Chapter 4.2.1 82 anatomical outcomes at 163 months whereas previous studies do so partly and at a maximum of 72 months.144 Our follow-up rate was high, certainly when considering the long duration of the study. Our study certainly has limitations. Although using two non-parallel cohorts, selection bias cannot be excluded. Our surgical technique has not changed over time and the only change in perioperative care was the reduction in length of hospital stay, as encouraged by the national health insurance. Both cohorts are comparable, but there were some differences, which according to us merely reflect changes in clinical practice over time. For instance, a previous hysterectomy and HRT use were less common in the second cohort, probably reflecting a more conservative attitude towards hysterectomy and hormone use in the last decade(s). Because concomitant hysterectomy is considered a risk factor for graft-related complications, we additionally compared graft-related complications-rates in patients with previous hysterectomy (n=238) to those without (n=101). We did not observe a difference (9.7% [23/238] and 12.9% [13/101], respectively). Conversely, graft-related complications were more frequent in patients who were not on hormone therapy (25.2% [28/111]) than in those who did receive hormone therapy (3.5% [8/225]). The higher rate of graft-related complications in patients not on hormone therapy, was higher in both cohorts, that is, irrespective of the implant weight (23.9% [17/71] in heavier-weight compared to 27.5% [11/40] in lightweight). Obviously given the small numbers in subgroups, one needs to be careful in the interpretation of this observation. The follow-up period had a larger range in the lightweight group as compared to the heavier weight mesh group, although median follow-up was comparable between groups. We could not assess all patients in person; therefore, we lack anatomical outcomes in 25% of participants. Although we have no reason to suspect different outcomes in the latter, based on the reintervention rates identified using the national records, the impact of selection bias among the sample is unclear. Finally, one could question the external validity of our results as our center is a referral center and patients were operated by or under supervision of a single trainer. Our practice is in that respect comparable to that of a subspecialist in urogynecology and the results at least generalizable to the subspecialists trained in our department. Although graft-related complications are more likely following transvaginal pelvic organ prolapse repair, 163 these may also present following transabdominal POP-repair.164 This study reports a longterm graft-related complications rate of 12.9% and suggests graft-related complications are less likely when lightweight implants are used. This is in line with earlier experimental and clinical findings demonstrating a lesser inflammatory response in lightweight implants.135-141 Other comparative and long-term cohort studies are required to confirm this to better inform patients, surgeons and policy makers on the actual risk of using durable mesh for sacrocolpopexy and what materials may be better suitable.
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