Table 1 summarizes the results of a randomized controlled study comparing the results of anterior colporrhaphy (AC) to those of mesh repair over the last 10 years [7891011121314151617181920212223]. When anatomic success was defined as achieving a POPQ stage 0 or 1, the results ranged from 39.5% to 75% for AC and 81.0% to 95% for mesh repair, with superior outcomes for mesh repair at 1-year follow-up [78101315161718]. In the mid-term follow-up (24–36 months), the results ranged from 39.5% to 86% for AC and 39.5% to 91.4% for mesh repair, indicating that mesh repair was superior in most studies [912142022].

Defining anatomic success as “No descent beyond the hymen (Ba ≤0)” yields different results. In some studies, AC showed anatomic success rates as high as 86% to 89%, which was not significantly different from the 84% to 96% success rates seen in mesh repair [112123]. However, in patients with severe POP (POPQ stage 3–4), the success rate for mesh repair (86.4%) was better than that for AC repair (70.4%) (p=0.019) [19].

Redefining the success of POP surgery has recently been suggested, and improvement of quality of life and patient satisfaction are now considered more important factors than anatomic success alone. The postoperative absence of vaginal bulge symptoms is significantly related to patient assessments of overall improvement and improvement in quality of life after surgery, while anatomic success alone does not ensure that vaginal bulge symptoms remain an important outcome assessment tool after POP surgery [5]. Several randomized trials have examined symptomatic success, using various measures such as the absence of vaginal bulge symptoms and several types of validated questionnaires (Table 1). When symptomatic success was defined as amelioration of vaginal bulge symptoms, symptoms remained in 0% to 37.9% of patients after AC, and in 5% to 24.6% after mesh repair [8910111417182122]. In half of the studies, the amelioration of bulging symptoms was superior to that in the mesh repair group, and the remaining studies did not reveal any significant differences between AC and mesh repair. A 2016 Cochrane review of anterior compartment prolapse reported that awareness of prolapse (risk ratio [RR], 0.56; 95% confidence interval [CI], 0.43–0.73) was significantly less common after mesh repair, compared to AC [24]. However, most questionnaires related to quality of life showed significant improvement after both treatments, but there was no significant difference in improvement between AC and mesh repair [71213192023]. Although the anatomic success of AC is inferior to that of mesh repair, it has some advantages for quality of life. However, the use of mesh should be considered for treating anterior compartment prolapse in order to reduce the risk of recurrence and improve symptoms.

The use of transvaginal mesh has been the subject of academic debate over the past decade. Vaginal mesh kits were first introduced in the USA in 2005 after being approved by the FDA in 2001 for POP repair. The vaginal mesh-kit is a simple device used for augmentation of native tissue in POP. Typically, the mesh consists of four arms and a main body that effectively covers both central defects and paravaginal defects. These standardized kits represent a departure from individualized assessments of patient anatomy [10]. Since their introduction into the market, the clinical use of mesh-kits has increased explosively, more quickly than evaluations of long-term safety have accumulated. In 2008, Sung et al. [25] reviewed studies comparing mesh use with native tissue for POP repair, and found that there was insufficient evidence to suggest that transvaginal mesh improves outcomes for POP. Adverse events associated with mesh were also evaluated, including erosion (0%–30%), visceral injury (1%–4%), urinary tract infection (0%–19%), and fistula formation (1%). Overall, the results suggested that well-designed and adequately powered randomized trials are needed. Feiner et al. [26] also assessed success and complications in all trials to date that used transvaginal mesh and found that apical augmentation with transvaginal mesh resulted in good surgical outcomes with the most common complication being mesh erosion, occurring in 4.6% to 10.7% of patients. In 2008, the FDA issued the first public health notification regarding complications associated with transvaginal mesh for POP repair. In 2009, Bako and Dhar [27] reported mesh erosion rates of 2% to 25% for anterior POP repair and mesh-related infection rates of up to 8%. In 2011, the FDA issued a safety communication updating the 2008 notification, as follows [28].

In response to increased reports of adverse events, the FDA concluded that transvaginal mesh has a higher complication rate than transabdominal mesh. In 2012, the FDA ordered mesh manufacturers to conduct post-market surveillance studies to evaluate efficacy and safety. In 2014, the FDA finally reclassified surgical mesh for POP as a class 3 (high-risk) device, with the reclassification formally implemented in January 2016. According to one study, vaginal mesh repairs decreased from 27% of POP repairs before 2008 to 15% after the first FDA notification in 2008 and 5% after the second notification in 2011, while the rates of minimally invasive surgeries such as laparoscopic or robotic sacral colpopexy or native tissue repair increased [29]. And finally, the FDA stopped selling transvaginal mesh for POP in April 2019. It does not apply to mesh products used to treat other conditions such as hernias or incontinence. The situation in Europe regarding the use of meshes in POP repair is no different. In 2014, the Medicines and Healthcare Products Regulatory Agency (MHRA) announced an official position on mesh for POP surgery, concluding that the use of mesh for POP surgery is safe and effective for the majority of patients, and that further research should be performed regarding implant types and surgical techniques. According to the official announcement of the National Institute for Health and Care Excellence (NICE) in April 2019, mesh should be considered as a final option for POP repair. In addition, when using a mesh, it is recommended that the patient be fully informed of outcomes and the possibility of mesh complication [30].

Is the use of synthetic mesh dangerous? It is important to not misunderstand the FDA's warning. Mesh exposure rates range from 3.2% to 20.5% according to recent randomized controlled studies and 3.1% to 14.4% according to single-arm studies. Mesh erosion rates vary between studies, so the risk of using synthetic mesh for POP cannot be determined. The mesh erosion rates for midurethral slings in patients with SUI also vary from study to study. In a study that analyzed 388 complications, the mesh erosion rate of the retropubic approach was 11.4% (24/210) and that of the transobturator approach was 25.7% (18/70) [31], which were moderately higher than the general mesh erosion rate of midurethral slings (3%–5%) [32]. Even when higher complication rates are reported, midurethral slings are not considered risky. In addition, when mesh exposure occurs, most cases are asymptomatic and conservative management can be expected to resolve symptoms. Patients who needed surgical treatment due to mesh exposure made up 0% to 16.4% of patients in randomized controlled trials [78910121314151617181920212223] and 1.7% to 8.9% in single-arm studies [3334353637], accounting for only half of all patients with mesh exposure (Table 2). Comprehensively judging the recent literature and based on our experience, we suggest that how to select the proper patient is more important. Proper patient selection as well as improvements of surgical technique is essential for optimizing the success of mesh repair. Severe prolapse (stage 3 or 4), patient age younger than 60 years, diabetes mellitus, and recurrent prolapse are associated with recurrent prolapse after native tissue repair, and it is necessary to consider mesh repair in these patients [38]. To date, known risk factors for mesh complications include diabetes, smoking, pelvic irradiation, and vaginal surgery [32]. In terms of surgical technique, full thickness vaginal wall dissection into the true vesicovaginal spaces is an integral technique for optimal mesh placement. The mesh should be placed flat without folding or excessive tension on the mesh.

The identification and correction of apical prolapse is critical to reduce recurrence after POP repair. Clinically significant apical prolapse is virtually always present in cases with both anterior and posterior compartment prolapse. If the anterior vaginal wall was at least 2 cm outside the hymen, 80% of the vaginal apices prolapsed to at least 2 cm inside the hymen, and 55% of the apices prolapsed >2 cm outside the hymen [39]. Another study also found that almost 60% of patients with stage 2 or greater cystoceles had clinically significant apical vaginal descent. As cystocele stage increases, the predictive value of apical prolapse also increases [40]. A study of over 2,700 women comparing isolated anterior repair versus combined anterior and apical repair found that 10-year reoperation rates were lower in the combined anterior and apical repair group (11.6% vs. 20.2%) [41]. These findings are important as a basis for preventing recurrences, apart from a simple correlation between apical support and anterior support. Proper suspension of the vaginal apex is an essential factor for treatment success in cases of anterior compartment prolapse. Although concurrent apical repair is an obvious modifiable factor that can reduce the risk of recurrence, there are surgeons who perform anterior compartment repair without prior careful vaginal examination. According to US data, the proportion of anterior repairs without apical suspension decreased from 77.7% in 2004 to 41.4% in 2012 (p<0.001). Since 2011, there has been a decrease in the number of anterior repairs without apical suspension, notably among clinicians applying for Female Pelvic Medicine and Reconstructive Surgery (FPMRS) certification (17.1% vs. 30.7% by all other urologists, p<0.001). Nonacademically-affiliated urologists are 2.1 times more likely to report anterior repair without apical suspension than academically-affiliated colleagues (p<0.001) [42]. Therefore, it is necessary to improve POP repair practice through lifelong education, and surgeons who incapable of adequately assessing apical prolapse and correspondingly performing apical suspension should not attempt anterior compartment prolapse repair.

Although open sacrocolpopexy is a good treatment option for apical prolapse repair, with long-term success rates of 78% to 100%, it is associated with increased length of hospital stay, analgesic requirements, and cost compared with transvaginal procedures [4445]. New surgical techniques such as LSC or RSC have been developed to overcome these limitations. Compared with open sacrocolpopexy, LSC or RSC decreases overall morbidity and has good anatomical durability [46474849505152]. Freeman et al. [47] performed a randomized study comparing open sacrocolpopexy and LSC in patients with vault prolapse, and found that the methods demonstrated clinical similar recurrence rates at 1 year. In 2016, Costantini et al. [52] conducted the longest randomized follow-up study (mean follow-up of 41.7 months) comparing open sacrocolpopexy and LSC, and found that both techniques are efficacious with no patients in their sample experiencing apical recurrences. The 2016 Cochrane review [43] reported that there may be no difference between the results of LSC and open sacrocolpopexy for repeat surgery for prolapse (RR, 1.04; 95% CI, 0.16–6.80).

Although LSC seems to overcome the shortcomings of open sacrocolpopexy, LSC is technically more challenging for those who are not proficient in laparoscopy. Since 2004, the implementation of RLC has allowed surgeons with good dexterity and precision to offer the procedure as an alternative to LSC. The learning curve is feasible without the need for laparoscopic skills. One of the largest prospective studies of RSC (n=120) showed that the anatomical success rate was 89% with 12-month follow-up [53]. According to a recent systematic review of LSC vs. RSC, RSC is associated with longer operation time, increased postoperative pain, and higher cost than LSC. However, both surgical options showed similar results regarding improvement of symptoms [54].

There are three options for the presence of prolapsed uterus in patients with apical prolapse: sacrohysteropexy, which fixes the uterus and vagina with a mesh to the sacral promontory, thereby preserving the uterus; supracervical hysterectomy with sacrocervicocolopopexy, which does not preserve the uterus; and sacrocolpopexy after total hysterectomy with closure of the vaginal cuff. Hysteropexy has the advantage of maintaining fertility and natural menopausal timing by preserving the uterus, and 36% to 60% of female patients choose uterine preservation assuming equal surgical efficacy. In addition, removal of the uterus may result in disruption of the uterosacral-cardinal ligaments and further weaken vaginal support. If there is no contraindication for uterine preservation, sacrohysteropexy may offer benefits. However, there is less surgical outcome data available for sacrohysteropexy, and the procedure requires continuous surveillance of the cervix and endometrium.

In an effort to decrease the morbidity associated with open sacrocolpopexy, RSC, which decreases the difficulty associated with laparoscopic knot tying, and 3-dimensional visualization aiding sacral dissection, has rapidly gained popularity. However, variation in surgical technique includes the amount of vaginal dissection, type of mesh, number or location of sutures that should be placed to secure the suspending mesh, retroperitonealization of the mesh, and cervix preservation [6364].

Single port approaches herald a new era in the field of minimally invasive surgery, with good cosmetic results and reduced patient morbidity compared with multiport surgery. Although single port robotic surgery is in an early stage of development, it has been implemented in various surgical fields. Since 2017, a few reports describing single port RSC have demonstrated that it is a feasible technique [74757677]. In 2017, Matanes et al. [76] reported their first 25 experiences with single port RSC and demonstrated significant decreases in median total operative and console times (226 minutes for the first 15 cases vs. 156 minutes for the next 10 cases), decreases that were within the same range as that reported for initial experiences with multiport access. There were no intraoperative adverse events. There was 1 case of small bowel obstruction that required reoperation, but this patient did not achieve retroperitonealized over the mesh, which altered the surgeon's approach toward all subsequent patients. Recently, Liu et al. [75] published a case series of patients treated with single port RSC following a modified technique. They attempted retroperitoneal tunneling techniques and asserted that they could more easily perform these techniques via a single port approach. A retroperitoneal tunnel was created by undermining the peritoneum with an articulated needle driver. The needle driver was placed in the peritoneal opening over the sacral promontory, and the tunnel was created just medial to the right uterosacral ligament in the direction of the vaginal vault by using forward pressure and a sweeping motion to create a space within the retroperitoneum. This approach allowed for easier adjustment and maintenance of mesh tension during the placement of sutures in the sacral promontory compared with opening the entire retroperitoneal space, and may reduce operative time and adhesion formation.