Introduction
The high recurrence rate (30%) after surgery for pelvic organ prolapse (POP) makes a more refined
reconstructive surgery imperative [1]. There are some risk factors for POP recurrence, e.g. poor tissue quality before and during surgery, impaired healing, chronic diseases causing increased intra-abdominal pressure (due to obstructive pulmonary disease, asthma or con-stipation), high-grade cystocele, and age 60 years or older [2,3]. Patients with risk factors may benefit from adjuvant prosthetic materials during pelvic reconstruc-tive surgery. Therefore, biological and synthetic prosthe-ses have emerged as adjuvant prosthetic materials [4]. Through the evolution of pelvic reconstructive surgery, prostheses have played important roles as reinforcement
T
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ROSTHESES IN
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Ming-Ping Wu1,2*
1Division of Urogynecology and Pelvic Floor Reconstruction, Department of Obstetrics and Gynecology, Chi Mei Foundation Hospital, Tainan, and 2Department of Obstetrics and Gynecology, College of Medicine, Taipei Medical University, Taipei, Taiwan.
SUMMARY
The high recurrence rate of pelvic organ prolapse (POP) of up to 30% after pelvic reconstructive surgery makes a more refined surgery imperative, as well as the need for either biological or synthetic prostheses as adjuvant treatment. Patients with recurrence risks may benefit from the adjuvant treatment: (1) to substitute for the lack of supportive tissue; (2) to reinforce inadequate tissue; (3) to induce new supportive tissue; and (4) to consolidate and complement the insufficient surgical techniques. However, some debatable issues in use of the prosthetics remain. The use of prosthetics enables the simultaneous repair of all vaginal defects of POP and concomitant anti-incontinence surgery to be faster, easier and more precise. Nevertheless, great care should be devoted to the actual and theoretical short- and long-term risks, many of which have not been fully elucidated. Despite the lack of various ideal characteristics, the type I monofilament, macroporous polypropylene, has been suggested to have the lowest incidence of infection and erosion among the nonabsorbable prostheses. There is good evidence to support the use of nonabsorbable synthetic mesh for abdominal sacrocolpopexy, while the use of prostheses for repairing isolated anterior and posterior compartment defects remains controversial. There have been no long-term studies with sufficient patient numbers to prove whether synthetic or biological prostheses are superior during vaginal surgery. Tension-free vaginal mesh techniques with procedural kits are being adopted increas-ingly, despite the paucity of data. Although short-term follow-up studies have shown tension-free vaginal mesh to be a safe and effective technique to correct POP, anatomic and functional results of long-term follow-up studies, however, have not yet confirmed the effectiveness and safety. Mesh erosion remains a concern, with variable rates according to different materials and approaches. Newly developed prostheses offer an alternative option to pelvic reconstructive surgery. However, some questions remain: (1) Should prostheses be considered for primary repairs, secondary repairs, or solely in patients with risk factors for recurrence? (2) Which prosthetic material is better: synthetic or biological ones; absorbable or nonabsorbable ones? (3) Do the benefits of pros-thetics in pelvic reconstructive surgery outweigh the risks of complications? These questions are explored and reports in the literature reviewed. [Taiwan J Obstet Gynecol 2008;47(2):151–156]
Key Words:pelvic organ prolapse, pelvic reconstructive surgery, prosthesis, tension-free vaginal mesh
*Correspondence to: Dr Ming-Ping Wu, Division of Urogynecology and Pelvic Floor Reconstruction, Department of Obstetrics and Gynecology, Chi Mei Foundation Hospital, 901, Chung Hwa Road, Yung Kang City, Tainan, Taiwan.
E-mail: mpwu@mail.chimei.org.tw Accepted: January 4, 2008
adjuvant (Figure). Once a successful material is identi-fied or developed, it may decrease operating time and morbidity during vaginal surgeries. However, some de-batable issues in the use of prostheses for pelvic floor reconstructive surgery remain.
Prostheses can serve as a scaffold for tissue in growth after pelvic reconstructive surgery with the purpose to: (1) substitute for the lack of supportive tissue; (2) rein-force inadequate tissue; (3) induce new supportive tissue growth; and (4) consolidate and complement insuffi-cient surgical techniques [5]. With the use of prosthe-ses, the surgeon can repair all vaginal defects faster, easier and more accurately. In the anterior compart-ment, a graft can be anchored bilaterally to the arcus tendineus fasciae pelvis, re-creating a level II attachment. In the apical and posterior compartment, it is located apical and posterior to the level of the ischial spine, re-creating a level I support [6]. Prostheses can also be potentially used to treat stress urinary incontinence con-comitantly using different shaped materials [7]. The ideal pelvic reconstructive surgery of severe cystocele should include repair of bladder herniation, correction of coincident stress urinary incontinence without causing obstruction, and retention or improvement of vaginal depth and axis [8].
Historically, the use of synthetic nonabsorbable pros-theses, recently reviewed by Birch [9], dates to the beginning of the 20thcentury with the use of metallic
silver mesh as early as 1903, which was followed by the use of nylon mesh in 1938, and Dacron (Mersilene) in 1956. Mersilene was a popular prosthetic material for many decades, but its use is rapidly declining in favor of polypropylene, which is now the most commonly used
synthetic product and was introduced as Marlex in 1958 [9].
With the accumulating experience in general sur-gery, more recent reports in the surgical literature has suggested the routine use of synthetic prosthesis for all primary hernia repairs. Luijendijk et al [10] reported on the recurrence rates of inguinal hernias following primary suture repair compared with augmented repair employing a synthetic graft, with a 43% recurrence in the suture repair group versus 24% in the mesh aug-mented repairs after 3 years of follow-up. Surgical prin-ciples for the correction of POP are similar to those employed for abdominal wall hernias. Gynecologists performing reconstructive pelvic floor surgery have begun to adopt these surgical principles and are using a variety of synthetic and biological products for both primary and secondary prolapse surgeries. Nevertheless, great care should be devoted to actual and theoretical short-and long-term risks, many of which have not been fully elucidated. In this review article, the characteristics of the different prostheses, the use synthetic prostheses for pelvic reconstructive surgery, and the associated complications of prostheses are included.
Characteristics of Different Prostheses
The ideal prosthesis should be sterile, durable, noncar-cinogenic, inexpensive, easily applied, and causes no antigenic response but withstands remodeling by body tissues [11]. Current prostheses are either synthetic (absorbable, nonabsorbable or mixed) or biological (autologous, allograft or xenograft donor tissue) for the purpose of integrating with the host tissue and supporting the attenuated areas.Synthetic absorbable and nonabsorbable materials
These implants differ not only with respect to the material (polyethylene, polypropylene, polypropylene terephthalate, Gore-Tex) but also in terms of structure (woven, knitted), fiber type (monofilament, multifila-ment, monofilament/multifilament), pore size, mechan-ical properties, shape, and surface characteristics [12]. Most commercially available synthetic prostheses in surgical fields are listed in the Table according to the Amid classification [13].
● Nonabsorbable materials: e.g. Prolene (Ethicon, Somerville, NJ, USA), Marlex (Bard, Cranston, RI, USA), Atrium (Atrium, Hudson, NH, USA), Gore-Tex (Gore, Flagstaff, AZ, USA), Mersilene (Ethicon, Somerville, NJ, USA), and Teflon (DuPont, Wilmington, DE, USA), Cellgard (Hoechst-Celanese, Charlotte, NC, USA).
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Vaginal total hysterectomy + anterior-posterior colporrhaphy Tension-free vaginal mesh with procedural kits*
Vaginal repair of anterior, posterior compartment+ mesh
Abdominal sacrocolpopexy ± mesh
Sacrospinous ligament suspension
Figure. The evolution of pelvic reconstructive surgeries. *Include Prolift (Gynecare, Ethicon, Somerville, NJ, USA); Perigee and Apogee (American Medical Systems, Minnetonka, MN, USA); posterior intravaginal slingplasty (United States Surgical, Tyco Healthcare, Norwalk, CT, USA); Nazca (Promedon, Cordoba, Argentina).
● Absorbable materials: e.g. Vypro, Vicryl (Ethicon, Somerville, NJ, USA).
Biological materials
Biological materials are categorized as follows:
● Xenograft: porcine small intestine submucosa (SIS; Cook, Letchworth, UK), bovine pericardium, and Pelvicol (Bard, Billerica, MA).
● Allograft: dura mater, fascia lata.
● Autologous material: rectus sheath, fascia lata, and vaginal mucosa.
The newly developed absorbable material called SIS (Cook, Lafayette, IN, USA) is also worth our attention [14]. SIS is a natural biomaterial harvested from the porcine small intestine and made into a biocompatible medical product. The emergence of absorbable material may bring a new era; however, owing to limited number of reports in the literature, the long-term effect remains unknown.
Since no ideal prosthesis with the various character-istics is available, the search for the optimal prosthesis remains uncertain.
Synthetic Prostheses for Pelvic
Reconstructive Surgery
Abdominal sacrocolpopexy
The efficacy of nonabsorbable synthetic prostheses for abdominal sacrocolpopexy is assured by supportive evidence [15]. There have been many reports in the lit-erature on the support of the middle compartment.
First described by Lane in 1962 [16], sacrocolpopexy has undergone numerous modifications, including the type of prosthesis used and placement onto the anterior and posterior walls of the vagina. In a recent comprehen-sive review of 98 articles on abdominal sacrocolpopexy, the success rate, when defined as lack of apical pro-lapse postoperatively, was 78–100% and when defined as no postoperative prolapse, was 58–100%; the follow-up duration for most studies ranged from 6 months to 3 years. The median rate for a second operation for POP and/or stress urinary incontinence after abdomi-nal sacrocolpopexy was 4.4% (range, 0–18.2%) [17]. Synthetic rather than biological prostheses for bridg-ing the vagina to the sacrum was supported by a recent randomized trial by Culligan et al [18], who asserted that polypropylene mesh (91% cure) was better than cadaveric fascia lata (68% cure) for abdominal sacro-colpopexy (p= 0.007) at 1 year of follow-up. There were significant differences in favor of the polypropylene mesh group at points Aa and C of the POP quantification system, as well as overall prolapse stages [18]. Fitzgerald et al [19] also noted poor anatomic outcomes (the failure rate of 83% by 17 months) when freeze-dried, irradiated donor fascia lata was used for abdominal sacrocolpopexy.
Vaginal repair of the anterior and posterior compartments
The data available on synthetic nonabsorbable pros-theses are sparse and largely consist of small retrospec-tive series with short-term follow-up. Julian [20] first described anterior vaginal colporrhaphy with prosthetic Table.Classification of synthetic prostheses
Type Fiber type Pore size Component Brand names
Type I Monofilament > 75 µm Polypropylene Prolene (Ethicon, Somerville, NJ, USA)
macroporous Marlex (Bard, Billerica, MA, USA)
Atrium (Atrium, Hudson, NH, USA)
Type II Monofilament <10 µm ePTFE Gore-Tex (Gore, Flagstaff, AZ, USA)
microporous
Type III Multifilament Polyethylene Dacron (Mersilene; Ethicone, Somerville, NJ, USA)
microporous/ Teflon (DuPont, Wilmington, DE, USA)
macroporous SurgiPro (Autosuture, Tyco Healthcare,
Norwalk, CT, USA)
Type IV Submicronic < 1 µm Polypropylene sheet Silastic (Dow Corning, Midland, MI, USA) Cellgard (Hoechst-Celanese, Charlotte,
NC, USA)
Absorbable Monofilament/ Polypropylene/ Vypro (Ethicon, Somerville, NJ, USA)
multifilament polyglactin 910
Multifilament Polyglactin 910 Vicyl (Ethicon, Somerville, NJ, USA)
reinforcement in 1996. The prospective study used Marlex (Bard, Billerica, MA, USA), a type I monofila-ment polypropylene prosthesis, which was randomly allocated to 24 patients with anterior colporrhaphy with or without prosthetic reinforcement, and showed suc-cess rates of 100% and 66%, respectively, at 24 months’ follow-up; however, there was a high erosion rate of 25% (4 /12) [20]. A retrospective analysis by Flood et al [21] of 142 women using Marlex revealed a success rate (prolapse less than grade 1) of 100% at a mean follow-up of 36 months, with no prosthetic-related complica-tions. Dwyer and O’Reilly [22] used a polypropylene prosthesis (Atrium) in the anterior and posterior com-partments and showed a recurrence rate of 6%. de Tayrac et al [23] reported a recurrence rate of 8% and seven erosions (8.3%) using the polypropylene pros-thesis Gynemesh (Gynecare, Ethicon, Somerville, NJ, USA) on 87 women with a mean follow-up of 24 months. The studies using polypropylene meshes to augment the surgically corrected anterior vaginal prolapse showed success rates of 87% [24], 91.6% [23], and 100% [25]. The researchers concluded that the use of nonabsorbable prosthetic reinforcement appeared to be an effective method of preventing prolapse recurrences; however, the concerns included the short-term follow-up periods and material erosion rates.
Owing to the limited number of reports on graft augmentation in the posterior vaginal wall, the data on the effects of graft augmentation on the bowel, bladder and sexual function are limited. Milani et al [25] reported a prospective observational cohort of 63 women who had conventional anterior (n= 32) or posterior (n= 31) colporrhaphies augmented with poly-propylene mesh. Both groups had excellent anatomic outcomes at 12 months after surgery (94% with stage 0) but had significant increases in the rates of dyspareu-nia. Of those who had anterior mesh repairs, 20% had worsening dyspareunia after their repairs, while 63% of those who had posterior mesh repairs developed wors-ening dyspareunia [25]. The authors concluded that while the studies showed good anatomic results with the use of Prolene mesh for vaginal prolapse repairs, the morbidity rates, however, were high [25]. In addi-tion, Deffieux et al [26] reported a comparable inci-dence of de novo dyspareunia in patients with vaginal erosion and those without it (9% vs. 11%; p= 0.85).
The use of synthetic absorbable prostheses is a response to the morbidity arising from the erosion rates with the use of synthetic nonabsorbable prostheses. Two prospective randomized controlled trials compared synthetic absorbable prostheses, polyglactin 910 (Vicryl; Ethicon, Somerville, NJ), with traditional transvaginal repairs. Sand et al [27] studied 161 women (21 recurrent
and 140 primary), with significantly lower recurrence rates found in the prosthetic-reinforced repair group compared with the non-reinforced group (25% vs. 43%; p= 0.002) at 12 months of follow-up. Weber et al [28] undertook a prospective three-armed randomized con-trolled trial on 114 patients and found that absorbable augmented meshes (polyglactin 910 mesh) did not im-prove anatomic results at a mean follow-up of 23 months (range, 4.5–44 months).
Tension-free vaginal mesh (TVM) techniques with procedural kits
The TVM techniques with procedural kits, which include disposable insertion needles, retrieval devices and pieces of polypropylene mesh, are increasingly being adopted, e.g. anterior, posterior and total Prolift (Gynecare, Ethicon, Somerville, NJ, USA), Apogee and Perigee (American Medical Systems, Minnetonka, MN, USA), and Nazca (Promedon, Cordoba, Argentina). These TVM techniques with procedure kits were designed to offer a simple and efficient surgical technique, re-duce the surgery time, shorten the learning curve, transfer the anchoring arms simply and precisely, and simplify the tension-free system. Also, the use of monofilament macroporous polypropylene mesh improves tissue inte-gration, promotes tissue ingrowth, and minimizes ero-sion and exposition risk. Therefore, they potentially offer a minimally invasive approach by the ergonomically designed handle system. Based on a retrospective mul-ticentric study, the perioperative and immediate post-operative results demonstrated a failure rate (recurrent prolapse even asymptomatic or low grade symptomatic prolapse) of 4.7% (5/110) [29]. The authors concluded that the Prolift repair seems to be a safe technique to correct POP. However, anatomic and functional results of a long-term follow-up study has not confirmed the effectiveness or safety of the procedure [29].
In summary, the synthetic prostheses for sacrocol-popexy are well established yet remain controversial for repairing isolated anterior and posterior compartment defects. No long-term studies with sufficient patient numbers have been conducted to conclude whether synthetic or biological prostheses are superior for use in vaginal surgery.
Complications of Use of Prostheses in
Pelvic Reconstructive Surgery
Mesh erosion remains a major concern in the use of prostheses in pelvic reconstructive surgery. In the study by Nygaard et al [17], the complications attributable to erosion occurred in 3% of patients in 20 studies of
abdominal sacrocolpopexy. The posterior placement of prosthesis to the perineal body using a combined abdominal and vaginal approach was associated with a high sepsis and erosion rate (40%) [30].
Based on a retrospective study of 138 transvaginal repairs of cystocele using Gynemesh or Gynemesh Soft mesh, age was an independent predictive factor of vagi-nal erosion (age, > 70 years; odds ratio, 3.6; p = 0.010). On the contrary, cystocele stage of more than 2 (Baden and Walker classification) was a protective factor against vaginal erosion (odds ratio, 0.3; p= 0.016) [26].
Mesh erosion differs in different types of prostheses
Erosion rates vary according to the different types of prostheses. Early experience with type II and type III synthetic prostheses for pelvic reconstructive surgery was associated with a significantly high postoperative mesh erosion rate of 20–30% after Dacron or Gore-Tex use [15,31]. The woven, multifilament nature of these mesh materials might cause limited host tissue ingrowths, leading to erosions, draining sinuses and fistulae. More recently, some concern has arisen about a relatively high erosion rate (17%) seen with the intravaginal slingplasty (United States Surgical, Tyco Healthcare, Norwalk, CT, USA) sling material [32]. The erosion rate decreased to 0.5–5% by using type I synthetic prosthesis [29]. The erosion rate of the currently available synthetic pros-thesis has been reported to be 0.5% for polypropylene, 3.1% for polyethylene terephthalate (Mersilene; Ethicon, Somerville, NJ, USA), 3.4% for Gore-Tex (Gore, Flagstaff, AZ, USA), 5.0% for polyethylene (Marlex; Bard, Billerica, MA, USA), and 5.6% for Teflon (DuPont, Wilmington, DE, USA) [17].
Mesh erosion differs in different approaches
Erosion rates also vary according to the different types of approaches. Visco et al [30] retrospectively analyzed Mersilene mesh erosion rates in 273 women who had undergone sacrocolpopexy or sacral colpoperineopexy; the overall risk of erosion was 3.2% for abdominal sacrocolpopexy (median time to erosion, 15.6 months) and 4.5% for abdominal sacral colpoperineopexy (median time to erosion, 12.4 months), by introducing the prostheses and sutures abdominally. Erosion rate increased to 16% when sutures were placed vaginally and attached to an abdominally introduced mesh dur-ing sacral colpoperineopexy (median time to erosion, 9.0 months). When the mesh was introduced vaginally, the erosion rate peaked at 40% (median time to ero-sion, 4.1 months). The three most recent studies of polypropylene mesh augmenting the surgical correction of anterior vaginal prolapse reported an erosion rate of 8.3–13% [23–25]. Deffieux et al [26] recommended
that vaginal mesh placement should be avoided for women with moderate cystocele, and those with total hysterectomy and vertical incision, if possible. Managing vaginal erosion is simple and associated with a low rate of morbidity. However, patients should be informed of the risk of postoperative mesh erosion.
TVM techniques with procedural kits
Analyzing the first 100 TVM procedures with proce-dural kits revealed a 17.5% erosion rate, which fell to 2.7% when T-shaped colpotomies, concomitant hyster-ectomy and perineal incisions were avoided [33]. In a retrospective multicentric study of 110 patients, peri-operative and immediate postperi-operative results showed mesh exposure in five cases (4.7%), two of which required surgical management [29]. Granuloma without exposure was found in three cases (2.8%) [29].
The choice for better prosthetic materials
The choices for better materials are of prime importance. Synthetic prostheses types II and III have resulted in unacceptably high rates of postoperative erosion and should be abandoned. One of the potential advan-tages of absorbable or biological prostheses is the low erosion rate. If erosion occurs, conservative manage-ment should be used and surgery is seldom required [9]. Although the reports in the literature are difficult to interpret because of the diversity of studies and other factors, synthetic grafts generally may have slightly higher success rates but higher erosion rates, whereas biological materials appear to be better tolerated with lower erosion rates [9]. Current evidence suggests that the use of monofilament, macroporous polypropylene has the lowest incidence of infection and erosion when compared among the nonabsorbable meshes [4].
Unanswered Questions and Discussion
The evolution of newly developed prostheses offers a new era in pelvic reconstructive surgery. However, some unanswered questions remain: (1) Should prostheses be considered for primary repairs, secondary repairs or solely in patients with risk factors for recurrence (diabetics, obesity, steroid use, chronic respiratory dis-ease)? (2) No ideal prostheses with the various charac-teristics are available now. Which prosthesis is optimal: synthetic nonabsorbable, synthetic absorbable, mixed synthetic or biological prostheses? (3) Do the benefits of prostheses for pelvic reconstructive surgery out-weigh their risk of complications? Therefore, further well-designed randomized control trials as well as basic studies are needed to answer these questions.References
1. Olsen AL, Smith VJ, Bergstrom JO, Colling JC, Clark AL. Epidemiology of surgically managed pelvic organ prolapse and urinary incontinence. Obstet Gynecol 1997;89:501–6. 2. Whitesides JL, Weber AM, Meyn LA, Walters MD. Risk
fac-tors for prolapse recurrence after vaginal repair. Am J Obstet
Gynecol 2004;191:1533–8.
3. Whitesides JL, Weber AM, Meyn LA, Walters MD. Risk factors for prolapse recurrence after vaginal repair. Obstet
Gynecol Surv 2005;60:164–5.
4. Birch C, Fynes MM. The role of synthetic and biological prostheses in reconstructive pelvic floor surgery. Curr Opin
Obstet Gynecol 2002;14:527–35.
5. Baessler K, Maher CF. Mesh augmentation during pelvic-floor reconstructive surgery: risks and benefits. Curr Opin
Obstet Gynecol 2006;18:560–6.
6. DeLancey JO. Anatomic aspects of vaginal eversion after hysterectomy. Am J Obstet Gynecol 1992;166:1717–24; discus-sion 1724–8.
7. Kobashi KC, Mee SL, Leach GE. A new technique for cysto-cele repair and transvaginal sling: the cadaveric prolapse repair and sling (CAPS). Urology 2000;56(6 Suppl 1):9–14. 8. Ng CC, Chong CY. The effectiveness of transvaginal
ante-rior colporrhaphy reinforced with polypropylene mesh in the treatment of severe cystoceles. Ann Acad Med Singapore 2006;35:875–81.
9. Birch C. The use of prosthetics in pelvic reconstructive surgery.
Best Pract Res Clin Obstet Gynaecol 2005;19:979–91.
10. Luijendijk RW, Hop WC, van den Tol MP, et al. A compari-son of suture repair with mesh repair for incisional hernia.
N Engl J Med 2000;343:392–8.
11. Karlovsky ME, Kushner L, Badlani GH. Synthetic biomaterials for pelvic floor reconstruction. Curr Urol Rep 2005;6:376–84. 12. Cosson M, Debodinance P, Boukerrou M, Chauvet MP, Lobry P, Crépin G, Ego A. Mechanical properties of syn-thetic implants used in the repair of prolapse and urinary incontinence in women: which is the ideal material? Int
Urogynecol J Pelvic Floor Dysfunct 2003;14:169–78.
13. Amid PK. Classification of biomaterials and their related complications in abdominal wall hernia surgery. Hernia 1997;1:15–21.
14. Mostow EN, Haraway GD, Dalsing M, Hodde JP, King D. Effectiveness of an extracellular matrix graft (OASIS Wound Matrix) in the treatment of chronic leg ulcers: a randomized clinical trial. J Vasc Surg 2005;41:837–43.
15. 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 77.
16. Lane FE. Repair of posthysterectomy vaginal-vault prolapse.
Obstet Gynecol 1962;20:72–7.
17. Nygaard IE, McCreery R, Brubaker L, et al. Abdominal sacrocolpopexy: a comprehensive review. Obstet Gynecol 2004; 104:805–23.
18. Culligan PJ, Blackwell L, Goldsmith LJ, Graham CA, Rogers A, Heit MH. A randomized controlled trial comparing fascia
lata and synthetic mesh for sacral colpopexy. Obstet Gynecol 2005;106:29–37.
19. Fitzgerald MP, Edwards SR, Fenner D. Medium-term follow-up on use of freeze-dried, irradiated donor fascia for sacro-colpopexy and sling procedures. Int Urogynecol J Pelvic Floor
Dysfunct 2004;15:238–42.
20. Julian TM. The efficacy of Marlex mesh in the repair of severe, recurrent vaginal prolapse of the anterior midvaginal wall.
Am J Obstet Gynecol 1996;175:1472–5.
21. Flood CG, Drutz HP, Waja L. Anterior colporrhaphy rein-forced with Marlex mesh for the treatment of cystoceles.
Int Urogynecol J Pelvic Floor Dysfunct 1998;9:200–4.
22. Dwyer PL, O’Reilly BA. Transvaginal repair of anterior and posterior compartment prolapse with Atrium polypropylene mesh. BJOG 2004;111:831–6.
23. de Tayrac R, Gervaise A, Chauveaud A, Fernandez H. Tension-free polypropylene mesh for vaginal repair of anterior vaginal wall prolapse. J Reprod Med 2005;50:75–80.
24. Salvatore S, Soligo M, Meschia M. Prosthetic surgery for genital prolapse functional outcome. Neurourol Urodyn 2002; 21:296–7.
25. 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;112:107–11.
26. Deffieux X, de Tayrac R, Huel C, et al. Vaginal mesh erosion after transvaginal repair of cystocele using Gynemesh or Gynemesh-Soft in 138 women: a comparative study. Int
Urogynecol J Pelvic Floor Dysfunct 2007;18:73–9.
27. Sand PK, Koduri S, Lobel RW, Winkler HA, Tomezsko J, Culligan PJ, Goldberg R. Prospective randomized trial of polyglactin 910 mesh to prevent recurrence of cystoceles and rectoceles. Am J Obstet Gynecol 2001;184:1357–62; discussion 1362–4.
28. Weber AM, Walters MD, Piedmonte MR, Ballard LA. Anterior colporrhaphy: a randomized trial of three surgical techniques. Am J Obstet Gynecol 2001;185:1299–304; discus-sion 1304–6.
29. Fatton B, Amblard J, Debodinance P, Cosson M, Jacquetin B. Transvaginal repair of genital prolapse: preliminary results of a new tension-free vaginal mesh (Prolift technique) – a case series multicentric study. Int Urogynecol J Pelvic Floor
Dysfunct 2007;18:743–52.
30. Visco AG, Weidner AC, Barber MD, Myers ER, Cundiff GW, Bump RC, Addison WA. Vaginal mesh erosion after abdom-inal sacral colpopexy. Am J Obstet Gynecol 2001;184:297–302. 31. Debodinance P, Cosson M, Burlet G. Tolerance of synthetic tissues in touch with vaginal scars: review to the point of 287 cases. Eur J Obstet Gynecol Reprod Biol 1999;87:23–30. 32. Siegel AL, Kim M, Goldstein M, Levey S, Ilbeigi P. High
incidence of vaginal mesh extrusion using the intravaginal slingplasty sling. J Urol 2005;174:1308–11.
33. Debodinance P, Berrocal J, Clave H, et al. Changing attitudes on the surgical treatment of urogenital prolapse: birth of the tension-free vaginal mesh. J Gynecol Obstet Biol Reprod
