Discussion 123 sacrocolpopexy is associated with an overall high patient satisfaction and functional improvement in patient quality of life.31 Since its first introduction in 1962, sacrocolpopexy has advanced significantly in terms of outcomes, procedural steps and risk profile. However, to this day, areas for improvement remain. One of the main concerns when using synthetic mesh is the occurrence of graft related complications. One of the claimed factors associated with the occurrence of graft-related complications, is the nature of the implant used. Experimental evidence, including from our team, suggests lighter-weight, more porous meshes experimentally induce a milder host response, potentially reducing the risk of complications, yet theoretically at the expense of higher recurrence rates.159 In our prospective cohort study, we found that at a median of 8 years after the index procedure, patients implanted with heavier weight polypropylene mesh were six times more likely to develop symptomatic graft-related complications, and five times more likely to undergo a reintervention for graft-related complications. The overall median exposure rate of sacrocolpopexy mesh reported in a recent systematic review is lower than in our report (1.9% vs 12.9%).144 This can be explained by the lack of (1) systematical clinical assessment of patients in the former studies, making an underreporting of asymptomatic exposures likely; and (2) long-term follow-up. In our experience the majority of graft related complications, hence reinterventions for this reason, occurred later on (>12 months) and the incidence increased slowly with time. Not only the mesh type but also the amount of foreign material used, may contribute to the occurrence of graft related complications. The rise in reluctance to have mesh inserted during the past decade prompts the need for exploration of the potential benefit of “mesh-less” surgical alternatives. In cervicosacropexy or vaginosacropexy, site-specific defect repair requires less mesh and therefore could be an alternative surgical approach to correct apical prolapse. However, our systematic review demonstrated that current evidence remains scarce and is of low quality and therefore this procedure needs a further thorough appraisal, according to the IDEAL framework133,134, before implementation in clinical practice. We considered a stage 2B exploration by a prospective cohort study but this was logistically not doable in our context. Other parameters that contribute to the risk of mesh morbidity following sacrocolpopexy include the choice of sutures for mesh fixation and/or performing a concomitant hysterectomy. Based on level I evidence, with no established anatomical benefit and a higher rate of suture exposure, the use of permanent sutures for vaginal attachment of mesh at the time of sacrocolpopexy cannot be recommended.216 Interestingly, most of the studies on the use of sacrocolpopexy were in patients with previous hysterectomy, in other words vault prolapse. In case of uterine prolapse, favorable anatomical outcomes for sacrocolpopexy with concomitant total hysterectomy have been reported, yet at the expense of a 3.5-fold higher risk of mesh exposure.215 To minimize the risk of mesh exposure whilst optimizing anatomical outcomes, it has been proposed to rather do a supracervical hysterectomy, or hysteropexy. However, today the efficacy and safety of sacrocolpopexy with
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