Apical vaginal support is very important for maintaining proper pelvic organ support. The mesh-augmented procedures result in high success and low recurrence rates. However, the mesh repair of pelvic organ prolapse (POP) is under much debate. The aim of the study was to evaluate the applicability of bilateral sacrospinous ligament fixation with the mesh (BSC) in daily clinical practice. The surgery was performed in women with baseline stage ≥3 prolapse and stage ≥2 apical prolapse according to the Pelvic Organ Prolapse Quantification (POP-Q). The objective and subjective effects of the surgery were assessed.

The prospective observational study was conducted in 64 women with symptomatic apical compartment defect scheduled for the surgery. The bilateral sacrospinous ligament fixation with mesh implant combined with native tissue repair (anterior and/or posterior colporrhaphy) was performed. Medical history was taken, urogynecological examination was performed according to the ICS standards with the POP-Q assessment. Patient-reported outcomes were assessed using the Incontinence Severity Index (ISI), the short form of the Pelvic Floor Distress Inventory (PFDI-20), the Pelvic Floor Impact Questionnaire (PFIQ-7), and a single prolapse question (#35) from the Epidemiology of Prolapse and Incontinence Questionnaire (EPIQ). Patients were followed at 6 months intervals postoperatively. POP-Q assessment was repeated at the follow-up visit, and patients were asked to complete the questionnaires 6 months after treatment. Baseline and post-treatment data were compared. Anatomical outcomes were assessed using the POP-Q staging, and functional outcomes were self-reported by patients. The objective anatomical cure rate was defined as POP-Q stage ≤1 for all anatomical landmarks. 
McNemar’s test was used to compare the change in the distribution of categorical variables between the baseline and follow-up. Whenever the change in mean distribution was under scrutiny, a paired t-test was applied.

In total, 64 patients with POP-Q ≥ stage 3 were included. Patients had a mean age of 68.63±6.06 years and BMI of 27.27±3.29 kg/m2 (Table 1). The mean operative time was 106.14 ± 24.2 min, and the change in hemoglobin was -1.89±0.82 g/dl (p<0.001). Complications according to the Clavien-Dindo classification were reported in 16(25.0%) patients grade I, and in 4(6.3%) patients grade II. No complications were reported in 44(68.8%) patients. The effect of surgery was assessed in 57(89.1%) women who presented at the follow-up visit. According to the anatomical definition of success, 33(57.9%) patients were completely recurrence free and only 1(1.75%) patient had apical recurrence (POP-Q stage 2). Most recurrences were asymptomatic cystoceles 11(19.3%) POP-Q stage 2, and one (1.75%) symptomatic cystocoele POP-Q stage 3. The mean PFDI-20 and PFIQ-7 scores in all subscales and the total scores (156.81±73.58 vs 51.20±44.19 and 113.72±72.63 vs 28.65±40.60, respectively) significantly improved 6 months after surgery (p<0.000). Median POP-Q stages in all landmarks improved significantly from the pre- to the postoperative visit (p<0.0002) (Table 2). Median EPIQ #35 changed from 10 to 0 (p=0.000), and ISI was not statistically different after surgery (p=0.625).

Pelvic organ prolapse stage ≥3 with apical compartment prolapse stage ≥2 can be successfully treated with apical mesh surgery combined with native tissue repair in the anterior and/or posterior compartment. The subjective assessment of the surgery results revealed significant improvement. Vaginal bulge symptoms reduced from 8.60±1.95 to 0.17±1.02 postoperatively (p=0.000), with no deterioration in urinary continence (p=0.625). The procedure was not connected with any serious adverse events according to the Clavien-Dindo classification.

Apical mesh support combined with the native tissue repair resulted in successful anatomical and functional outcomes after 6 months of follow-up. We found 98.25% apical compartment success rate, and significant improvement in PFDI-20 and PFIQ-7 prolapse, colorectal, and urinary subscales with no deterioration in the Incontinence Severity Index.