In spite of FDA warnings regarding the use of mesh implants in transvaginal  pelvic organ prolapse repairs, FDA and UK national institute for health and care excellence recommended more research on risk/benefit profile of transvaginal mesh usage in POP surgeries [1]. This study aimed to compare the subjective and objective mid-term outcomes of using low-weighted monofilament PVDF mesh  to levatorplasty method for repairing high grade entero-rectocele via vaginal route and assess surgical outcome and mesh-associated adverse events.

In this retrospective cohort study, women with symptomatic stage ≥3 entero-rectocele prolapse, were assigned to transvaginal sacrospinous fixation with PVDF mesh implant (DynaMeshR-PR2 Soft kit) or classic levatorplasty between August 2012 and April 2023. All the surgeries were done by a single female urologist. The objective outcome was measured using the Pelvic Organ Prolapse Quantification (POP-Q) stage ≤1. Subjective outcomes evaluated by ICIQ-VS (International Consultation of Incontinence-Vaginal Symptoms) questionnaire. Patient satisfaction was quantified using the Patient Global Improvement Scale Inventory (PGI-I) at postoperative follow-up. All eligible women were followed up 3 and 12 months after surgery and then yearly.

Seventy eight  women were enrolled in this study (21 females in PVDF mesh implant group and 57 females in levatorplasty group). Duration of the medical condition was longer in PVDF mesh implant group (6.8 ± 6.6 vs. 2.6 ± 1.8 years). The median time of follow-up was 5.5 ± 0.2 years and 6.9 ± 2.2 years for PVDF mesh implant group and Levatorplasty group, respectively (ranging from 1.5-11 years). At 12  months, both groups showed improvement in terms of POP-Q exam and ICIQ-VS score. Vaginal symptoms disappeared or improved but differed between the PVDF mesh implant group and the levatorplasty group: 86.2% (PVDF mesh implant) vs. 70.7% (levatorplasty), respectively (P value: 0.029). During follow up period, no recurrence was reported in both groups. Only one patient (5%) experienced vaginal mesh exposure 3 months post operation and underwent surgical intervention. She was the first patient who underwent mesh implant 11 years ago. Two cases (13.3%) in levatorplasty group, complicated with constipation and post-operative dysfunctional defecation and vaginal infection required re-hospitalization and intravenous antibiotics. In PVDF mesh implant group, two patients died 3 and 4 years after surgery. The causes of death were unrelated to urologic problems.

in our study, sacrospinous ligament fixation with PVDF mesh interposition was a combined approach to treat rectocele and enterocele as posterior and apical compartment prolapse simultaneously with acceptable outcomes and less morbidity and pain in comparison to levatorplasty. PVDF mesh implantation did not require levatorplasty and involved less dissection.

Overall, the posterior interposition of PVDF mesh for entero-rectocele repair offers good anatomical results without significant medium-term complications in concomitant high grade posterior and apical compartment prolapse.

Urogynecologic surgical mesh implants. US Food and Drug Administration website. https://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/ImplantsandProsthetics/UroGynSurgicalMesh/default.htm. Updated July 10, 2019. Accessed August 13, 2019.