Mesh Kits Research Articles

Purely Transvaginal/Perineal Management of Complications From Commercial Prolapse Kits Using a New Prostheses/Grafts Complication Classification System

Commercial prolapse mesh kits are increasingly used in the management of pelvic organ prolapse. We present our experience with the transvaginal/perineal management of synthetic mesh related complications from prolapse kits. In addition, we used the new ICS/IUGA (International Continence Society/International Urogynecological Association) prostheses/grafts complication classification system to report on our contemporary series. A retrospective chart review of all patients who underwent surgical removal of transvaginal mesh for mesh related complications after prolapse kit use from November 2006 to April 2010 at 1 institution was performed. We report our contemporary series of mesh complications using the new ICS/IUGA prostheses/grafts complication classification system. Postoperative pain, degree of improvement and presence of continued symptoms were reported by patients at last followup. A total of 23 patients underwent transvaginal removal of mesh during the study period. Mean patient age was 61 years. Median period of latency to mesh related complication was 10 months (range 1 to 27). Indications for mesh removal included vaginal/pelvic pain (39%), dyspareunia (39%), vaginal mesh extrusion/exposure (26%), urinary incontinence (35%), recurrent pelvic organ prolapse (22%), bladder mesh perforation with recurrent urinary tract infection (22%), rectal mesh perforation (4%), ureteral perforation injury (4%), retained foreign body (surgical sponge) in the bladder (4%) and vesicovaginal fistula (9%), with most patients citing more than 1 reason. Although technically difficult in some cases, purely transvaginal mesh excision appears to be safe with resolution of almost all presenting symptoms. Although slightly cumbersome, the new ICS/IUGA prostheses/graft complication classification system can be used to report and more accurately characterize mesh complications.

Obturator Foramen Dissection for Excision of Symptomatic Transobturator Mesh

Groin pain after transobturator synthetic mesh placement can be recalcitrant to conservative therapy and ultimately requires surgical excision. We describe our experiences with and technique of obturator foramen dissection for mesh excision. The records of 8 patients treated from 2005 to 2010, were reviewed. Obturator dissection was performed via a lateral groin incision over the inferior pubic ramus at the level of the obturator foramen, typically in conjunction with orthopedic surgery. Five patients had transobturator mid urethral sling surgery for stress urinary incontinence, 2 had mid urethral sling and trocar based anterior vaginal wall mesh kits with transobturator passage of mesh arms for stress urinary incontinence and pelvic organ prolapse, and 1 had an anterior vaginal wall mesh kit for pelvic organ prolapse. Patients had 0 to 2 prior transvaginal mesh excisions before obturator surgery. All patients presented with intractable pain in the area of the obturator foramen and/or medial groin for which conservative treatment measures had failed. Six patients underwent concurrent vaginal and obturator dissection and 2 underwent obturator dissection alone. In all cases residual mesh (3 to 11 cm) was identified and excised from the obturator foramen. Mesh was closely associated to or traversing the adductor longus muscle and tendon with significant fibrous reaction in all cases. Postoperatively 5 patients were cured of pain and/or infection, and 3 reported no or some improvement at a mean followup of 6 months (range 1 to 12). Our experience suggests that surgical excision of residual mesh can alleviate many of the symptoms in many patients. In all cases mesh remnants were identified and removed, and typically involved neuromuscular structures adjacent to the obturator foramen.

Sexual function in women following transvaginal mesh procedures for the treatment of pelvic organ prolapse

Synthetic mesh kits recently adopted in pelvic reconstructive surgeries have achieved great surgical efficacy, but the effects of transvaginal synthetic mesh procedures on women's sexual function are still controversial. This study was conducted to demonstrate sexual function in women before and after surgery with transvaginal mesh (TVM) repair for pelvic organ prolapse (POP). A total of 93 sexually active women scheduled for correcting POP with synthetic mesh kits were recruited. In addition to urogynecological history, pelvic examination by the Pelvic Organ Prolapse Quantification system, and urodynamic testing, consenting participants were asked to complete the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12) to evaluate sexual function before and after surgery. At the 3-month urodynamic studies, among the 25 patients with coexistent urodynamic stress incontinence (USI) who had undergone a concomitant transobturator suburethral tape procedure (TOT), 1 (4 %) had persistent USI; 8 of 68 (11.8 %) patients with a negative pessary test developed postoperative USI. Six-month prolapse recurrence rates following TVM alone and TVM with concomitant TOT were 9 and 12 %, respectively. The total PISQ-12 score after surgery showed worse results in the TVM alone group but not in the TVM with concomitant TOT group. The individual scores of PISQ-12 after surgery demonstrated prolapse-related items improved in both TVM groups; sexual function worsened in dyspareunia and behavior domains. Our data revealed that transvaginal synthetic mesh procedures for the treatment of POP generated favorable clinical outcomes, but situations might worsen in dyspareunia and behavior domains, thereby invoking a negative emotional reaction during intercourse after surgery.

Optimizing Safety and Appropriateness of Graft Use in Pelvic Reconstructive Surgery: Introduction to the 2nd IUGA Grafts Roundtable

Urogynecologic surgeons, regulatory bodies, and their patients are currently embroiled in a divisive debate regarding the appropriate use of grafts in the vaginal repair of pelvic organ prolapse. This debate has spilled over onto the public and legal domains with lightning speed thanks in great part to the widespread marketing of new mesh kits by surgical device companies and prompt adoption of new techniques by pelvic surgeons, as well as widespread access to an uncensored internet. “Good evidence either way” is slow to come, as with most innovative surgical progress. We have been keenly aware that this was likely to happen. It is reported that over 300,000 prolapse procedures are performed annually in the USA [1]. It is unknown exactly how many mesh kits are implanted per year, but it is likely a growing volume due to widespread marketing and increased surgeon training. Although the currently available kits have basic similarities, including the use of lightweight type 1 polypropylene mesh, they did not begin that way. It was our growing concern regarding the use of a wide variety of reconstructive materials—and their unknown postimplantation behavior—that led us to sponsor the initial International Urogynecological Association (IUGA) Grafts Roundtable in 2005 [2]. The goals of that meeting included:

Cystoscopic removal of intravesical synthetic mesh extrusion with the aid of Endoloop sutures and endoscopic scissors

Synthetic mesh is commonly used in urogynecologic surgical procedures for correction of stress urinary incontinence and pelvic organ prolapse. Bladder mesh extrusion is a recognized complication and frequently requires extensive mesh resection. We present a case of intravesical polypropylene mesh extrusion following a combined mesh kit and midurethral sling placement. A novel transurethral approach, employing Endoloop sutures with endoscopic scissors, was used to resect the protruding mesh located in close proximity to a ureteral orifice. Medline was searched for other minimally invasive treatment strategies for bladder mesh extrusion. Various techniques for minimally invasive resection of extruded intravesical mesh have been described in the literature. Our strictly transurethral approach avoids the use of an energy source and eliminates the need for open or extensive surgery. Advantages of this new transurethral operative technique include decreased risk of injury associated with the use of an energy source within the bladder and avoidance of open surgical complications.

Surgery for cystocele I—questions

In May 2011, an important article on the surgical correction of cystocele was published in the New England Journal of Medicine: “Anterior colporrhaphy versus transvaginal mesh for pelvic organ prolapse” [1]. In this multicenter randomized controlled trial, the use of a trocar-guided, transvaginal polypropylene-mesh repair kit was compared with traditional colporrhaphy in 389 women with prolapse of the anterior vaginal wall. The primary outcome was a composite of objective anatomical pelvic organ prolapse (POP) stage 0 or I [2] and the subjective absence of symptoms of vaginal bulging 12 months after surgery. As compared with anterior colporrhaphy, use of a standardized, trocar-guided mesh kit for cystocele repair resulted in higher (60.8% versus 34.5%) short-term rates of successful treatment. Surgical reintervention to correct mesh exposure during follow-up occurred in 3.2% of patients in the mesh-repair group. We congratulate the authors on publishing a multicenter randomized trial on a very controversial subject using internationally accepted validated outcome instruments. However, we have the following concerns about the study set-up and the way the data were presented. For anatomic outcomes the authors used the POP-Q system which clearly states: “Point Aa: a point located in the midline of the anterior vaginal wall 3 cm proximal to the external urethral meatus, corresponding to the approximate location of the ‘urethrovesical crease,’ a visible landmark of variable prominence that is obliterated in many patients. By definition, the range of position of point Aa relative to the hymen is −3 to +3 cm. Point Ba: a point that represents the most distal (i.e., most dependent) position of any part of the upper anterior vaginal wall from the vaginal cuff or anterior vaginal fornix to point Aa. By definition, point Ba is at −3 cm in the absence of prolapse and would have a positive value equal to the position of the cuff in women with total post hysterectomy vaginal eversion”.2 The authors present POP-Q values as median with ranges in Table 1 in the Supplementary Appendix (original version, before 23th of June). Ranges for point Aa vary from −4 to 5, which, as noted above, is, by definition, not possible. The same applies to values of point Ba which range from −8 to 7. Also, the authors state a value for point D of −13 which is also not possible, since the maximal tvl (total vaginal length) in the same table is 12. This would seem to indicate that the POP-Q measurements were not performed according to ICS standards. Since there are 21 ‘non-existing’ values in Table 1 (of the Supplementary Appendix), we have serious doubts about the anatomic outcomes the authors’ report. Apparently, the authors updated the Appendix on June 23, and a number of incorrect values were omitted in Table 1B. They state that “the incorrect values were omitted before final analysis, while treatment assignment was still blinded.” We wonder how many data or cases exactly were excluded as no numbers are given in the table for crude or corrected data. Furthermore, there is no recognition in the flow chart (Fig. 1) of these patients that have been excluded at this point. The surgical procedure the patients received was either an anterior tension-free vaginal mesh or an anterior colporrhaphy. No concomitant surgery was permitted. How did the specific study sites counsel their patients regarding the fact that a portion of their prolapse would not be addressed, as in patients in which the descending point of the posterior wall was 4 cm beyond the hymen (Bp = 4, Table 1 Supplementary Appendix) or if the cervix or vaginal apex was 4 or 6 cm beyond the hymen (C = 4 and D = 6, Table 1 Supplementary Appendix). Are we to assume that these segments of the pelvic floor were ignored even though the prolapse extended well beyond the hymen? Finally, we were surprised that the authors only reported on surgical reinterventions for mesh exposure (3.2%) and did not report the total number of mesh exposures. Mesh exposure is the most significant complication of transvaginal mesh surgery for pelvic organ prolapse. The total percentage of mesh exposure is presented by virtually all comparable papers and not presenting these data makes comparison of this study with previous literature impossible. Furthermore, only reporting on reinterventions of mesh exposure is subject to considerable bias. The optimal indications and timing of reintervention is ultimately the decision of the individual surgeon, thus, potential bias such as not to reintervene or to delay the reintervention until after the study period is a real possibility.

Outcome and efficacy of a transobturator polypropylene mesh kit in the treatment of anterior pelvic organ prolapse

Objective To report the efficacy and complications of anterior pelvic organ prolapse (POP) repair with mesh placed through the transobturator route (Perigee system; AMS, Minnetonka, MN, USA). Methods In total, 198 women with anterior POP grade II or higher according to the POP Quantification (POP-Q) system were treated with the Perigee procedure. The primary outcome was defined as anterior POP grade I or lower at 12 months’ follow-up. The secondary outcomes included the incidences of perioperative, mesh-related, short-term, and long-term postoperative complications. Results The cure rate was 92.9% overall and 90.6% among women who had previously undergone a hysterectomy or a traditional anterior colporrhaphy. The mean POP-Q Aa and Ba values were significantly improved after the procedure (Aa 2.2 cm [0.0 to 3.0 cm] versus − 2.1 cm [− 3.0 to − 1.2 cm]; Ba − 2.5 cm [− 1.0 to 4.2 cm] versus − 2.2 cm [− 5.5 to − 1.0 cm]; P < 0.001). Vaginal or bladder erosions were observed in 3 patients. Other short- and long-term complications were infrequent and not statistically significant. Conclusion The Perigee procedure is effective in the treatment of anterior POP and does not have serious complications even among women with previous hysterectomy or traditional anterior colporrhaphy.

A prospective comparison of two commercial mesh kits in the management of anterior vaginal prolapse

Vaginal mesh kits are increasingly used in the management of pelvic organ prolapse. This study aimed to determine similarity of outcomes of the Anterior Prolift with Perigee systems for anterior compartment prolapse. Consecutive women undergoing Perigee or Anterior Prolift for symptomatic stage 2 or greater anterior vaginal prolapse were prospectively evaluated. Main outcome measures included objective and subjective success rates, perioperative outcomes, patient satisfaction, and complications. One hundred and six women (Prolift, 52; Perigee, 54) completed questionnaires, and 91 (Prolift, 46; Perigee, 45) were examined postoperatively. At follow-up (Prolift: median, 11.0; range, 5-23 months; Perigee: median, 11.5; range, 6 - 23 months), objective success rates (Prolift, 89%; Perigee, 80%; p = 0.23), subjective success rates (Prolift, 94%; Perigee, 96%; p=0.62), mean ± SD patient satisfaction (Prolift, 8.2 ± 2.0; Perigee, 8.2 ± 1.8; p = 0.91), and complication rates did not differ significantly between the two groups. The Anterior Prolift was found to not differ significantly from Perigee at 11 months.

Interventional Radiology Used To Treat Pelvic Hemorrhage after Reconstructive Pelvic Surgery

In order to illustrate the successful use of pelvic artery embolization we report on a patient who underwent transvaginal mesh placement presenting with pelvic hematomas in the obturator space. The wide-spread adoption reconstructive pelvic surgery has brought with it the prospect of challenging vascular morbidity. A thorough understanding of pelvic anatomy is essential for management of vascular complications from mesh kits, sacrospinous ligament fixation, and retropubic surgery.

Surgical Outcomes with Single Mesh Kit for Female Urogenital Prolapse Repair, Experience with EXAIR

Surgical Outcomes with Single Mesh Kit for Female Urogenital Prolapse Repair, Experience with EXAIR

Anterior colporrhaphy versus transvaginal mesh for pelvic-organ prolapse

BACKGROUND The use of standardized mesh kits for repair of pelvic-organ prolapse has spread rapidly in recent years, but it is unclear whether this approach results in better outcomes than traditional colporrhaphy. METHODS In this multicenter, parallel-group, randomized, controlled trial, we compared the use of a trocar-guided, transvaginal polypropylene-mesh repair kit with traditional colporrhaphy in women with prolapse of the anterior vaginal wall (cystocele). The primary outcome was a composite of the objective anatomical designation of stage 0 (no prolapse) or 1 (position of the anterior vaginal wall more than 1 cm above the hymen), according to the Pelvic Organ Prolapse Quantification system, and the subjective absence of symptoms of vaginal bulging 12 months after the surgery. RESULTS Of 389 women who were randomly assigned to a study treatment, 200 underwent prolapse repair with the transvaginal mesh kit and 189 underwent traditional colporrhaphy. At 1 year, the primary outcome was significantly more common in the women treated with transvaginal mesh repair (60.8%) than in those who underwent colporrhaphy (34.5%) (absolute difference, 26.3 percentage points; 95% confidence interval, 15.6 to 37.0). The surgery lasted longer and the rates of intraoperative hemorrhage were higher in the mesh-repair group than in the colporrhaphy group (P<0.001 for both comparisons). Rates of bladder perforation were 3.5% in the mesh-repair group and 0.5% in the colporrhaphy group (P=0.07), and the respective rates of new stress urinary incontinence after surgery were 12.3% and 6.3% (P=0.05). Surgical reintervention to correct mesh exposure during follow-up occurred in 3.2% of 186 patients in the mesh-repair group. CONCLUSIONS As compared with anterior colporrhaphy, use of a standardized, trocar-guided mesh kit for cystocele repair resulted in higher short-term rates of successful treatment but also in higher rates of surgical complications and postoperative adverse events. (Funded by the Karolinska Institutet and Ethicon; ClinicalTrials.gov number, NCT00566917.).

Sacrospinous ligament fixation for pelvic organ prolapse in the era of vaginal mesh kits

To examine the sacrospinous ligament as a point of attachment for pelvic organ prolapse procedures, including vaginal mesh kits. Pelvic surgeons are increasingly employing the sacrospinous ligament as a point of attachment for biologic grafts and synthetic mesh kits during uterovaginal prolapse repairs. These techniques may have introduced a novel set of complications (mesh extrusion, erosion) in addition to those already known to occur in traditional sacrospinous ligament fixations. Except for limited short-term results, little data are available in the literature regarding surgical outcomes and complications for mesh and graft augmented repairs attached to the sacrospinous ligament. The sacrospinous ligament fixation is a well tolerated and effective procedure for suspension of the vaginal apex. Mesh augmentation using the sacrospinous ligament may improve objective prolapse recurrence, but complications still occur, including those specific to mesh placement.

Internal Pudendal Artery Injury during Prolapse Surgery Using Nonanchored Mesh

Herein is presented the case of a patient with stage 2 uterine prolapse treated surgically using nonanchored mesh. Complications were internal pudendal artery injury and a massive presacral hematoma that formed after surgery. Transcatheter arterial embolization was performed immediately, and the bleeding stopped. The patient subsequently experienced difficulty micturating and defecating because of presacral hematoma compression. Self-micturation and defecation capabilities were regained gradually at approximately 1 week after surgery. The hematoma resolved completely by 71 days postoperatively. Comprehensive knowledge of pelvic anatomy is important when performing surgery to treat prolapse using mesh kits. Removing the mesh and prophylactic antibiotic therapy is a means of conservatively managing a pelvic hematoma caused by prolapse surgery.

Should mesh be used to correct anterior vaginal prolapse?

A multicenter randomized trial comparing a trocar-guided mesh kit to anterior colporrhaphy for treatment of cystocele adds to evidence that transvaginal mesh for treatment of anterior vaginal prolapse improves anatomical outcomes at the expense of greater complications. Careful consideration of benefits and risks is required when considering transvaginal mesh for prolapse repair.

Management of recurrent vault prolapse

In the ageing female population, recurrent vaginal vault prolapse is a significant healthcare burden. There is limited evidence regarding the optimal management strategy for recurrent vault prolapse. This paper aims to discuss treatment modalities available for recurrent vault prolapse. A literature search and analysis was performed using Medline, PubMed, Cochrane database, current texts and references from relevant articles. We found inconclusive evidence supporting conservative, mechanical and some surgical options for treating recurrent vault prolapse; including iliococcygeal fixation, McCall culdoplasty, and infracoccygeal sacropexy. Sacrospinous ligament fixation (SSLF), sacrocolpopexy, mesh implants and colpocleisis are shown to have good outcomes in Level II studies. Nevertheless, the first two are associated with haemorrhage, dyspareunia and scarring whilst colpocleisis is limited to selected patients. More well-designed studies are required for recurrent vault prolapse. Current evidence suggests SSLF, and sacrocolpopexy are alternative surgical options to colpocleisis in treating recurrent vault prolapse. Randomised trials are required to determine the efficacy and safety of trocar-guided mesh kits.

Shifts in national rates of inpatient prolapse surgery emphasize current coding inadequacies.

: This study aimed to assess national rates, types, and routes of inpatient surgery for pelvic organ prolapse in the United States in 1998 compared to those in 2007. : We used the 1998 and 2007 Nationwide Inpatient Sample, which represents a stratified, random sample of discharge data from US hospitals. We included women 20 years and older who underwent surgery for prolapse based on diagnosis and procedure codes of the International Classification of Disease, 9th Revision, Clinical Modification. We calculated the number of women undergoing surgery each year and incidence rates. : The total number of women undergoing prolapse surgeries was 92,503 in 1998 versus 113,646 in 2007. The incidence rate of surgery increased slightly, from 90.8 to 100.9 per 100,000 women, respectively. The most common procedure was hysterectomy, representing approximately half of prolapse surgeries in 1998 and 2007. Suspension procedures accounted for 18.8% of procedures in 2007, an increase from 6.1% in 1998. Surgeries performed via a minimally invasive route increased from 4.8% in 1998 to 9.4% in 2007. However, it was difficult to determine the route for many procedures based on current ICD-9 codes. There were also no codes that specifically designated mesh kit procedures or minimally invasive sacrocolpopexies. : During the last decade, the rate of inpatient prolapse surgery has slightly increased. The proportion of suspension procedures has increased; however, it is difficult to determine the route of these procedures based on current ICD-9 codes. These findings emphasize that ICD-9 procedure codes have not kept up with changes in clinical practice.

Anterior Colporrhaphy versus Transvaginal Mesh for Pelvic-Organ Prolapse

The use of standardized mesh kits for repair of pelvic-organ prolapse has spread rapidly in recent years, but it is unclear whether this approach results in better outcomes than traditional colporrhaphy. In this multicenter, parallel-group, randomized, controlled trial, we compared the use of a trocar-guided, transvaginal polypropylene-mesh repair kit with traditional colporrhaphy in women with prolapse of the anterior vaginal wall (cystocele). The primary outcome was a composite of the objective anatomical designation of stage 0 (no prolapse) or 1 (position of the anterior vaginal wall more than 1 cm above the hymen), according to the Pelvic Organ Prolapse Quantification system, and the subjective absence of symptoms of vaginal bulging 12 months after the surgery. Of 389 women who were randomly assigned to a study treatment, 200 underwent prolapse repair with the transvaginal mesh kit and 189 underwent traditional colporrhaphy. At 1 year, the primary outcome was significantly more common in the women treated with transvaginal mesh repair (60.8%) than in those who underwent colporrhaphy (34.5%) (absolute difference, 26.3 percentage points; 95% confidence interval, 15.6 to 37.0). The surgery lasted longer and the rates of intraoperative hemorrhage were higher in the mesh-repair group than in the colporrhaphy group (P<0.001 for both comparisons). Rates of bladder perforation were 3.5% in the mesh-repair group and 0.5% in the colporrhaphy group (P=0.07), and the respective rates of new stress urinary incontinence after surgery were 12.3% and 6.3% (P=0.05). Surgical reintervention to correct mesh exposure during follow-up occurred in 3.2% of 186 patients in the mesh-repair group. As compared with anterior colporrhaphy, use of a standardized, trocar-guided mesh kit for cystocele repair resulted in higher short-term rates of successful treatment but also in higher rates of surgical complications and postoperative adverse events. (Funded by the Karolinska Institutet and Ethicon; ClinicalTrials.gov number, NCT00566917.).

Degradation, infection and heat effects on polypropylene mesh for pelvic implantation: what was known and when it was known.

Many properties of polypropylene mesh that are causative in producing the complications that our patients are experiencing were published in the literature prior to the marketing of most currently used mesh configurations and mesh kits. These factors were not sufficiently taken into account prior to the sale of these products for use in patients. This report indicates when this information was available to both mesh kit manufacturers and the Food and Drug Administration.

V677 PURE TRANSVAGINAL EXCISION OF MESH EROSION INVOLVING THE BLADDER

Introduction and hypothesis We present a pure transvaginal approach to the removal of eroded mesh involving the bladder secondary to placement of transvaginal mesh for management of pelvic organ prolapse (POP) using a mesh kit.

2078 SURGICAL MANAGEMENT OF PELVIC ORGAN PROLAPSE IN FEMALES: ANATOMICAL AND FUNCTIONAL OUTCOMES OF SACROSPINOUS COLPOPEXY AND CYSTOCELE REPAIR AS A COMBINED PROCEDURE

INTRODUCTION AND OBJECTIVES: High stage cystocele usually occurs concomitantly with apical prolapse, and is likely to recur when only the cystocele is surgically corrected. We investigated the anatomical and functional outcome of patients who underwent sacrospinous colpopexy and cystocele repair simultaneously. METHODS: We retrospectively reviewed 71 consecutive women who underwent sacrospinous colpopexy and cystocele repair as a combined procedure and were followed up more than 12 months after surgery. Anti-incontinence surgery was performed when indicated. Severity of prolapse was assessed by the POP-Q staging system. Prolapse-related and lower urinary tact symptoms were assessed. Cystocele was corrected using designed mesh or mesh kits of Perigee or Prolift. For apical correction, sacrospinous ligament fixation was performed. Postoperatively, an anatomical assessment and standardized interview was performed at predetermined intervals. The primary outcome measure was anatomical cure rate. Anatomical cure was defined as stage I or less. Secondary outcomes included subjective cure, symptom status, subjective or objective stress urinary incontinence and uroflowmetric parameters. Women reporting they were never or rarely bothered by prolapse-related symptoms were classified as subjectively cured. RESULTS: All cystoceles were stage III or more and all apical prolapses were stage II or more preoperatively. The success rates of cystocele repair and apical wall repair were 76.1% and 97.2% at postoperative 1 year, respectively. Among the 17 patients in which cystocele recurrence occurred, 15 cases were in stage 2 and none of them showed apical prolapse recurrence or prolapse-related symptoms. There were only 2 cases in which cystocele recurrence occurred higher than stage 3, and all of them had simultaneous apical wall prolapse. In both of these cases, abdominal sacrocolpopexy was performed. Postoperatively, prolapse-related symptoms were completely improved and lower urinary tract symptoms were much improved. Maximal flow rates and postvoid residual urine volumes were significantly improved. De novo incontinence occurred in 23.3% of the patients who did not undergo anti-incontinence surgery simultaneously. All complications were managed conservatively. No mesh erosion was identified. CONCLUSIONS: When apical prolapse was corrected successfully, cystocele recurrence did not exceed stage 2 and no symptoms were identified. When apical correction was not successful, high stage cystocele recurrence occurred.