: Pelvic organ prolapse (POP) is a common condition which is due to the weakness of pelvic floor supports.Anterior vaginal wall prolapse is the most common type. This study is to evaluate the medium term clinical results of the surgical treatment of high stage anterior vaginal wall prolapse through the trans- Obturator route with the aid of vaginal wall tissues versus  four arm non absorbable polypropylene mesh.

: This is a retrospective analysis of 89/98 patients with anterior vaginal wall prolapse of stage≥ Ⅲ(Point Ba>= +1) enrolled either in non-absorbable Poly propylene mesh (group 1) or native vaginal wall tissue (group 2). The exclusion criteria was history or evidence of genitourinary malignancy,history of previous vaginal wall repair with non absorbable mesh,vaginal vault prolapse(Point C >= +1). In those cases with active genitourinary infection surgical repair was performed after prompt medical therapy and eradication of infection. The primary outcome was objective and subjective improvement (Pelvic Floor Distress Inventory short form: PFDI-20, Pelvic Floor Impact Questionnaire short form: PFIQ-7). The secondary endpoint was postoperative complications.

46 and 43 patients were enrolled in group 1 and group 2 respectively. The most common cheif complaint was lump sensation in 95.6% and 93.2% in groups 1 and 2 respectively.Operative time was 70+- 20 minutes and 45+- 10 minutes for groups 1 and 2 respectively(P< 0.05).The was no major intra operative complication in either group.The duration of folow up was 29.2+- 4 months and 27.3+- 5 months for groups 1 and 2 respectively(P=0.6).The anatomical success rate was 95.6% in group 1 and 93.2% in group 2 (P=0.1) and the scores of PDFI -20 and PFIQ -7 were improved in both groups(P=0.2). The complications of mesh group were mesh extrusion(8.6%) and de novo mild dyspareunia (6.52%)in group one.. 4.6% of patients in the vaginal wall tissue group complained of mild de novo dyspareunia as well, which did not interfere with their sexual life in either groups

Anterior colporrhaphy was considered the procedure of choice in the treatment of anterior vaginal wall prolapse with anatomic success rates of 80% - 100% . Other native tissue repair options include: abdominal or vaginal para vaginal repair, historically advocated by White in 1912 with the success rates of 67%- 100% . However, the high failure rate of anterior colporrhaphy and major complications with the paravaginal repair were the key factors to popularize mesh- augmented repairs . Parker placed the Marlex Mesh in the vaginal cavity during the surgical  treatment of rectocele.Reviews in the Cochrane database regarding the surgical management of POP in women revealed that the risk of cystocele recurrence is reduced by placing polypropylene mesh [16]. However there are specific complications (pain, vaginal extrusion, shrinkage of mesh, etc,,).In our study, subjective and objective success rates of both approaches (mesh and vaginal wall tissue) are promising and comparable. The operating time was significantly shorter in the surgical repair by vaginal wall tissue. There were no major complications in the vaginal cavity. Dyspareunia was mild, nor was any sexual dysfunction, limiting intimacy related to native tissue or mesh augmented repair.
According to our knowledge, the study described herein, is the first to prospectively evaluate the clinical results of the unilateral trans obturator native vaginal wall flap compared to the bilateral four arms trans obturator polypropylene mesh repair. However, multi center trials with large number and longer follow up will more precisely evaluate the efficacy of this approach. 
There are some limitations to this study which should be considered: small number of patients, and relatively short follow up time. In addition, the group allocation was according to patient’s preference which could be as a source of biases.

: The medium term results of the trans -Obturator with native tissue vaginal wall tissue compared to Poly propylene mesh augmented approach are comparable with promising results. However, the assessment of long term results of this novel technique are needed.