1) Recurrent anterior vaginal wall prolapse can be repaired using traditional native tissue repair involving re-suturing of fascial attachments or using mesh-augmented repairs. 2) Studies show anatomical success rates are higher with mesh but mesh repairs also carry higher risks of complications like erosion. 3) Ensuring apical support with procedures like sacrocolpopexy may reduce recurrence rates compared to anterior repair alone. 4) Tissue quality, surgical technique including suture type and tension, and risk factors like wide genital hiatus can also affect recurrence rates.

1. Colpocele anteriore recidivante:Colpocele anteriore recidivante:
- riparazione fasciale- riparazione fasciale
Michele MeschiaMichele Meschia

2. What’s old is new again
Owing to reports of high recurrence, the traditional,
plication-based, native-tissue repairs have been seemingly
relegated to sideshow curiosity, while, on the other hand,
mesh-augmented repairs have been thrust into the spotlight.

3. Kaplan-Meier survival curve of recurrent prolapse within 10 years
Overall there were 36 recurrences out of 142 pts (25.3%) for an incidence rate ofOverall there were 36 recurrences out of 142 pts (25.3%) for an incidence rate of
recurrence of 3.7 per 100 woman years (95% CI= 2.6-5.1 per 100 woman-years)recurrence of 3.7 per 100 woman years (95% CI= 2.6-5.1 per 100 woman-years)
Incidence of recurrent pelvic organ prolapse 10 years following
primary surgical management: a retrospective cohort study.
Fialkow MF, Newton KM, Weiss NS. Int Urogynecol J 2008;19:1483-7

4. Prolapse recurrence 5 years after surgeryProlapse recurrence 5 years after surgery
Compartment Anatomical Symptomatic
Any vaginal
site
31% 7.4%
Anterior 20% 5.5%
Apical 7% 4.2%
Posterior 15% 2.4%
Dietz-Itza, 2007

5. What is cure?
• Any definition of success after POP surgery should include the
absence of bulge symptoms
• Many patients with unsatisfactory anatomical results (POPQ stage
II) are asymptomatic
• Using the hymen as a threshold for anatomic success seems a
reasonable and defensible approach
• Patient perspective of cure must be considered to ensure a
mutually agreement on definition of an acceptable outcome
An ideal outcome measure should be clinically relevant

6. • Inclusion criteria are often poorly specified
primary and recurrent cases
different POP classifications
• Outcomes often include only anatomical factors
• Inadequate description of the surgical technique (i.e.
concomitant apical support procedures)
• Functional outcome data poorly investigated
Anterior Repair
Reports bias

7. 1-year results of 699 women having had native
tissue repair for POP from 2002 to 2005
• 94% subjective satisfaction
• 84% had stage 0-1 in any compartment
• 1.1% 1-year re-operation rate
• 4.7% 5-year re-operation rate

8. Reoperation rate for traditional anterior vaginal repair: analysis
of 207 cases with a median 4-year follow-up.
Kapoor DS, Nemcova M, Pantazis K, Brockman P, Bombieri L, Freeman RM.
Int Urogynecol J 2010;21:27-31
Methods:
Retrospective case note review of 207 cases of primary anterior colporrhaphy
with/without other prolapse surgery.
Results:
While the anatomical recurrence rate of cystoceles at 3 months postoperatively
was 12%, the reoperation rate for recurrent cystocele by 50 months was 3.4%.
Comclusions:
While the anatomical recurrence rates for cystocele following traditional anterior
colporrhaphy might be high, the low reoperation rate at more than 4 years (3.4%)
suggests that patient's symptoms might not be bothersome enough to require
further surgery.

9. Outcome data from Olsen et al., with a 40% non-return correction factor applied to the known failure
count. Repairing recurrent prolapse by traditional re-suture of native tissues was associated with
approximately 60% higher failure rates, compared with surgical outcome in primary cases (67% v
41%).
The challenge of recurrent POPThe challenge of recurrent POP

10. Mission impossible?Mission impossible?

11. Primary versus recurrent prolapse surgery: differences in
outcomes.
Peterson TV, Karp DR, Aguilar VC, Davila GW Int Urogynecol J 2010; 21;483-8
Methods:
A retrospective study was performed comparing patients who underwent AC for
recurrent cystocele (group I) and a matched control group who underwent
primary AC (group II).
Results:
At 1 year
Successful anterior vaginal support was obtained in 78.2% of patients in group I
and in 81% in group II (p = 1.000)
At 2 years
42.8% of patients in group I and 71.4% in group II (p = 0.031) had no evidence
of POP
Conclusions:
Alternative surgical techniques that provide better long-term durability may be
beneficial in repair of recurrent anterior wall prolapse.

12. • inappropriate choice of procedure (plan of surgery)
• defect in restoring fascial attachments
• inappropriate choice of suture materials
• inadequate control of bleeding (pelvic hemathoma)
• persistent increase in intra-abdominal pressure
• poor connective tissue quality
Birch C and Fynes MM, 2002Birch C and Fynes MM, 2002
Pelvic Organ Prolapse repairPelvic Organ Prolapse repair
Surgical failuresSurgical failures

13. Wide genital hiatus is a risk factor for recurrence following
anterior vaginal repair.
Medina CA, Candiotti K, Takacs P. Int J Ob/Gyn 2008; 101:184-7
Methods:
A retrospective cohort study was performed on patients who had undergone an
anterior vaginal wall repair. Patients were placed into 1 of 2 groups: wide
genital hiatus (> or =5 cm) or normal genital hiatus (<5 cm). The wide genital
hiatus group (n=35) was compared with the normal genital hiatus group
(n=30)
for surgical failure.
Results:
The rate of postoperative anterior vaginal wall prolapse was greater in patients
with a wide genital hiatus compared with those with a normal genital hiatus
(34.3% vs 10% respectively; odds ratio 4.7 [95% confidence interval, 1.0
24.1]; P=0.02).

14. Ensure apical fixationEnsure apical fixation

15. The cumulative reoperation rates were highest among women who had
an isolated anterior repair (20.2%) and significantly exceeded
reoperation rates among women who had a concomitant apical support
procedure (11.6%; P<.01).
32.8% (95% CI 30.4-35.1) had a colporrhaphy without colpopexy
Role of apical support
Eilber et al, Obstet Gynecol 2013
Fairchild et al, Am J Obstet Gynecol 2015
3244 women underwent POP surgery
1557 hysterectomies performed for POP
Use of colpopexy was independently associated with a surgeon
specializing in urogynecology (OR 8.2, 95% CI 5.156-12.923).

16. Repair of recurrent AVW prolapse
• Midline PCF plication
• Bilateral fixation of PCF to USL
remnants
• Bilateral re-attachment of PCF
to the ATFP proximal to the
ischial spine

17. Enterocele repair
• Commonly found in association with vault prolapse
• Ligation of hernia sac and obliteration of the pouch of
Douglas
Associated defectsAssociated defects

18. Permanent suture used in uterosacral ligament suspension
offers better anatomical support than delayed absorbable
suture.
Chung CP, Miskimins R, Kuehl TJ, Yandell PM, Shull BL.
Prospective series of 248 women
• 1% vs 6% loss of support beyond the hymen, p=0.034
Int Urogynecol J 2012
Reattachment of the endopelvic fascia to the apex
during anterior colporrhaphy: does the type of suture matter?
Zebede S, Smith AL, Lefevre R, Aguilar VC, Davila GW.
230 patients were reviewed (permanent vs absorbable suture)
• Statistically significant improvement in anterior wall anatomy
Ba (-2.68±0.65cm vs -2.51±0.73cm, p=0.03) with permanent suture
• Exposure of the permanent suture occurred in 12 patients (15 %) and 5 (6.5 %)
required suture trimming to treat the exposure.
Int Urogynecol J 2013
Type of suture

19. Poor tissue quality
Khaja et al IUJ 2014 25:181–187

20. 5 year cumulative risk of any repeat surgery
• Vaginal mesh: 15.2% (5.9% risk of mesh revision/removal)
• Native tissue: 9.8% p<0.0001
5-year risk of surgery for recurrent prolapse
• Vaginal mesh: 10.4%
• Native tissue: 9.3% p=0.70
27,809 anterior prolapse surgeries
• 20,938 (75.3 %) native tissue repairs
• 6,871 (24.7 %) vaginal mesh

21. Trocar-guided mesh compared with conventional vaginal
repair in recurrent prolapse: a randomized controlled trial.
Withagen MI, Milani AL, den Boon J, Vervest HA, Vierhout ME.
Methods:
Patients were randomly assigned to either conventional vaginal prolapse surgery
or polypropylene mesh insertion.
Results:
97 women underwent conventional repair and 93 mesh repair.
Twelve months post-surgery, anatomic failure in the treated compartment was
observed in 45.2% of patients in the conventional group and in 9.6% in the mesh
group (P<.001; odds ratio, 7.7; 95% confidence interval, 3.3-18).
Patients in either group reported less bulge and overactive bladder symptoms.
Subjective improvement was reported by 80% of patients in the conventional
group compared with 81% in the mesh group.
Mesh exposure was detected in 14 of 83 patients (16.9%).
Obstet Gynecol 2011; 117:242-50Obstet Gynecol 2011; 117:242-50

22. The UK national prolapse survey: 5 years on.
Jha S, Moran P.
Int Urogynecol J 2012; 22:517-28Int Urogynecol J 2012; 22:517-28
5 years
ago
Current
Procedure of choice for
recurrent anterior vaginal
wall prolapse
Ant. colporraphy
Graft + fascial
plication
45%
34%
21%
56%

23. Recurrent prolapse surgery
• Reasonable anatomic results without mesh
• Significant symptoms improvement
• No erosions, few infections, quick recovery
• Mesh complications remain a challenging issue

24. The fear of unknownThe fear of unknown
Thus conscience does make cowards of us allThus conscience does make cowards of us all
Hamlet: Act III, scene 1, line 82Hamlet: Act III, scene 1, line 82
The decision to perform a mesh augmented POP repair is often
a difficult one for even the most experienced pelvic surgeon
Pelvic organ prolapse (POP) surgery: the evidence for the repairsPelvic organ prolapse (POP) surgery: the evidence for the repairs
Alex Gomelsky, David F Penson and Roger DomochowskiAlex Gomelsky, David F Penson and Roger Domochowski
BJU 2011; 107:1704-1719 Review articleBJU 2011; 107:1704-1719 Review article