Search

Objective: To assess the incidence of serious complications and reoperations for recurrence after surgery for pelvic organ prolapse (POP) and compare the three most common types of repair., Design: Prospective cohort study using a registry., Setting: Nineteen French surgical centres., Population: A total of 2309 women participated between 2017 and 2019., Methods: A multivariate analysis including an inverse probability of treatment weighting approach was used to obtain three comparable groups., Main Outcome Measures: Serious complications and subsequent reoperations for POP recurrence., Results: The median follow-up time was 17.6 months. Surgeries were native tissue vaginal repairs (n = 504), transvaginal mesh placements (n = 692) and laparoscopic sacropexies with mesh (n = 1113). Serious complications occurred among 52 women (2.3%), and reoperation for POP recurrence was required for 32 women (1.4%). At 1 year the cumulative weighted incidence of serious complications was 1.8% for native tissue vaginal repair, 3.9% for transvaginal mesh and 2.2% for sacropexy, and the rates for reoperation for recurrence of POP were 1.5, 0.7 and 1.1%, respectively. Compared with native tissue vaginal repair, the risk of serious complications was higher in the transvaginal mesh group (weighted hazard ratio, wHR 3.84, 95% CI 2.43-6.08) and the sacropexy group (wHR 2.48, 95% CI 1.45-4.23), whereas the risk of reoperation for prolapse recurrence was lower in both the transvaginal mesh (wHR 0.22, 95% CI 0.13-0.39) and sacropexy (wHR 0.29, 95% CI 0.18-0.47) groups., Conclusions: Our results suggest that native tissue vaginal repairs have the lowest risk of serious complications but the highest risk of reoperation for recurrence. These results are useful for informing women and for shared decision making., Tweetable Abstract: Laparoscopic sacropexy had fewer serious complications than transvaginal mesh and fewer reoperations for recurrence than vaginal repair., (© 2021 John Wiley & Sons Ltd.)

Implants for the cure of female genital prolapse still show numerous complications cases that sometimes have dramatic consequences. These implants must be improved to provide physiological support and restore the normal functionalities of the pelvic area. Besides the trend towards lighter meshes, a better understanding of the in vivo role and impact of the mesh implantation is required. This work investigates the mechanical impact of meshes after implantation with regards to the behavior of the native tissues. Three meshes were studied to assess their mechanical and biological impact on the native tissues. An animal study was conducted on rats. Four groups (n = 17/group) underwent surgery. Rats were implanted on the abdominal wall with one of the three polypropylene knitted mesh (one mesh/group). The last group served as control and underwent the same surgery without any mesh implantation. Post-operative complications, contraction, mechanical rigidities, and residual deformation after cyclic loading were collected. Non-parametric statistical comparisons were performed (Kruskal-Wallis) to observe potential differences between implanted and control groups. Mechanical characterization showed that one of the three meshes did not alter the mechanical behavior of the native tissues. On the contrary, the two others drastically increased the rigidities and were also associated with clinical complications. All of the meshes seem to reduce the geometrical lengthening of the biological tissues that comes with repetitive loads. Mechanical aspects might play a key role in the compatibility of the mesh in vivo. One of the three materials that were implanted during an animal study seems to provide better support and adapt more properly to the physiological behavior of the native tissues., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Introduction: Vaginal mesh has been proven to be an effective aid in the treatment of cystocele. Could an ambulatory approach be feasible for the Uphold Lite®-mesh?, Hypothesis: We investigate the feasibility of an ambulatory approach of Uphold Lite® insertion in a well-selected population. Risk factors for a non-successful ambulatory approach are identified., Methodology: We conducted a retrospective case series of 236 women who underwent Uphold Lite® vaginal mesh insertion for the treatment of pelvic organ prolapse at our center. Indications for surgery were symptomatic anterior and/or apical prolapse, stages POPQ≥2. We compared women having an ambulatory approach, to those having a one day hospitalization planned but needed to stay. Comparisons between percentages were calculated using the chi-square or Fisher's exact test, depending on the number of women in each group. The mean comparisons were performed using the Student t-test, and the median test comparisons by the Kruskal-Wallis test. A difference was considered significant if p<0.05., Results: The most common reason for staying (85.7% of all ambulatory failures) after Uphold® surgery is the presence of an elevated post void residual. This complication was more found in the following: surgery in the afternoon, use of high-dose morphinics in general anesthesia, and in women with a higher parity., Conclusions: Our study shows that Uphold® surgery in a one-day setting is feasible and safe. Women desiring this approach should be counselled on the 42.6% risk of one-day failure though, mostly due to non-validation of a post void residual. General anesthesia with high-dose morphinics, a higher parity, and surgery in the afternoon are risk factors for failure of an ambulatory protocol., Competing Interests: Declaration of Competing Interest The corresponding author declares no conflict of interest., (Copyright © 2020 Elsevier Masson SAS. All rights reserved.)

Objective: To assess the short-term incidence of serious complications of surgery for urinary incontinence or pelvic organ prolapse., Design: Prospective longitudinal cohort study using a surgical registry., Setting: Thirteen public hospitals in France., Population: A cohort of 1873 women undergoing surgery between February 2017 and August 2018., Methods: Preliminary analysis of serious complications after a mean follow-up of 7 months (0-18 months), according to type of surgery. Surgeons reported procedures and complications, which were verified by the hospitals' information systems., Main Outcome Measures: Serious complication requiring discontinuation of the procedure or subsequent surgical intervention, life-threatening complication requiring resuscitation, or death., Results: Fifty-two women (2.8%, 95% CI 2.1-3.6%) experienced a serious complication either during surgery, requiring the discontinuation of the procedure, or during the first months of follow-up, necessitating a subsequent reoperation. One woman also required resuscitation; no women died. Of 811 midurethral slings (MUSs), 11 were removed in part or totally (1.4%, 0.7-2.3%), as were two of 391 transvaginal meshes (0.5%, 0.1-1.6%), and four of 611 laparoscopically placed mesh implants (0.7%, 0.2-1.5%). The incidence of serious complications 6 months after the surgical procedure was estimated to be around 3.5% (2.0-5.0%) after MUS alone, 7.0% (2.8-11.3%) after MUS with prolapse surgery, 1.7% (0.0-3.8%) after vaginal native tissue repair, 2.8% (0.9-4.6%) after transvaginal mesh, and 1.0% (0.1-1.9%) after laparoscopy with mesh., Conclusions: Early serious complications are relatively rare. Monitoring must be continued and expanded to assess the long-term risk associated with mesh use and to identify its risk factors., Tweetable Abstract: Short-term serious complications are rare after surgery for urinary incontinence or pelvic organ prolapse, even with mesh., (© 2019 Royal College of Obstetricians and Gynaecologists.)

Background: Our study aimed at understanding the influence of healing time on the mechanical properties of meshes used in pelvic organ prolapse, once implanted in an animal model using the rat., Methods: A standard polypropylene mesh was implanted in 42 rats in order to evaluate the mechanical properties of the implanted mesh. Explantation occurred at 1, 2, 3, 4 and 5 months and mechanical tests were performed. Each sample was mechanically evaluated by a uniaxial tensile test with a machine (BIOTENS). Biological tissues presented a nonlinear relation between stress and strain so it could be modeled by the 2 parameters C 0 and C 1 of a second-order Mooney-Rivlin law., Results: The rigidity in small deformation might not be affected by healing time or the presence of the synthetic implant. On the contrary, changes seemed to occur on the stiffness in large deformation (C 1 ). The stiffness with the mesh composite changed with healing time. The "two-month implantation" rat group was significantly more rigid than the two control groups (p control/2months  = 0,04 and p placebo/2months  = 0,04). The 2- and 3-month healing groups were significantly more rigid than the 1-month healing group (p 1/2months  = 0,01 and p 1/3months  = 0,003). After 2 months, the mechanical properties seemed to stabilize (p 2/3months  = 0,44, p 2/5months  = 0,16 et p 3/5months  = 0,3)., Conclusion: In order to evaluate the mechanical properties of an implanted mesh, the optimal time for explantation seems to be 2 months. Once this period is over, a more physiological mesh will be developed in order to be similar to native vaginal tissue once implanted and colonized by scar tissue., (Copyright © 2019. Published by Elsevier B.V.)

Background: Laparoscopic mesh sacropexy (LS) or transvaginal mesh repair (TVM) are surgical techniques used to treat cystoceles. Health authorities have highlighted the need for comparative studies to evaluate the safety of surgeries with meshes., Objective: To compare the rate of complications, and functional and anatomical outcomes between LS and TVM., Design, Setting, and Participants: Multicenter randomized controlled trial from October 2012 to April 2014 in 11 French public hospitals. Women with cystocele stage ≥2 (pelvic organ prolapse quantification), aged 45-75 yr, without previous prolapse surgery., Intervention: Synthetic nonabsorbable mesh placed in the vesicovaginal space, sutured to the promontory (LS) or maintained by arms through pelvic ligaments (TVM)., Outcome Measurements and Statistical Analysis: Rate of surgical complications ≥grade II according to the modified Clavien-Dindo classification at 1 yr. Secondary outcomes were reintervention rate, and functional and anatomical results., Results and Limitations: A total of 130 women were randomized in LS and 132 in TVM; five women withdrew before intervention, leaving 129 in LS and 128 in TVM. The rate of complications ≥grade II was lower after LS than after TVM, but did not meet statistical significance (17% vs 26%, treatment difference 8.6% [95% confidence interval, CI -1.5 to 18]; p=0.088). The rate of complications of grade III or higher was nonetheless significantly lower after LS (LS=0.8%, TVM=9.4%, treatment difference 8.6% [95% CI 3.4%; 15%]; p=0.001). LS was converted to TVM in 6.3%. The total reoperation rate was lower after LS but did not meet statistical significance (LS=4.7%, TVM=10.9%, treatment difference 6.3% [95% CI -0.4 to 13.3]; p=0.060). There was no difference in symptoms, quality of life, improvement, composite definition of success, anatomical results rates between groups except for the vaginal apex and length, and dyspareunia (in favor of LS)., Conclusions: LS is a valuable option for primary repair of cystocele in sexually active patients. LS is safer than TVM, but may not be feasible in all cases. Both techniques offer same functional outcomes, success rates, and anatomical outcomes, but sexual function is better preserved by LS., Patient Summary: Our study demonstrates that laparoscopic sacropexy (LS) is a valuable option for primary repair of cystocele. LS offers equivalent success rates to vaginal mesh procedures, but is safer with a lower rate of complications and reoperations, and sexual function is better preserved., (Copyright © 2018 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Introduction and Hypothesis: There is a lack of knowledge concerning long-term reoperation and complications after laparoscopic sacrocolpopexy (LSCP). We analyzed the rates and indications and potential risk factors for reoperation after LSCP in a large series of consecutive patients., Methods: This was a single-center, retrospective study including all patients who underwent LSCP between 2003 and 2013. Data regarding pelvic organ prolapse (POP), surgical modalities and perioperative complications were collected. Patients were then contacted by telephone or postal letter in 2014. The main outcome criteria were grade III Dindo classification complications: reoperation for POP recurrence, mesh complications, and urinary incontinence (UI)., Results: Between January 2003 and December 2013, a total of 464 consecutive patients (mean age, 59 years) underwent LSCP. Almost all (99.1 %) patients presented with POP ≥ grade 3 (POP-Q classification). Long-term evaluations were completed for 391 (84.1 %) patients. The median follow-up was 53.5 ± 28.2 months. The global reoperation rate was 12.5 %. The main reoperation indications were UI-related surgery in 21 patients (5.5 %), POP recurrence surgery in 20 patients (5.1 %), and mesh-related surgery in 11 patients (2.8 %). Multivariate analysis showed that older age at the time of initial surgery and concomitant subtotal hysterectomy were significant protective factors against global reoperation (HR = 0.606, CI 95 % [0.451-0.815] and 0.367, CI 95 % [0.193-0.698] respectively) and reduced the risk of POP recurrence surgery., Conclusion: Prolapse recurrence and mesh-related surgery occurred in 5.1 and 2.8 % of patients respectively, 4 years after laparoscopic sacrocolpopexy. Age and concomitant subtotal hysterectomy could play a role in the incidence of long-term reoperation.

To better understand the in vivo mechanical behavior of synthetic mesh implants, we designed a specific experimental protocol for the mechanical characterization of explanted mesh under uniaxial tension. The implantation of a mesh leads to the development of scar tissue and the formation of a new composite made of native tissue, a mesh implant and scar tissues. This study focused on three points: determining the minimum representative size of mesh implants required for mechanical test samples, highlighting the influence of healing, and defining the healing time required to ensure stabilized mechanical properties. First, we determined the minimum representative size of mesh implants for the mechanical characterization with a study on a synthetic composite made of mesh and an elastomeric matrix mimicking the biological tissues. The size of the samples tested was gradually decreased. The downsizing process was stopped, when the mechanical properties of the composite were not preserved under uniaxial tension. It led to a sample representative size 3cm long and 2cm wide between the grips. Then an animal study was conducted on Wistar rats divided into eight groups. One group was set as control, consisting of the healthy abdominal wall. The other seven groups underwent surgery as follows: one placebo (i.e., without mesh placement), and six with a mesh installation on the abdominal wall and healing time. The rats were sacrificed after different healing times ranging from 1 to 5 months. We observed the influence of healing and healing time on the mechanical response under uniaxial tension of the new composite formed by scar, native tissue, and textile. It seems that 2 months are required to ensure the stabilization of the mechanical properties of the implanted mesh. We were not able to tell the control group (native abdominal wall) from the placebo group (native and scar tissue). This protocol was tested on two different prostheses after 3 months of healing. With this protocol, we were able to differentiate one mesh from another after host integration., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Introduction and Hypothesis: Sacral colpopexy (SC) is a classic procedure used for the surgical treatment of pelvic organ prolapse. Although the procedure boasts excellent success rates, there are risks of complications and reoperation may be required. The purpose of this study was to evaluate the extent of complications following SC, requiring reoperation(s), and to describe the reoperations performed., Methods: A retrospective monocentric study of patients who were operated on following a mesh complication after SC was conducted, at Lille University Hospital, between January 2007 and January 2013. Information relating to medical and surgical history, SC surgical technique, type of complication, and reoperation techniques was gathered., Results: Twenty-seven patients required surgery for complications after SC. Nineteen patients were treated for vaginal mesh exposures (VME), four for intravesical mesh (including one with VME), one for ano-rectal dyschezia, one for spondylodiscitis with a VME, one for mesh infection, and one for vaginal fistula communicating with a collection in the ischio-coccygeal muscle. The median time between the initial SC and the first reoperation was 3.9 ± 5.7 years. The median operating time was 40 ± 95 min, and the length of hospital stay was 3.0 ± 3.0 days. Ten patients needed several interventions., Conclusion: This case series provides a description of surgical interventions for complications related to sacral colpopexy. These complications may be serious and occur years after the initial surgery.

Objective: To report our experience regarding the use of partially absorbable mesh, evaluating the nature and rate of re-intervention after transvaginal pelvic organ prolapse repair., Materials and Methods: We retrospectively collected data on 269 consecutive patients who underwent partially absorbable mesh repair between January 2009 and January 2011. Data were obtained from our hospital medical records and we phoned patients to check if they had surgery in another hospital since then., Results: 250 patients were included, with a median follow-up duration of 20 months (range 8-34 months). The global rate of re-interventions was 8%. The main indications were mesh exposure (2%), prolapse recurrence (1.2%), and urinary complications such as de novo stress urinary incontinence (4.8%). Afterwards, we compared these data with those previously obtained in our centre with non-absorbable mesh., Conclusion: Our study shows that the use of a partially absorbable mesh is efficient and reliable with relatively low rates of re-intervention. According to the available literature data, a partially absorbable mesh does not seem to give advantages in comparison with classic non-absorbable mesh regarding rates of re-intervention., (Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.)

Introduction and Hypothesis: To evaluate clinical effectiveness and complication rates at 5 years following the total Trans Vaginal Mesh (TVM) technique to treat pelvic organ prolapse., Methods: Prospective, observational, multi-centre study in patients with prolapse of stage II or higher., Results: Of the 90 women enrolled in the study, 82 (91%) were available for the 5-year follow-up period. At the 5-year endpoint, success, defined as no surgical prolapse reintervention and leading edge <-1 (International Continence Society [ICS] criteria) or above the level of the hymen, was 79% and 87% respectively. A composite criterion of success defined as: leading edge above the hymen (<0) and no bulge symptoms and no reintervention for prolapse was met by 90%, 88% and 84% at the 1-, 3-, and 5-year endpoints respectively. Quality of life improvement was sustained over the 5 years. Over the 5-year follow-up period, a total of only 4 patients (5%) required re-intervention for prolapse, while a total of 14 patients (16%) experienced mesh exposure for which 8 resections needed to be performed. Seven exposures were still ongoing at the 5-year endpoint, all asymptomatic. Only 33 out of 61 (54%) sexually active patients at baseline remained so at 5 years. De novo dyspareunia was reported by 10%, but no new cases at the 5-year endpoint. One patient reported de novo unprovoked mild pelvic pain at 5 years, 5 reported pains during pelvic examination only., Conclusions: Five-year results indicated that TVM provided a stable anatomical repair. Improvements in QOL and associated improvements in prolapse-specific symptoms were sustained. Minimal new morbidity emerged between the 1- and 5-year follow-up.

Background: Cystocele is a frequent and invalidating type of genital prolapse in woman. Sacropexy using synthetic mesh is considered the surgical gold standard, and the laparoscopic approach has supplanted the open abdominal route because it offers the same anatomical results with a lower morbidity. The use of mesh through the vaginal route may have many advantages: easiness to perform, shorter operative time and recovery, but may increase morbidity. In France, both laparoscopic sacropexy and vaginal mesh are commonly used to treat cystoceles. The French Haute Autorité de santé (HAS) has highlighted the lack of evaluation of safety assessment for vaginal meshes., Method/design: The main objective of the study is to compare the morbidity of laparoscopic sacropexy with vaginal mesh for cystocele repair. The primary endpoint will be the rate of surgical complications greater or equal to grade 2 of the Clavien-Dindo classification at 1-year follow-up. The secondary aims are to compare the functional results in the medium term (sexuality, urinary and bowel symptoms, pain), the impact on quality of life as well as anatomical results. PROSPERE is a randomized controlled trial conducted in 12 participating French hospitals. 262 patients, aged 45 to 75years old, with cystocele greater or equal to stage 2 of the POP-Q classification (isolated or not) will be included. Exclusion criterias are a previous surgical POP repair, and inability or contra-indication to one or the other technique. We have designed this study to answer the question of the choice between laparoscopic sacropexy and vaginal mesh for the treatment of cystocele. The PROSPERE trial aims to help better determine the indications for one or the other of these techniques, which are currently based on subjective choices or school attitudes. This is the reason why competent authorities have asked for such studies., (Copyright © 2013 Elsevier Masson SAS. All rights reserved.)

Introduction and Hypothesis: The recent rapid and widespread adoption of the use of mesh, and mesh-based surgical kits for pelvic organ prolapse (POP) repair surgery has occurred largely unchecked, and is now being subjected to critical analysis and re-evaluation., Methods: There have been multiple driving forces for this phenomenon, including aggressive marketing by surgical device manufacturing companies, contagious hype among pelvic surgeons and regulatory processes which facilitated relatively rapid marketing of new devices., Results: Patient-related factors such as indications for mesh use, expected risks and benefits relative to mesh implantation, and appropriately selected outcome measures have been slow to be defined., Conclusions: This manuscript reviews the currently available literature in the use of grafts and mesh in POP surgery with a focus on identifying situations where graft use may be appropriate for an individual patient. It also identifies specific clinical situations where mesh use may not be recommended.

Objective: The aim of this study was to explore the nature and rate of surgical intervention after transvaginal Prolift mesh repair for pelvic organ prolapse., Study Design: This was a retrospective study of all patients who underwent Prolift mesh repair between January 2005 and January 2009. Patient data were obtained from medical records, and patients were telephoned to check if they had surgery in other hospitals., Results: A total of 600 consecutive patients were identified. Of these, 524 patients (87.3%) were included in the study, with a median follow-up duration of 38 months (range, 15-63). Global reoperation rate was 11.6%. Indications of intervention were surgery for urinary incontinence (6.9%), mesh-related complications (3.6%), or prolapse recurrence (3%)., Conclusion: The global reoperation rate after transvaginal Prolift mesh repair was 11.6%, with urinary incontinence surgery being the most common indication. Rates of mesh complications and prolapse recurrence are relatively low in an experienced team., (Copyright © 2012 Mosby, Inc. All rights reserved.)

Introduction and Hypothesis: EndoFast Reliant system is a novel technology for pelvic organ prolapse (POP) repair that attaches mesh directly with metal fasteners., Methods: This was a prospective multicenter study in 20 women who underwent vaginal POP repair to evaluate safety and efficacy. The patients were followed for 12 months, using POP-Q measures, questionnaires on symptoms (PFDI), and sexual function (FSFI)., Results: No intraoperative complications occurred. Prolapse has been anatomically resolved (< stage 2) in 85% at 1-year follow-up (17/20 patients). Pelvic Floor Distress Inventory (PFDI) scores showed significant improvement for 1 year in symptoms related to prolapse (4.1-0.7, p < 0.001) and bladder (1.4-0.7, p = 0.06) but not to rectum. Female Sexual Function Index (FSFI) scores did not change significantly. One case of mesh exposure was found (5%) and treated conservatively. No migration of fasteners was observed on X-ray., Conclusions: The EndoFast Reliant system was found safe and efficacious. Future studies are needed to evaluate its advantages over techniques using trocars.

The use of mesh for pelvic organ prolapse repair through the vaginal route has increased within the last decade. The main objective is to improve anatomical results (based on the superiority of sacropexy with meshes when compared to vaginal traditional surgery), with the advantages of the vaginal route. An increasing number of cohort series and randomized control trials have been published. There is level-1 evidence that the use of mesh for the treatment of cystocele through the vaginal route improves anatomical results when compared to traditional surgery. The rates of complications between these two techniques seem equivalent, even for de novo dyspareunia., (Copyright © 2011 Elsevier Masson SAS. All rights reserved.)

Objective: To evaluate anatomic and functional outcomes at 1-year following trocar-guided transvaginal prolapse repair using a partially absorbable mesh., Study Design: Prospective multicentre cohort study at 11 international sites. One hundred twenty-seven patients with pelvic organ prolapse stage ≥ III had surgery and were evaluated at 3 months and 1-year postsurgery compared with baseline. Instruments of measurements: Pelvic Organ Prolapse Quantification, Pelvic Floor Distress Inventory-20, Pelvic Floor Impact Questionnaire-7, Pelvic Organ Prolapse/Urinary Incontinence Sexual Function Questionnaire-12, and Patients Global Impression of Change., Results: Anatomic success, defined as prolapse stage ≤ I in the treated vaginal compartments, was 77.4% (95% confidence interval, 69.0-84.4%). Significant improvements in bother, quality of life, and sexual function were detected at 3 months and 1 year compared with baseline. At 1-year after surgery, 86.2% of patients indicated their prolapse situation to be "much better." Mesh exposure rate was 10.2% and rate of de novo dyspareunia 2% at 1 year., Conclusion: These results demonstrate improved anatomic support, associated with excellent functional improvements, without apparent safety concerns., (Crown Copyright © 2011. Published by Mosby, Inc. All rights reserved.)

Introduction and Hypothesis: A terminology and standardized classification has yet to be developed for those complications arising directly from the insertion of synthetic (prostheses) and biological (grafts) materials in female pelvic floor surgery., Methods: This report on the above terminology and classification combines the input of members of the Standardization and Terminology Committees of two International Organizations, the International Urogynecological Association (IUGA) and the International Continence Society (ICS) and a Joint IUGA/ICS Working Group on Complications Terminology, assisted at intervals by many expert external referees. An extensive process of 11 rounds of internal and external review took place with exhaustive examination of each aspect of the terminology and classification. Decision-making was by collective opinion (consensus)., Results: A terminology and classification of complications related directly to the insertion of prostheses and grafts in female pelvic floor surgery has been developed, with the classification based on category (C), time (T) and site (S) classes and divisions, that should encompass all conceivable scenarios for describing insertion complications and healing abnormalities. The CTS code for each complication, involving three (or four) letters and three numerals, is likely to be very suitable for any surgical audit or registry, particularly one that is procedure-specific. Users of the classification have been assisted by case examples, colour charts and online aids (www.icsoffice.org/complication)., Conclusion: A consensus-based terminology and classification report for prosthesis and grafts complications in female pelvic floor surgery has been produced, aimed at being a significant aid to clinical practice and research., (© 2010 Wiley-Liss.)

Introduction and Hypothesis: a terminology and standardized classification has yet to be developed for those complications arising directly from the insertion of synthetic (prostheses) and biological (grafts) materials in female pelvic floor surgery., Methods: this report on the above terminology and classification combines the input of members of the Standardization and Terminology Committees of two International Organizations, the International Urogynecological Association (IUGA) and the International Continence Society (ICS) and a Joint IUGA/ICS Working Group on Complications Terminology, assisted at intervals by many expert external referees. An extensive process of 11 rounds of internal and external review took place with exhaustive examination of each aspect of the terminology and classification. Decision-making was by collective opinion (consensus)., Results: a terminology and classification of complications related directly to the insertion of prostheses and grafts in female pelvic floor surgery has been developed, with the classification based on category (C), time (T) and site (S) classes and divisions, that should encompass all conceivable scenarios for describing insertion complications and healing abnormalities. The CTS code for each complication, involving three (or four) letters and three numerals, is likely to be very suitable for any surgical audit or registry, particularly one that is procedure-specific. Users of the classification have been assisted by case examples, colour charts and online aids ( www.icsoffice.org/complication )., Conclusions: a consensus-based terminology and classification report for prosthess and grafts complications in female pelvic floor surgery has been produced, aimed at being a significant aid to clinical practice and research.

Introduction and Hypothesis: Treatment of genital prolapse in very elderly women is challenging. Although pessary therapy and colpocleisis are effective, they also have drawbacks. There is only scarce literature about surgical therapy in this age cohort, particularly regarding the use of meshes., Methods: We aimed to evaluate the feasibility, intraoperative complications, and short-term follow-up results of the Prolift™ technique in 62 women aged over 80 years. Mean follow-up time was 6.2 months., Results: Prolift™ implantation was well tolerated by patients with regard to surgery and anesthesia, and hospitalization was relatively short (mean, 3.9 days). Intraoperative complications occurred in 1.6%. Early postoperative complications included increased post-void residual volume (25.8%), urinary tract infection (3.2%), and moderate or severe pain (17.7%). Five patients (8.3%) developed prolapse recurrence, and mesh retraction was observed in six patients (10%). There was no mesh erosion at short-term follow-up., Conclusions: Treatment of advanced prolapse using Prolift™ in very elderly women is a feasible, safe, and effective surgical option, preserving a functional vagina. Thus, this may represent one alternative to colpocleisis.

Introduction and Hypothesis: To evaluate clinical outcomes at 3 years following total transvaginal mesh (TVM) technique to treat vaginal prolapse., Methods: Prospective, observational study in patients with prolapse ≥ stage II. Success was defined as POP-Q-stage 0-I and absence of surgical re-intervention for prolapse. Secondary outcome measures were: quality of life (QOL), prolapse-specific inventory (PSI), impact on sexual activity and complications., Results: Ninety women underwent TVM repair, 72 a hysterectomy. Anatomical failure rate was 20.0% at 3 years. Three patients required re-intervention for prolapse. Improvements in QOL- and PSI-scores were observed at 1 and 3 years. Vaginal mesh extrusion occurred in 14.4% patients. After 3 years, 4.7% asymptomatic extrusions remained present. Of 61 sexually active women at baseline, a significant number of patients (41%) ceased sexual activity by 3 years; de novo dyspareunia was reported by 8.8%. One vesico-vaginal fistula resolved after surgery., Conclusion: Medium-term results demonstrate that the TVM technique provides a durable prolapse repair.

Introduction and Hypothesis: The aim of this study was to evaluate, retrospectively, the place of sub-urethral mesh readjustment when treating recurrent stress urinary incontinence (SUI) after TVT-O., Methods: Between August 2006 and August 2008, eight patients had recurrent or persistent SUI. They were treated surgically by tightening the pre-implanted sling., Results: Medium delay between first surgery and mesh adjustment was 6 months. One patient needed a second TVT-O for rupture of the pre-implanted mesh during adjustment. Among the seven patients who underwent a mesh readjustment, three were cured, three improved, there was one failure. Mean follow-up was 25 months., Conclusions: The sub-urethral mesh readjustment is a simple and safe procedure for patients with recurrent SIU after TVT-O procedure. Success rates are high, surgery minimally invasive but long-term follow-up is needed to evaluate efficiency.

Even if genital prolapse does particularly affect the elder woman, we often have to face a surgical demand with conservation of the uterus from a patient less than 50 years. Before making the decision of treating a non life-threatening symptom by a specific surgical technique, it is important to ask who should be operated and when. Then, the route of the surgery has to be chosen considering that the woman wants to preserve her fertility. In the past decade, some surgical acts, like the sacrohysteropexy, were known as having poorer results if the women got pregnant. Thus, if there was a persistent childbearing desire, more interventions allowing pregnancy (like the Manchester's or the Richardson's procedures) were preferred. Nowadays, the sacrohysteropexy is considered as the gold standard technique, but one question is coming out: could we substitute this traditional surgery by a vaginal repair with meshes? Despite the big diversity of the so-called "sacrohysteropexy", we think that it remains the first choice technique to cure a young woman. Vaginal meshes have too high a rate of morbidity (especially on sexual activity) to be considered as the best surgical treatment. But this question could probably find another answer in the future, when all the studies about the component of the meshes will be finished.

Aim: To study peri-surgical complications after cure of genital prolapse by vaginal route using interposition of synthetic prostheses Gynemesh Prolene Soft (Gynecare) following the Trans Vaginal Mesh (TVM) technique., Methods: The present retrospective multicentered study comprised 684 patients who underwent surgery at seven French centers between October 2002 and December 2004. All patients had a genital prolapse >or=3 (C3/H3/E3/R3) according to International continence society (ICS) classification. According to each case, prosthetic interposition was total, or anterior only or posterior only. Patients were systematically seen 6 weeks, 3 months and 6 months after surgery. Multivaried statistical analysis followed a model of logistic regression applied to each post-surgical complication., Results: The mean age of patients was 63.5 years (30-94). The mean follow-up period was 3.6 months. 84.3% of patients were post-menopause, 24.3% had hysterectomy, 16.7% previous cure of prolapse, and 11.1% cure of stress urinary incontinence (SUI). During the procedure, hysterectomy was combined in 50.3% of cases, cervix amputation in 1.5%, and cure of SUI in 40.9%. 15.8% were treated for a cystocele only. 14.8% had only a rectocele +/- elytrocele and 69.4% had a prolapse touching both compartments, anterior and posterior. In peri-surgical complications, (2%) were five bladder wounds (0.7%), one rectal wound (0.15%) and seven hemorrhages greater that 200 mL (1%). Among early post-surgical complications (during the first month after surgery) (2.8%) were two pelvic abscesses (0.29%), 13 pelvic hematomas (1.9%), one pelvic cellulitis (0.15%), two vesicovaginal fistulas and one rectovaginal fistula (0.15%). Among late post-surgical complications (33.6%) there were 77 granulomas or prosthetic expositions (11.3% [6.7% in the vaginal anterior wall, 2.1% in the vaginal posterior wall and 4.8% in the fornix]), 80 prosthetic retractions (11.7%), 36 relapse of prolapse (6.9%) and 37 SUI de novo (5.4%). Multivaried analysis shows that previous history of hysterectomy or placing of an isolated anterior prosthesis increase the risk of peri-surgical complication; preserved uterus and isolated posterior prosthesis lessen the risk of granulomas and prosthetic retractions; and association of a Richter's intervention increases the rate of prosthetic retractions., Conclusion: Cure of genital prolapse with synthetic prostheses interposed by vaginal route is now reliable and can be reproduced with a low rate of peri- and early post-surgical complications. However, our study shows a certain number of late post-surgical complications after insertion of strengthening synthetic vaginal implants (prosthetic expositions and prosthetic retractions). These retrospective results will soon be compared to a prospective study.

The aim of this study is to examine the role of bacterial infection in complications following surgical management of urinary incontinence and genital prolapse using meshes. There were sixteen prostheses removed. Eight were monofilament polypropylene-knitted meshes, one was a silicone-coated polypropylene mesh, another was a collagen-coated polypropylene mesh, four were silicone-coated polyester meshes and two were polyester meshes. The most frequent cause for removal was symptomatic vaginal erosion (62%). Cultures were performed under aerobic, anaerobic and enrichment conditions. Infection was multimicrobial for 31% of meshes. When only one bacteria was found, it was Proteus mirabilis in 25% of cases. Forty-three per cent of bacterial quantifications were under 10(3) colony-forming units per millilitre. Bacterial contamination was found in all meshes, quantification was often low, and therefore, its exact role is not yet clear.

Objective: The objective was to develop an animal model using bacterial inoculation to evaluate tissue integration and tolerance to meshes used in genital prolapse surgery., Study Design: We placed three different meshes under the abdominal skin of 120 Wistar rats: a polypropylene monofilament non-coated mesh (Parietene), a polypropylene monofilament collagen-coated mesh (Ugytex) and a polyethylene terephthalate mesh (Mersuture). We performed bacterial inoculation just after implantation with 1 ml of 10(7) colonies forming unit (CFU) of Staphylococcus epidermidis or Escherichia coli. Rats were sacrificed 7, 14, 60, and 90 days after intervention. We used polarised light microscopy to analyse the collagen deposition and organisation. We quantified the inflammation cells. Bacterial analysis and quantification of the explanted meshes were performed. The exact Fisher's test and Kruskal-Wallis test were used for statistics., Results: We did not find any significant difference between inoculated or non-inoculated meshes in terms of collagen deposition. The scarring process seemed stable at day 90. Tissue integration was best with the polypropylene meshes, which allowed the development of a well-organised, mature connective tissue. Inflammatory reaction was higher in inoculated meshes, but only at day 7. At day 90, we found a high number of macrophages and multinuclear cells around all the meshes. There was no significant difference between prostheses that had been inoculated and those that had not with regard to positive bacterial culture. Quantification of bacterial colonies decreased with time., Conclusion: In this animal model, we did not find any clinically related difference in infection and tissue integration between the meshes used in genital prolapse. Such experimental studies must be carried out whenever new prostheses become available before their use is validated in common practice.

Objective: The objective was to assess in an animal model the mechanical properties of five prostheses used for pelvic floor repair., Study Design: Two months after pre-peritoneal implantation of the five types of prosthesis: Prolene, Prolene Soft, Mersuture, Vicryl and Vypro, we sacrificed the animals to measure retraction of the prosthesis, maximal resistance to traction, and maximal elongation., Results: Non-absorbable prostheses retracted least. Forces at rupture were disparate with a significant difference in favor of Prolene (p<0.001). Resistance was variably affected by cicatrization. There were no significant differences in elongation., Conclusions: This study is an introductory exploration. Monofilament and macroporous propylene prostheses seem, after implantation, to have the best mechanical performance and best tissue integration. This underlines the need for experimental prostheses, which are increasingly used, but still lack the extensive evaluation needed by the surgeon. Knitted polypropylene seems to be one of the best materials at present, but is probably not sufficient.

Our goal was to report the preliminary results of a transvaginal mesh repair of genital prolapse using the Prolift system. This retrospective multicentric study includes 110 patients. All patients had a stage 3 (at the hymen) or stage 4 (beyond the hymen) prolapse. Total mesh was used in 59 patients (53.6%), an isolated anterior mesh in 22 patients (20%) and an isolated posterior mesh in 29 patients (26.4%). We report one bladder injury sutured at surgery and two haematomas requiring secondary surgical management. At 3 months, 106 patients were available for follow-up. Mesh exposure occurred in five patients (4.7%), two of them requiring a surgical management. Granuloma without exposure occurred in three patients (2.8%). Failure rate (recurrent prolapse even asymptomatic or low grade symptomatic prolapse) was 4.7%. According to the perioperative and immediate post-operative results, Prolift repair seems to be a safe technique to correct pelvic organ prolapse. Anatomical and functional results must be assessed with a long-term follow-up to confirm the effectiveness and safety of the procedure.

Objective: To search if the prosthetic kits bring an interest, other that financier., Materials and Method: Authors have counted 5 firms presenting the varied kits. The Prolift kit with synthetic pre- cut mesh made of polypropylene, standardized needle, cannulas and protective devices of recovery of mesh arms in 3 versions, anterior, posterior and total. Perigee and Apogee systems in a synthetic version (IntePro) and a biological version (InteXen ++LP) matched of specific needles for the different obturator passages and infra coccygeus. The Avaulta kit declines in a biosynthetic version and a hybrid version with a specific needle for its anterior kit and an other for its posterior kit. The Biomesh Soft system presents a polypropylène mesh posed on a multi pattern sheet to carve following dots with a share of 3 needles according to the type of arm passage ended by a recuperator thread. The Nazca POP Repair System, in its anterior version claims to be able to correct in the same time a urinary incontinence by pre-pubic arms. The polypropylene mesh is perforated and is had with the help a needle for its anterior and posterior kit. Authors have been interested in the research of studies on prosthesis with and without kit., Results: The Prolift kit contains the alone prosthesis having been evaluated without (TVM) and with kit. Authors remind results of two studies, understanding 684 cases without kit and 110 cases with kit. The rate of early per and postoperative complications has been decreased half, the rate of mesh exposure decreased from 11,3 to 4,7%. Studies on Perigee and Apogee IntePro kits, whose meshe and the procedure are similar to the Prolift seem to obtain from results equal. The Biological version has not made the object of study. For the Avauta kit, alone the mesh in plate not pre-cut has been well studied as for its tolerance for the biosynthetic version. Nothing on the hybrid version. No study is found for the Biomesh Soft kit and Nazca POP repair system., Discussion: The cost of these kits, varying 1 to 4, is to take in consideration and to put in scale with the returned service. Alone TVM/Prolift allows to advance in a reply. The utilization of needles, presents in all the kits, but especially devices facilitating the passage and the recovery of prosthesis arms, presents solely in the Prolift kit, reduce the utilization of valves and the risk of tear tissues during their job. The improvement of techniques by elements of the kit make that the surgical procedure become mini invasive., Conclusion: The full kits allow a best security of procedures, facilitate the surgical gesture and limit complications. It is necessary to remain vigilant in the evaluation of these new materials "ready to wear" and to require pre clinic and clinic studies before their distribution.

Objectives: The purpose is to quantify objective tissue resistances before healing of prostheses used in pelvic floor surgery., Patients and Methods: We measured tissue resistances offered to five types of meshes by four classical surgical routes. We also tested the incidence of the modification of the width of meshes on tissue resistance. This study was realized on frozen cadavers, by pull on prostheses just after implantation. Tests are realized with a dynamometer and results obtained in Newton., Results: In the Retzius space, TVT offers a better resistance than IVS or LIFT meshes. We did not bring to the fore a significant difference between four routes for 1 cm wide prosthesis. The increase of width of Prolene meshes improves their resistance in tissues and thus quality of their fixation. We underscore a better resistance of the trans sacrospinous route with regard to the trans muscular one., Discussion and Conclusion: The increase of resistance is bound to the increase of the contact area between the prosthesis and the tissues. This increase of resistance should be taken into account in prolapse surgery: constraints are stronger than for stress incontinence. The posterior arms of meshes have to measure more than 1 cm wide and be set up through the sacrospinous ligament rather than through the elevator muscles. The type of knitting of prostheses is important and influences the resistance in tissues in the immediate postoperative time. Manufacturers should be interested in conceiving specific meshes for the tension-free fixation, with special and adapted mechanical properties.

Since 1996, prosthetic meshes have become increasingly popular for transvaginal surgical cure of genital prolapse. In light of the growing number of proposed techniques and materials we reviewed the experience of the pioneers in order to provide surgeons with the most objective information available. We reviewed the literature indexed in Meline/PubMed and Current Contents retaining all work concerning resorbable and non-resorbable meshes. For the larger class of non-resorbable meshes we also reviewed articles by category of material, each type of mesh being carefully defined: different compositions of polypropylene, polyester, composite meshes and also insertion kits. Resorbable meshes were evaluated in two randomized studies which did not demonstrate better results than with simple folding known to have a high rate of recurrence. For polypropylene meshes, Marlex was studied in six trials which demonstrated a high rate of cure at one year but also a high rate of erosion which reached 25%. Use of Atrium was mentioned in three studies with a 6 to 12% recurrence rate and an erosion rate nearly reaching 20%. The majority of studies used Prolene and Gynemesh. Seventeen authors reported their experience, generally reviewing retrospective series, with recurrence rates of less than 10% for follow-up periods rarely greater than two years. A large variety of forms and sizes have been used, hindering comparisons. The rate of erosion was also quite variable, as high as 45%, demonstrating the need for a precise definition of erosion. Only recently have authors shown interest in the impact of prosthetic meshes on quality of life and sexual activity. An improvement is generally noted for defecation but the rate of dyspareunia has reached as high as 60%. Here again grades of prosthetic retraction should be better defined. Proposed to improve these phenomena, soft Prolene recently used by several authors does not appear to fulfil expectations. Since 2005, several precut polypropylene meshes have been proposed with an insertion kit. The Prolift kit has been followed prospectively in 100 patients undergoing regular surveillance. Surgipro has been used sporadically in small series but follow-up is still too short for proper assessment. Polyester meshes (Mersilene and Paritex) have been presented by three authors who have found them useful but reports have been vague concerning results and complications. Polytetrafluoroethylene has not been evaluated for transvaginal surgery, probably because of the poor tolerance of suburetral bands. For composite meshes, Vypro has been used by four authors who noted about 10% erosion but with a short follow-up insufficient to draw conclusions about the functional and anatomic outcome. Surfaced meshes, advocated for transvaginal treatments, have been studied in only two reports. Plevitex is a polypropylene mesh coated with collagen; another polyester composite with polyglactin 910. The rate of dyspareunia varied from 14 to 24%. Other composites with antiadherents or antiseptics are also proposed for transvaginal insertion but have not been studied. This work demonstrated the lack of sufficient evidence from prospective randomized trials and the lack of standardized techniques to draw any definite conclusions. While evidence is being accumulated on the lower rate of recurrence for anterior compartment prolapse, the lack of data on the rate of complications and patient quality of life is unacceptable for this functional surgery. We still have reservations about widespread use of synthetic meshes. A special chapter is detailed in appendix on post-operative complications. These new specific complications call to a new semiology, with a classification in 4 types and under-types, proposed by authors. Type 1: defects of healing. Type 2: the infection of the graft. Type 3: the shrinkage of the mesh. Type 4: erosions. Authors detail the symptoms of these 4 types as well as the prevention and the treatment of these complications.

Prosthetic reinforcement in the surgical repair of pelvic prolapse by the vaginal approach is not devoid of tolerability-related problems such as vaginal erosion. The purposes of our study are to define the risk factors for exposure of the mesh material, to describe advances and to recommend a therapeutic strategy. Two hundred and seventy-seven patients undergoing surgery due to pelvic prolapse with transvaginal mesh technique were included in a continuous, retrospective study between January 2002 and December 2003. Thirty-four cases of mesh exposure were observed within the 2 months following surgery, which represents an incidence of 12.27%. All the patients were medically treated, nine of whom were found to have completely healed during the check-up performed at 2 months. In contrast, 25 patients required partial mesh exeresis. Risk factors of erosion were concomitant hysterectomy [OR = 5.17 (p = 10(-3))] and inverted T colpotomy [OR = 6.06 (p = 10(-2))]. Two technical guidelines can be defined from this study as regards the surgical procedure required in order to limit mesh exposure via the vaginal route. The uterus must be preserved, and the number and extent of colpotomies needed to insert the mesh must be limited.

Objective: To evaluate the tissue integration of and tolerance to five different mesh types used in genital prolapse surgery to provide mechanical support., Study Design: We placed five different meshes (Vicryl, Vypro, Prolene, Prolene soft, and Mersuture) on the peritoneums of 12 pigs. After 10 weeks, we used light microscopy to analyze the tissue integration of and tolerance to these meshes. We looked for inflammation, vascularization, fibroblasts, collagen fibers and the organization of connective tissue., Results: The absorbable prostheses made of polyglactin 910 (Vicryl) and the non-absorbable prostheses made of polypropylene (Prolene and Prolene soft) induced the least severe inflammatory reactions. Tissue integration was best with the polypropylene meshes, which allowed the development of a well-organized, fibrous, mature, connective tissue., Conclusion: The tissue response to prosthetic meshes depends on the material used and its structure. This work highlights the feasibility of carrying out experimental studies to test the tolerance to and integration of biomaterials used in gynecology. Such studies need to be carried out whenever new prostheses become available to validate their use in common practice.

Introduction: The "tension-free" procedures are widely used by surgeons for the treatment of urinary incontinence and prolapse. The clinical results are largely in favour of these procedures. The aim of our study is to determine objectively the mechanical tissue resistance when using these techniques, before healing begins., Material and Methods: We measured the mechanical resistance using four different routes: the retro-pubic space, the transobturator, the translevator ani muscle and the trans-sacrospinous ligament. We compared five different meshes, TVT, IVS, Lift, Prolene and Prolene Soft. In order to study the effect of increasing dimensions, we tested Prolene tapes measuring 1, 1.5 and 2 cm in width. We performed traction tests on meshes implanted in cadavers. Measurements were made with a dynamometer and the results expressed in Newtons., Results: This study shows that TVT offers a better resistance to traction via the retro-pubic space route. There was no significant difference among the four routes when the same type of mesh measuring 1cm was used. However, an increase in the dimensions of Prolene tapes improves their resistance in the tissues, thereby facilitating fixation before healing begins. Also, these increasing dimensions (in width) show that there is better resistance with the trans-sacrospinous ligament compared with the transmuscular one., Discussion: The increasing size of prosthetic meshes does not show the superiority of certain routes with commercial meshes of 1cm in width. The higher resistance obtained with wider tapes is probably due to an increased surface area between the tissues and meshes. This increase in resistance does not seem to be important for the treatment of urinary incontinence. However, it should be of interest for the treatment of prolapse where traction and surface are more important., Conclusion: Two different recommendations can be deduced from our study. On one hand, the arms of prosthetic meshes for pelvic floor repair should measure more than 1cm in width in order to improve their maintenance in the tissues in the immediate post-operative period. On the other hand to improve fixation, the posterior arms of the transperineal mesh should be passed through the sacrospinous ligament rather than via the transmuscular route. The resistance of tissues is also influenced by the armature of the prosthetic mesh. They must therefore be developed commercially specifically for "tension-free" fixation. Our results need to be confirmed by further studies including more cadavers and younger patients.

Objectives: To describe, in view of the new standardization, the technique for urogenital prolapse repair using a one-piece synthetic mesh., Materials and Methods: The history and development steps through which the Tension free Vaginal Mesh (TVM) technique emerged are described. The use of a mesh was prompted by the 20-30% recurrence rate associated with conventional repair techniques. Selection of the type of mesh is discussed. Non-absorbable synthetic meshes have shown their usefulness in visceral surgery. A list of materials along with their respective advantages and inconveniences is reviewed and particular emphasis is put on both the tolerance and erosion issues, the latter being specific to the vaginal route. The TVM Group selected a one-thread polypropylene mesh, Prolene Soft, which seemed the most appropriate for the transvaginal approach of prolapse surgical repair. The prosthesis and its design rationale are described. Full details are given on the consecutive intervention steps and underlying concepts., Results: The relevant literature is scarce and there is a lack of methodologically sound studies validating the materials and techniques used. After completion of a first step of technique refinement and feasibility assessment involving about 300 surgical interventions, the authors initiated a prospective multicenter study. Clinical outcome assessments using feasibility, complications, and efficacy endpoints will be published after twelve months, three years, and five years of follow-up., Conclusion: Fruitful reasoning led to the development of the TVM technique of complete surgical repair of genital prolapse, which uses a synthetic materiel carefully selected after several tests. All surgeons can apply this technique after a short training period.

Objective: The aim of this study was to assess the factors of success in abdominal colposacropexy (CSP) procedures., Patients and Methods: We performed 271 consecutive CSP between 1986 and 1997 (mean age: 48.8 years +/- 11.1). We reviewed 217 patients (80.1%). Mean duration of follow-up was 5.5 years (1-136 months). We performed: 18 CSP with Goretex mesh, 3 with resorbable mesh and 196 with Mersilene; 179 CSP with posterior colporraphy and 38 without; 208 CSP with culdoplasty (Moschowitz's procedure) and 9 without; 182 CSP with anterior and posterior meshes, 26 with posterior mesh only and 9 with anterior mesh only., Results: 97.7% (212/217) of patients were cured for prolapse. 58% (125/217) had urinary stress incontinence totally cured and 82% (178/217) had urinary stress incontinence improved. Rejected grafts were 16.7% (3/18) with Goretex mesh and 1.1% with Mersilene mesh (p = 0.004). Recurrent prolapses were 1.1% (2/196) with CSP with posterior colporrhaphy and 7.9% (3/38) in CSP without (p = 0.009; OR = 0.14, CI = 0.02-0.86); 4/208 with CSP with culdoplasty and 1/9 with CSP without (p = 0.04; OR = 0.17, CI = 0.02-1.58). Recurrent stress incontinence was observed in 4/9 cases with CSP with anterior mesh only and 28/182 with CSP with anterior and posterior meshes (p = 0.03; OR = 0.34, CI = 0.12-0.97)., Conclusion: CSP must use anterior and posterior Mersilene mesh. The CSP must be systematically combined with posterior colporraphy and culdoplasty (Moschcowitz's procedure).

We report the first case of rejection of prosthetic mesh after laparoscopic sacropexy using a Roticulator stapler. The risk of this complication is extremely low if simple precautions are observed. Our experience suggests that the use of staples to attach the mesh to the vaginal apex should be avoided. At the end of the procedure a careful assessment should be made to ensure that the vaginal wall is intact and not penetrated by staples.