Advanced stage of prolapse and levator ani muscle avulsion are known risk factors for recurrence of prolapse after surgical repair. Mesh repair has shown to reduce risk of recurrence of prolapse. However, mesh use is associated with mesh complications. This study aims to evaluate the outcome of surgical repair for patients with advanced stage of prolapse with pre-operative evaluation of levator ani muscle avulsion; and mesh repair was offered only to patients with levator ani muscle avulsion.

This is a retrospective analysis of patients who had stage III or IV prolapse and received surgical repair in year 2021 and 2022 in the study institute. Background demographics and symptoms of urinary incontinence were collected before the operation. Perineal ultrasound was used to evaluate any levator ani muscle avulsion before the operation. Mesh repair, either vaginal mesh or sacrocolpopexy, was offered to patients with levator ani muscle avulsion. Patients were followed up annually after the operation. Patients were asked if they have symptoms of prolapse, urinary incontinence, per vaginal bleeding and vaginal pain, if any. Per vaginal examination and POP-Q was done. Subjective recurrence was defined as report of symptoms of prolapse. Objective recurrence of prolapse is defined as stage II or above. Treatment for recurrence of prolapse, if any, was explored.

A total of 108 patients were included. Their mean age, parity and body mass index were 71.6±6.3 years, 2.8±1.3 and 25.6±3.2 kg/m2, respectively. Overall, 65% (n = 70) had levator ani muscle avulsion and 55% (n = 59) had opted for mesh repair. Among those with mesh repair, 39 and 20 had anterior vaginal mesh repair and sacrocolpopexy, respectively. The mean duration of follow up was 40 months, with an intended longer period in the mesh repair group to look for any mesh complication. Only 5% of patients had subjective recurrence of prolapse. Two (1.8%) patients had treatment of prolapse; one received colpocleisis and one had gelhorn pessary. Symptoms of urinary incontinence were reduced after the operation. Two patients had mesh exposure with one received local estrogen treatment, and one had excision of exposed mesh for one time under local anaesthesia. No patients had vaginal pain.

In patients with stage III/IV prolapse, 65% had levator ani muscle avulsion. Despite a higher risk of recurrence of prolapse with advanced stage of prolapse and presence of levator ani muscle avulsion, there was a low rate of subjective recurrence of prolapse for mesh repair group. The rate of complication of mesh exposure was low.

The strategy of evaluating levator ani muscle avulsion for patient with advanced stage of prolapse, and offering option of mesh repair for patients with the avulsion can reduce the proportion of patients receiving mesh repair and hence the complications. Mesh repair could achieve a low rate of subjective and objective recurrence of prolapse, with a low complication rate.