Sacral colpopexy has superior outcomes to a variety of vaginal procedures including sacrospinous colpopexy, uterosacral colpopexy and transvaginal mesh. These benefits must be balanced against a longer operating time, longer time to return to activities of daily living, and increased cost of the abdominal approach.The use of mesh or graft inlays at the time of anterior vaginal wall repair reduces the risk of recurrent anterior wall prolapse on examination. Anterior vaginal polypropylene mesh also reduces awareness of prolapse, however these benefits must be weighted against increased operating time, blood loss, rate of apical or posterior compartment prolapse, de novo stress urinary incontinence, and reoperation rate for mesh exposures associated with the use of polypropylene mesh.Posterior vaginal wall repair may be better than transanal repair in the management of rectocele in terms of recurrence of prolapse. The evidence is not supportive of any grafts at the time of posterior vaginal repair. Adequately powered randomised, controlled clinical trials with blinding of assessors are urgently needed on a wide variety of issues, and they particularly need to include women's perceptions of prolapse symptoms. Following the withdrawal of some commercial transvaginal mesh kits from the market, the generalisability of the findings, especially relating to anterior compartment transvaginal mesh, should be interpreted with caution.

Sacral colpopexy is associated with lower risk of awareness of prolapse, recurrent prolapse on examination, repeat surgery for prolapse, postoperative SUI and dyspareunia than a variety of vaginal interventions.The limited evidence does not support use of transvaginal mesh compared to native tissue repair for apical vaginal prolapse. Most of the evaluated transvaginal meshes are no longer available and new lighter meshes currently lack evidence of safetyThe evidence was inconclusive when comparing access routes for sacral colpopexy.No clear conclusion can be reached from the available data comparing uterine preserving surgery versus vaginal hysterectomy for uterine prolapse.

While transvaginal permanent mesh is associated with lower rates of awareness of prolapse, reoperation for prolapse, and prolapse on examination than native tissue repair, it is also associated with higher rates of reoperation for prolapse, stress urinary incontinence, or mesh exposure and higher rates of bladder injury at surgery and de novo stress urinary incontinence. The risk-benefit profile means that transvaginal mesh has limited utility in primary surgery. While it is possible that in women with higher risk of recurrence the benefits may outweigh the risks, there is currently no evidence to support this position.Limited evidence suggests that absorbable mesh may reduce rates of recurrent prolapse on examination compared to native tissue repair, but there was insufficient evidence on absorbable mesh for us to draw any conclusions for other outcomes. There was also insufficient evidence for us to draw any conclusions regarding biological grafts compared to native tissue repair.In 2011, many transvaginal permanent meshes were voluntarily withdrawn from the market, and the newer, lightweight transvaginal permanent meshes still available have not been evaluated within a RCT. In the meantime, these newer transvaginal meshes should be utilised under the discretion of the ethics committee.

The rate of complications requiring reoperation and the total reoperation rate was highest for vaginal mesh kits despite a lower reoperation rate for prolapse recurrence and shorter overall follow-up.

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The inclusion of new randomised controlled trials showed that the use of mesh at the time of anterior vaginal wall repair reduced the risk of recurrent anterior vaginal wall prolapse on examination. However, this was not translated into improved functional or quality of life outcomes. The value of a continence procedure in addition to a prolapse operation in women who are continent pre-operatively remains uncertain. Adequately powered randomised controlled trials are needed and should particularly include women's perceptions of prolapse symptoms and functional outcome.

Biological graft repair or absorbable mesh provides minimal advantage compared with native tissue repair.Native tissue repair was associated with increased awareness of prolapse and increased risk of repeat surgery for prolapse and recurrence of anterior compartment prolapse compared with polypropylene mesh repair. However, native tissue repair was associated with reduced risk of de novo SUI, reduced bladder injury, and reduced rates of repeat surgery for prolapse, stress urinary incontinence and mesh exposure (composite outcome).Current evidence does not support the use of mesh repair compared with native tissue repair for anterior compartment prolapse owing to increased morbidity.Many transvaginal polypropylene meshes have been voluntarily removed from the market, and newer light-weight transvaginal meshes that are available have not been assessed by RCTs. Clinicans and women should be cautious when utilising these products, as their safety and efficacy have not been established.

Background Vaginal mesh kits are being used to surgically treat apical vaginal prolapse; however, their safety and efficacy are currently unknown.Objectives To summarise success and complication rates for commonly used vaginal mesh kits in the treatment of apical prolapse.Search strategy MEDLINE and other scientific databases were queried for primary research addressing the use of vaginal mesh kits for apical prolapse published between 1950 and 2007, including abstracts presented in major scientific meetings.Selection criteria Studies describing the use of mesh to support either the anterior or posterior compartment alone, for incontinence or fistula repair or not addressing the vaginal apex were excluded.Data collection and analysis Identified studies were grouped by the mesh kit and complications categorised using the Dindo classification system. Weighted averages and confidence intervals were calculated on objective success, follow-up length and complications.Main results Thirty studies totalling 2653 women met inclusion criteria. Objective success rates (95% CI) were ApogeeÔ (American Medical Systems Inc., Minnetonka, MN, USA) 95% (95-96), ProliftÔ (Ethicon Women's Health and Urology, Somerville, NJ, USA) 87% (86-87) and posterior intravaginal slingplasty 88% (87-89). Reoperations not requiring anaesthesia (Dindo IIIa) occurred in 0.4-2.3% and requiring anaesthesia (Dindo IIIb) in 1.5-6.0%, with a follow up between 26 and 78 weeks. Mesh erosion was the most commonly reported complication occurring in 4.6-10.7%.Author's conclusions Overall objective success using transvaginal mesh kits in restoring apical vaginal prolapse is high. However, an increasing number of women require surgical intervention for mesh-related complications based on limited data quality and short follow up. Further research addressing functional outcomes and the impact of these procedures on women's symptoms and quality of life is mandatory.