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We agree with the opinions expressed by Drs Jacquetin and Hinoul that apical support is important and that anterior mesh kits may not have been designed to offer apical support.1Hinoul P. Jacquetin B. The total (not the anterior) vaginal mesh concept would be considered when apical vaginal support is the issue [letter].Am J Obstet Gynecol. 2010; 202: e9Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar However, as mentioned in the initial article, while some manufacturers specify their intent to provide level II support, others are not clear that their product is not intended to provide apical support.2Larson K.A. Hsu Y. DeLancey J.O. The relationship between superior attachment points for anterior wall mesh operations and the upper vagina using a 3-dimensional magnetic resonance model in women with normal support.Am J Obstet Gynecol. 2009; 200: 554.e1-554.e6Abstract Full Text Full Text PDF Scopus (14) Google Scholar In addition, we had seen several patients with apical prolapse after a primary surgery performed with anterior mesh that did not provide apical support. The reason we conducted the study is 2-fold: (1) some have assumed that anterior meshes do support the apex; and (2) there remain differences of opinion about the contribution of apical support in anterior wall prolapse. Because not all authors have suggested the need for apical support, it seemed appropriate to conduct an objective study to define the normal relationship of the vagina to suspension points to provide additional data to guide these decisions. In addition, we thought this was a simple way for people to see that they would need to do something in addition to an anterior mesh if there was a significant apical support defect. We should have been more explicit in the discussion to make this point and appreciate that your letter will do that for us. Which of the many techniques available for apical support should be used will need to be established by surgical trials with objective outcomes. Hopefully this study will stimulate surgeons to clarify this important issue. The total (not the anterior) vaginal mesh concept should be considered when apical vaginal support is the issueAmerican Journal of Obstetrics & GynecologyVol. 202Issue 4PreviewWe read with interest the article by Larson et al,1 which states that the superior suspension points for anterior wall mesh operations are below the normal upper vagina. They imply that the limited ability to correct for apical support by these anterior mesh kits may explain operative failure. Full-Text PDF