% risk of recurrence. The National Institute for Health and Clinical Excellence (NICE) is examining insertion of mesh uterine suspension sling procedures and its guidance is currently under consultation. Use of mesh in laparoscopic surgery Laparoscopic sacrocolpopexy This procedure was first described by Nezhat et al. 22 It involves attaching a piece of mesh or fascia from the vaginal vault to the sacral promontory, in what is essentially the same technique as with the open method (Figure 3). There is an associated risk of injury to the bowel, bladder, ureters and iliac and presacral vessels. The posterior cul-de-sac is closed, as in the open method. This technique, although providing excellent visualisation, requires considerable surgical skill and the operating time is longer. It is associated with less postoperative pain and a shorter hospital stay and is suitable for elderly women. 23 Ross et al. 24 showed an objective cure rate of 93% at 5 years. When compared to the open method, the laparoscopic route has a comparable clinical outcome 25 with mesh extrusion rates of 6%. 26 The (4 of 9)

5 preferred route should, therefore, be individualised according to the woman s needs and the skills of the surgeon. Di Marco et al. 27 described preliminary reports with robot-assisted laparoscopic prolapse repair using a silicone mesh. They performed sacrocolpopexy and culdoplasty in five women with post-hysterectomy vaginal vault prolapse. All of the women were discharged after 24 hours and no major complications were reported. They concluded that robotic surgery aided precise intracorporeal suture placement. Good-quality evidence from randomised trials is lacking and until proper evidence is available it remains to be seen if robotic surgery, with its associated expense, will supersede other approaches. Use of mesh in vaginal surgery In an attempt to improve the success rate of traditional vaginal prolapse repair, a variety of synthetic materials have been used in both the anterior and posterior compartments. With the success of monofilament polypropylene mesh in midurethral tapes for stress incontinence, the same mesh has been adapted for use in prolapse surgery. When synthetic meshes were first used in vaginal surgery they were cut to the desired shape, placed in the anterior or posterior compartment and sutured in place (Figure 4 and Figure 5). Various factors affect the occurrence of mesh extrusion after vaginal prolapse surgery.atchari et al. 28 found that less surgical experience and advanced patient age increased the risk of extrusion. In addition, the type of surgery (whether primary or secondary repair) and performing concurrent hysterectomy also influence mesh extrusion rates. In the recent NICE guideline 7 based on the systematic review by Jia et al. 29 on efficacy and safety of use of mesh in vaginal surgery, the objective failure rate in the anterior compartment was 29% without mesh, 23% with absorbable synthetic mesh and 9% for nonabsorbable synthetic mesh. There was no significant difference in objective failure rate in the posterior compartment with or without mesh. For combined repair, the objective failure rate was 25% without mesh and 6 8% with absorbable synthetic mesh. There was, however, a lack of long-term data and uncertainty about recurrence rates with mesh. Table 1 summarises the various synthetic graft materials used in the anterior compartment, their success rates and morbidity, and Table 2 in the posterior compartment. The above studies report an anatomical cure rate with synthetic mesh in the anterior compartment of between 75 97%, although the randomised controlled trial by Weber et al. 31 reported a low success rate of 42%, suggesting that the addition of synthetic mesh offered no advantage. Apart from Figure 4 Mesh in anterior compartment Figure 5 Mesh in posterior compartment (5 of 9)

6 The Obstetrician & Gynaecologist Table 1 Repair of anterior compartment prolapse with synthetic mesh: outcome and morbidity Study Type of mesh Number of women Follow-up (months) Success rate (%) Extrusion (%) Flood et al. 30 Marlex Weber et al. 31 Polyglactin Migliari et al. 32 Polypropylene Sand et al. 33 Polyglactin and polyester Migliari et al. 34 Polyglactin Milani et al. 35 Prolene Cronje et al. 36 Vypro De Tayrac et al. 37 Polypropylene Bader et al. 38 Polypropylene Table 2 Use of synthetic mesh in posterior compartment: success rate and complications Study Type of mesh Number of women Follow-up (months) Success rate (%) Extrusion (%) Lim et al. 40 Vypro II De Tayrac et al. 41 Polypropylene Watson et al. 42 Polypropylene Table 3 Use of synthetic mesh in both anterior and posterior compartments (combined surgery) Number of Follow-up Success rate (%) (anterior Extrusion (%) (anterior Study Type of mesh women (months) versus posterior) versus posterior) Sand et al. 33 Polyglactin versus Milani et al. 44 Polypropylene versus versus 6.5 Caquant et al. 45 Prolift versus 2.1 Dwyer et al. 46 Polypropylene versus (88.2 combined) Adhoute et al. 47 Polypropylene versus Borrell Palanca et al. 48 Polypropylene Canepa et al. 49 Polypropylene No data available Figure 6 Intravaginal slingplasty: position of mesh mesh extrusion (0 13%), other complications described are de novo dyspareunia, urgency, urge incontinence and urinary retention. Although good success rates have been described in the posterior compartment repair (83 96%), there are limited long-term data, and other complications such as mesh extrusion (12%), constipation (18%), dyspareunia and difficulty in defaecation (20%) have been noted. A biological mesh in the posterior compartment may be more appealing than a synthetic mesh as it is softer and does not retract therefore giving a lesser chance of dyspareunia, but the results are variable and evidence of clinical recurrence is as high as 41%. 43 Table 3 shows the results of combined surgery and the associated extrusion rates. It appears that mesh overlay does provide good short-term success rates. However, long-term data on quality of life and subjective effect on bowel, bladder and sexual functions are unavailable. Posterior intravaginal slingplasty This was first described by Petros 50 for the treatment of vault prolapse as a less invasive alternative to abdominal sacrocolpopexy. It involves insertion of a polypropylene tape through two small incisions in the buttock, lateral to the anal orifice, into the ischiorectal fossae and rectovaginal septum on both sides and attachment of the tape to the vaginal vault (Figure 6). The tape is inserted with a tunnelling device and the aim is to suspend the vaginal apex in its natural position in a tension-free manner. 51 Thakur and Varma 52 have modified this technique by attaching the sling to the cervix, thereby avoiding hysterectomy. They report good medium-term results (93% cure rate at 24 months). In a randomised controlled trial by Meschia et al. 53 of 66 women, which compared posterior intravaginal slingplasty with vaginal sacrospinous colpopexy, no significant difference was found in terms of prolapse recurrence. Both groups had similar operating times and hospital stays. Posterior intravaginal slingplasty was associated with pararectal pain (9%), pararectal abscess (3%) and vaginal vault tape extrusion (3%). Women who underwent sacrospinous fixation had more buttock (6 of 9)

7 pain, although this resolved spontaneously. They concluded that sacrospinous fixation and posterior intravaginal slingplasty are equally effective in restoring anatomy at the upper vaginal segment. In a case series of 35 women with multifilament slings, Siegel et al. 54 reported defective vaginal healing in 17% of cases with mesh extrusion. Baessler et al. 55 reported similar severe mesh-related complications including retropubic abscess, vesicovaginal fistula, severe dyschezia and dyspareunia necessitating sling removal. A host of commercial kits with precut polypropylene mesh in a variety of shapes are now available for use with the aim of improving surgical success rates. There have been attempts to improve the success rate by standardisation of the techniques and by the addition of arms and wings to the mesh to improve placement, spread and anchorage. The success of the tension-free vaginal tape (TVT) procedure introduced surgeons to several principles that facilitate the safe usage of synthetic material in pelvic reconstruction. The use of small incisions and minimal dissection decreases the potential for bacterial exposure; the avoidance of tension on the mesh prevents local tissue ischaemia. 56 Jha et al. 57 studied trends in surgical management of pelvic organ prolapse among UK practitioners and noted wide variation in the choice of technique. The devices commonly used in the UK are the transvaginal mesh (Gynecare Prolift, Ethicon Inc., Somerville, NJ, USA) (Figure 7), the Perigee system used for anterior compartment prolapse (Figure 8) and Apogee system used for vault prolapse (Figure 9) (both from American Medical Systems Inc., Minnetonka, MN, USA), the Nazca POP repair system (Albyn Medical Ltd, Dingwall, Ross-Shire, UK) and the Avaulta biosynthetic system (CR Bard Inc., Covington, GA, USA). Each of these mesh repair devices uses woven monofilament polypropylene mesh with extension arms to reinforce permanently the pubocervical and rectovaginal fascia. All these devices use insertion needles to anchor the mesh arms and insertion techniques are very similar. 58 No long-term data exist on the effectiveness and morbidity of these repair devices. In a French multicentre trial, Cosson et al. 59 reported a cure rate of 94.7% with a short-term complication rate of 2.4%. The recurrence rate was 5% at 3 months, but at 12 months the rate of recurrence rose to 18%. Some 4.9% reported newonset dyspareunia and the vaginal extrusion rate was 6.7%. The rate of recurrence was quite high at 12 months and long-term results are awaited. Altman and Falconer 60 performed a multicentre study on 248 women who underwent surgery using Prolift transvaginal mesh over a 6-month period and reported on immediate morbidity. They noted that the overall incidence of serious complications was 4.4% and for minor complications 14.5%. Gauruder-Bermester et al. 61 studied 120 women undergoing Perigee and Apogee mesh repair for recurrent prolapse and reported an overall cure rate of 93% with a mesh extrusion rate of 3% and a failure rate of 7% at 1 year.nguyen et al. 62 randomised 76 women either to anterior colporrhaphy or to Perigee polypropylene mesh. Although objective cure rates were 87% with Perigee compared with 55% with anterior colporrhaphy at 1 year, the subjective cure rates were not significantly different in the two groups.yamada et al. 63 reported a case of vescicovaginal fistula and mesh erosion into the bladder after Perigee mesh repair of cystocele. A Figure 7 Position of total transvaginal mesh (Gynecare Prolift). Image from Gynecare, Ethicon Inc, reproduced with permission Figure 8 (a) The AMS Perigee system, from American Medical Systems Inc., Minnetonka, MN, USA. Reproduced with permission (b) Perigee mesh in place. Copyright Miklos/Moore, Atlanta Urogynaecology Associates; from Reproduced with permission (7 of 9)

8 The Obstetrician & Gynaecologist Figure 9 The AMS Apogee system, from American Medical Systems Inc., Minnetonka, MN, USA. Reproduced with permission targeted prolapse repair techniques without the use of mesh may become more popular. We would like to refer the readers to the article by McCracken and Lefebvre 65 published recently in this journal. Before new techniques are introduced widely, welldesigned trials to determine success rates and outcomes are needed. With vaginal kit procedures becoming more widely available, it is important that long-term data from randomised trials are produced before these procedures are routinely used in reconstructive pelvic surgery. Acknowledgement We are grateful to Brendan Ellis, Medical Artist, Belfast Trust, for the drawings used in this article. search on MEDLINE did not identify any studies for the Avaulta Biosynthetic and Nazca POP systems. Abdel-Fattah et al. 58 conducted a retrospective multicentre cohort study to assess complications and short-term outcomes of prolapse repair mesh devices and concluded that, although they demonstrate excellent short-term cure and low morbidity rates, some complications, such as vascular injury and necrotising fasciitis, are serious and require highly specialised management. Longterm studies to demonstrate the superiority of one system over the other are lacking. Randomised trials are needed to study long-term safety and efficacy. Conclusion Although it is important to improve the success rate of surgery and enhance quality of life, it is equally important that the use of mesh in pelvic organ prolapse surgery is individualised. It is important to balance the benefits and risks in any individual woman, as surgical techniques need to be altered according to their individual requirements. Type I monofilament polypropylene mesh seems to be the synthetic mesh of choice at present. Abdominal sacrocolpopexy provides excellent long-term results and is associated with less recurrence and less dyspareunia than vaginal sacrospinous colpopexy. With the literature available, no recommendation can be made on the efficacy and safety of synthetic mesh in the repair of anterior vaginal wall prolapse. 18 Data on patient satisfaction, quality of life and impact on bowel, bladder and sexual function are limited. Similarly, prosthetic mesh in the posterior compartment has not improved outcomes (level 1 evidence) and, therefore, cannot be recommended for first-line management, but may have a role in recurrent prolapse. 64 With better understanding of the pelvic anatomy and improvement in surgical techniques, better Conflict of interest Paul Fogarty has acted as a surgical trainer for Gynecare TVT and Prolift devices. References 1 Olsen AL, Smith VJ, Bergstrom JO, Colling JC, Clark AL. Epidemiology of surgically managed pelvic organ prolapse and urinary incontinence. 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Biological grafts and synthetic meshes in pelvic reconstructive surgery. Clin Obstet Gynecol 2007;50: Boulanger L, Boukerrou M, Lambaudie E, DefossezA, Cosson M. Tissue integration and tolerance to meshes used in gynaecologic surgery: an experimental study. Eur J Obstet Gynecol Reprod Biol 2006;125: Amid PK. Classification of biomaterials and their related complication in abdominal wall surgery. Hernia 1997;1: Rosch R, Junge K, Schachtrupp A, Klinge U, Klosterhalfen B, SchumpelickV. Mesh implants in hernia repair: inflammatory cell response in a rat model. Eur Surg Res 2003;35: Baessler K, Maher CF. Mesh augmentation during pelvic-floor reconstructive surgery: risks and benefits. CurrOpin Obstet Gynecol 2006;18: Debodinance P, Cosson M, Colliet P, Boukerrow M, Lucot JP, Madi N. Synthetic meshes for transvaginal surgical cure of genital prolapse: evaluation in J Gynecol Obstet Biol Reprod 2006;35: De Tayrac R, Devoldere G, Renaudie J, Villard P, Guilbard O. Prolpase repair by vaginal route using the new protected low-weight polypropylene mesh: 1-year functional and anatomical outcome in a prospective multicentre study. Int Urogynecol J 2007;18: Baggish M, Karram M. Atlas of Pelvic Anatomy and Gynecologic Surgery, 2nd ed. Philadelphia: Elsevier/Saunders; p Nygaard IE, McCreery R, Brubaker L, Connolly A, Cundiff A, Weber AM, et al. Abdominal sacrocolpopexy: a comprehensive review. Obstet Gynecol 2004;104: Maher C, Baessler K, Glazener CMA, Adams EJ, Hagen S. Surgical management of pelvic organ prolapse in women: a short version Cochrane. Neurourology and Urodynamics 2008;27: National Institute for Health and Clinical Excellence. Mesh sacrocolpopexy for vaginal vault prolapse. November 2006 [ 20 Altman D, Anzen B, BrismarS, LopezA, Zetterström J. Long-term outcome of abdominal sacrocolpopexy using xenograft compared with synthetic mesh. Urology 2006;67: Barranger E, Fritel X, Pigne A. 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9 22 Nezhat CH, Nezhat F, Nezhat C. Laparoscopic sacral colpopexy for vaginal vault prolapse. Obstet Gynecol 1994;84: Ismail SIMF. Posthysterectomy vaginal vault prolapse. Prog Obstet Gynecol 2006;17: Ross JW, Preston M. Laparoscopic sacrocolpopexy forsevere vaginal vault prolapse: five year outcome. J Minim Invasive Gynecol 2005;12: Paraiso MF, Walters MD, Rackley RR, MelekS, Hugney C. Laparoscopic and abdominal sacral colpopexies: a comparative cohort study. Am J Obstet Gynecol 2005;192: Higgs PJ, Chua HL, Smith AR. Long term review of laparoscopic sacrocolpopexy. BJOG 2005;112: Di Marco DS, Chow GK, Gettman MT, Elliott DS. Robotic-assisted laparoscopic sacrocolpopexy for treatment of vaginal vault prolapse. Urology 2004;63: Atchari C, Hiscock R, O Reilly BA, SchierlitzL, Dwyer PL. Risk factors for mesh erosion after transvaginal surgery using polypropylene (Atrium) or composite polypropylene 910 (Vypro II) mesh. Int Urogynecol J Pelvic Floor Dysfunct 2005;16: Jia X, Glazener C, Mowatt G, MacLennan G, Bain C, Frazer C, et al. Efficacy and safety of using mesh or grafts in surgery for anterior and/or posterior vaginal wall prolapse: systematic review and meta-analysis. BJOG 2008;115: Flood CG, DrutzHP, Waja L. Anterior colporrhaphy reinforced with Marlex mesh for the treatment of cystoceles. Int Urogynecol J 1998;9: Weber AM, Walters MD, Piedmonte MR, Ballard LA. Anterior colporrhaphy: a randomized trial of three surgical techniques. Am J Obstet Gynecol 2001;185: Migliari R, De Angelis M, Madeddu G, Verdacchi T. Tension-free vaginal mesh repair for anterior vaginal wall prolapse. Eur Urol 2000;38: Sand PK, Koduri S, Lobel RW, Winkler HA, Tomezsko J, Culligan PJ, et al. Prospective randomised trial of Polyglactin 910 mesh to prevent recurrences of cystoceles and rectoceles. Am J Obstet Gynecol 2001;184: Migliari R, Usai E. Treatment results using a mixed fiber mesh in patients with grade IV cystocele. J Urol 1999;161: Milani R, Salvatore S, Soligo M, Pifarotti P, Meschia M, Cortese M. Functional and anatomical outcome of anterior and posterior vaginal prolapse repair with prolene mesh. BJOG 2005;112: Cronje HS, Prollius A. Vaginal anterior colposuspension (VACS) for cystocele. Int J Gynecol Obstet 2004;87: De Tayrac R, Gervaise A,FernandezH. Cystocele repair by the vaginal route with a tension-free sub-bladder prosthesis. J Gynecol Obstet Biol Reprod (Paris) 2002;31: Bader G, Fauconnier A, Roger N, HeitzD, Ville Y. Cystocele repair by vaginal approach with a tension-free transversal polypropylene mesh. Technique and results. Gynecol Obstet Fertil 2004;32: Birch C, Fynes M. The role of synthetic and biological prosthesis in reconstructive pelvic floor surgery. CurrOpin Obstet Gynecol 2002;14: Lim YN, Rane A, Muller R. An ambispective observational study in the safety and efficacy of posterior colporrhaphy with composite Vicryl- Prolene mesh. Int Urogynecol J Pelvic FloorDysfunct 2005;16: de Tayrac R, Picone O, Chauveaud-Lambling A, FernandezH. A 2-year anatomical and functional assessment of transvaginal rectocele repair using a polypropylene mesh. Int Urogynecol J Pelvic FloorDysfunct 2006;17: Watson SJ, Loder PB, Halligan S, Bartram CI, Kamm MA, Phillips RK. Transperineal repair of symptomatic rectocele with Marlex mesh: a clinical, physiological and radiologic assessment of treatment. J Am Coll Surg 1996;183: Kovoor E, Hooper P. Assessment and management of pelvic organ prolapse. Obstet Gynecol Reprod Med 2008;18: Milani R, Salvatore S, Soligo M, Pifarotti P, Meschia M, Cortese M. Functional and anatomical outcome of anterior and posterior vaginal prolapse repair with prolene mesh. BJOG 2005;112: Caquant F, Collinet P, Debodinance P, Berrocal J, Garbin O, Rosenthal C, et al. Safety oftrans Vaginal Mesh procedure: retrospective study of 684 patients. J Obstet Gynecol Res 2008;34: Dwyer PL, O Reilly BA. Transvaginal repair of anterior and posterior compartment prolapse with Atrium polypropylene mesh. BJOG 2004;111: Adhoute F, Soyeur L, Pariente JL, Le Guillou M, Ferriere JM. Use of transvaginal polypropylene mesh (Gynemesh) for the treatment of pelvic floor disorders in women; prospective study in 52patients. Prog Urol 2004;14: Borrell Palanca A, Chicote PerezF, Queipo Zaragoza JA, Beltran Meseguer JF, Esteve Claramunt J, Pastor Sempere F. Cystocele repair with a polypropylene mesh: our experience. Arch Esp Urol 2004;57: Canepa G, Ricciotti G, Introini C, Vigliercio G, Puppo P. Horseshoeshaped marlex mesh for the treatment of pelvic floor prolapse. Eur Urol 2001;39 Suppl 2:23 6; [discussion 27]. 50 Petros PE. Vault prolapse II: restoration of dynamic vaginal supports by infracoccygeal sacropexy, an axial day case vaginal procedure. Int Urogynaecol J 2001;12: National Institute for Health and Clinical Excellence. Posterior infracoccygeal sacropexy for vaginal vault prolapse. May 2005 [ 52 ThakurY, Varma R. New developments in the management of uterovaginal prolapse. Prog Obstet Gynaecol 2006;17: Meschia M, Gattei U, Pifarotti P, et al. Randomised comparison between infracoccygeal sacropexy (posterior IVS) and sacrospinous fixation in the management of vault prolapse. Abstracts from the Joint Meeting of the International Continence Society and the International UroGynecological Association 34th Annual Meeting. Paris, France, 25 27August Neurourol Urodyn 2004;23: Siegel AL, Kim M, Goldstein M, Levi S, Ilbeigi P. High incidence of vaginal mesh extrusion using the intravaginal slingplasty sling. J Urol 2005;174: Baessler K, Hewson AD, Tunn R, Schuessler B, Maher CF. Severe mesh complications following intravaginal slingplasty. Obstet Gynecol 2005;106: Winters JC, Fitzgerald MP, Barber MD. The use of synthetic mesh in female pelvic reconstructive surgery. BJU Int 2006;98 Suppl 1:70 6; discussion Jha S, Moran PA. National Survey on the management of prolapse in the UK. Neurourol Urodyn 2007;26: ; discussion Abdel-Fattah M, Ramsay I on behalf ofwest ofscotland Study Group. Retrospective multicentre study of the new minimally invasive mesh repair devies for pelvic organ prolapse. BJOG 2008;115: Cosson M, Rosenthal C, Clave H, Debodinance P, Garbin O, Berrocal J, et al. Prospective clinical assessment of the total transvaginal mesh technique for treatment of pelvic organ prolapse 6 and 12 month results. Int Urogynecol J 2006;17 Suppl 2:S Altman D, Falconer C. Perioperative morbidity using transvaginal mesh in pelvic organ prolapse repair. Obstet Gynecol 2007;109: Gauruder-Burmester A, Koutouzidou P, Rohne J, Gronewold M, Tunn R. Follow-up after polypropylene mesh repair of anterior and posterior compartments in patients with recurrent prolapse. Int Urogynecol J Pelvic Floor Dysfunct 2007;18: Nguyen JN, Burchette RJ. Outcome after anterior vaginal prolapse repair: a randomised controlled trial. Obstet Gynecol 2008;111: Yamada BS, Govier FE, Stefanovic KB, Kobashi KC. Vesicovaginal fistula and mesh erosion after Perigee (transobturator polypropylene mesh anterior repair). Urology 2006;68:1121.e Maher C, Baessler K. Surgical management of posterior vaginal wall prolapse: an evidence-based literature review. Int Urogynecol J 2005;17: McCracken GR, Lefebvre G. Mesh-free anterior vaginal wall repair: history or best practice? The Obstetrician & Gynaecologist 2007;8: (9 of 9)

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