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\begin{document}

\title{Surgery for vaginal vault prolapse: is autologous fascia a viable
alternative to mesh?}



\author[1]{Arvind Vashisht}%
\author[1]{Maria Masha Ben Zvi}%
\author[1]{Nikolaos Thanatsis}%
\affil[1]{University College London Hospitals NHS Foundation Trust}%


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  \date{May 16, 2024}


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The surgical management of prolapse has undergone a meandering path,
with innovation, controversy and legislation all being encountered en
route. Some of the dust is now settling with respect to the role of mesh
implant surgery, and whilst it continues to have albeit a contracted
role, there is very much a new direction set on native tissue and
non-mesh repairs with the advent of techniques such as laparoscopic
suture hysteropexy, cervicopexy and colporrhaphy.

The authors of this paper present the largest series of women undergoing
autologous fascia sacrocolpopexy for the treatment of moderate-severe
prolapse. Learning from the past, two key questions that must always be
answered when evaluating any new procedure are safety and efficacy. For
both these measures, the authors show encouraging results comparable
with current gold-standard, mesh augmented repairs.

The use of autologous fascia has been well established to treat women
with urinary incontinence -the pubovaginal / rectus fascial sling
(Mcguire EJ et al . Pubovaginal sling procedure for stress
incontinence.~\emph{J Urol.~} 1978;119:82--4) -- the use of which has
resurged following the widespread suspension of synthetic sling
procedures. Reports of autologous fascial support of the vaginal vault
however are limited to a few short-term case series.

This series involves 132 women, followed up for a median of 2.2 years;
the authors present five-year data with comparable success rates to
those reported in the landmark CARE study (Nygaard I, et al. Long-term
outcomes following abdominal sacrocolpopexy for pelvic organ
prolapse.\emph{JAMA} . 2013 May 15;309(19):2016-24) without the
complication of mesh erosion.

The mixed bag of patient types and concomitant surgery in this study
underscores the myriad of pathology and presenting symptoms to the
pelvic floor surgeon; sadly, this reality hinders forensic evaluation of
the single procedure. It is noted that around three-quarters of the
women in the study were having primary prolapse surgery, with a similar
proportion undergoing some form of hysterectomy coupled with autologous
fascial vault support. Other sacrocolpopexy series have involved women
the majority who have already had primary procedures, are without a
uterus and represent an already failed and perhaps more difficult to
successfully treat group (Maher C, et al. Surgery for women with apical
vaginal prolapse. \emph{Cochrane Database Syst Rev.} 2016 Oct
1;10(10):CD012376.)~The addition of a hysterectomy, as well as the
harvesting of autologous fascia inevitably means a lengthening of
procedure time compared to those usually quoted for women undergoing
laparoscopic vault suspension procedures of hysteropexy or
sacrocolpopexy.

The complexities of pelvic floor patients and their symptoms mean that
additionally nearly 2/3 of the patients had Burch colposuspensions
performed at the time of index surgery. The unpredictability of pelvic
floor surgery on bladder symptoms is amply demonstrated by around 1/3 of
women complaining of stress incontinence and a third suffering
overactive bladder symptoms following the procedure. It's clear that
functional improvements do not always go hand in hand with anatomical
correction for the pelvic floor patient.

Many women remain alarmed by the adverse reports of mesh augmentation
surgery in gynaecology (Izett-Kay ML, et al 'What research was carried
out on this vaginal mesh?' Health-related concerns in women following
mesh-augmented prolapse surgery: a thematic analysis. \emph{BJOG} . 2021
Jan;128(1):131-139). Contemporary best practice involves distilling out
irrefutable principles such as recognising the importance of appropriate
apical support which is usually optimally achieved abdominally, as well
as an awareness of risks of surgery, careful counselling regarding mesh
and being able to offer evidence-based alternatives. This paper provides
valuable long-term data for a further promising meshless surgical
technique.

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