Tremendous decline of transvaginal mesh (TVM) usage is seen globally following restrictions imposed by FDA.  Despite this, the usage of TVM remains a viable option, especially in large Asian population, with promising outcomes. This study aims to compare the outcomes of  TVM (Surelift) and Sacrospinous ligament fixation with anterior repair (SSF+A)  using objective and subjective cure rates. Secondly, to compare the quality of life and its major and minor complications.

Records of 181 women who underwent prolapse surgery for symptomatic advanced POP Stage III and IV from December 2011 and January 2020 were reviewed. The decision to use TVM or native tissue repair (NTR) is based on the patient's preferences, after a thorough explanation of the risks and advantages. Patients who underwent previous POP mesh insertion and were found ineligible for transvaginal surgery were excluded. Pre-and post-operative evaluation included history and physical exam, urodynamics and validated questionnaires (IIQ-7, UDI-6, POPDI-6) at baseline, one, three, and five years later. 
The Surelift mesh is made up of 6 arms and the middle arms were removed. Support was provided from the anterior (proximal) arms and the distal end where the SSL was attached.  SSF for NTR was done using the posterior approach following anterior colporrhaphy.

181 patients were included: 98 underwent Surelift and 83 had SSF+A. (Fig.1) Surelift and SSF+A patients had mean follow-up periods of 83.5±6.1 and 91.6±39 months, respectively. (Tab.1) At one-year, there was no statistically significant difference was noted in objective and subjective cure rates between Surelift (96.8% and 94.7%) and SSF+A (89.9% and 88.6%).(Fig.1) However, after three and five years, Surelift showed superior results with objective cure rates of 94.1% and 89.1%, respectively, compared to  80% and 64.4% for SSF+A (p=0.008). At 3 and 5 years, Surelift had 92.9% and 85.9% subjective cure rates compared to SSF's 77.1% and 60%, respectively (p=0.005). 
Four cases of recurrent prolapse were noted in the SSF+A group, with 2 requiring secondary prolapse surgery (p=0.019)(Tab.1). Four patients (4.1%) had vaginal mesh exposure. All patients tolerated the exposed mesh excision at outpatient setting.
UDI-6 and IIQ-7 were not statistically significant. The POPDI-6 questionnaire revealed a significant difference after three years (p=0.019) and five years (p=0.005).
Surelift group outperformed the SSF+A group in terms of time to prolapse for all compartments (Mantel-Haenszel log-rank test, p = 0.003). (Fig.2)

Although the demographics of the mesh group (higher mean age, post-menopausal status, higher parity, and more prior pelvic surgeries) suggested a higher risk of recurrence, this group showed superior long-term outcomes. Significant differences on the objective and subjective cure rates were observed by the third and fifth year post-operatively. No significant differences were observed in the lower urinary tract symptoms or QoL between the two groups over the five years. 
The TVM group had a low vaginal mesh exposure rate of 4.1%. There were no recurrences in the mesh group while the SSF+A group had 4 recurrences that required further treatment (p=0.019), suggesting the benefit of the mesh in reducing prolapse recurrence. Logistic regression analysis supported these findings, showing that the use of NTR vs. mesh was significantly associated with higher odds of treatment failure. Age, pre-operative stage (stage III-IV),  and concomitant posterior repair did not significantly influence recurrence rates. Length of follow-up demonstrated a trend towards reduced recurrence risk with longer follow-up periods.

Surelift has better long-term outcomes and lower recurrence rates than SSF+A, with effective management of minor complications in both groups. These findings attests its use as a superior surgical option for pelvic organ prolapse.

Haylen BT, de Ridder D, Freeman RM, et al. An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for female pelvic floor dysfunction. Neurourol Urodyn. 2010;29(1):4-20.
Lo TS, Harun F, Jhang LS, Hsieh WC, Tan YL, Alzabedi A. Modified Surelift Anterior-Apical Transvaginal Mesh for Advanced Urogenital Prolapse: Surgical, Functional and Sonographic Outcomes at 3 Years. Eur J Obstet Gynecol Reprod Biol. 2025;304:1-8.
Lo TS, Lin YH, Chua S, Chu HC, Uy-Patrimonio MC, Ng KL. Immunochemical analysis on polypropylene mesh: does mesh size make a difference? Int Urogynecol J. 2021 Jan;32(1):47-55