Surgery for vaginal vault prolapse: Is autologous fascia a viable alternative to mesh?

The surgical management of prolapse has followed a meandering path, with innovation, controversy and legislation all being encountered en route. Some of the dust is now settling with respect to the role of mesh implant surgery, and although it continues to have a role, albeit a contracted one, there is very much a new direction set on native tissue and nonmesh repairs with the advent of techniques such as laparoscopic suture hysteropexy, cervicopexy and colporrhaphy. The authors of this paper present the largest series of women undergoing autologous fascia sacrocolpopexy for the treatment of moderate– severe prolapse (Wang et al. BJOG 2022; https://doi.org/10.1111/1471-0528.17107). Learning from the past, two key questions that must always be answered when evaluating any new procedure are safety and efficacy. For both these measures, the authors show encouraging results comparable with the current gold standard— meshaugmented repairs. The use of autologous fascia has been well established for treatment of women with urinary incontinence, namely, pubovaginal/rectus fascial sling (Mcguire et al. J Urol 1978;119:824). There has been a resurgence of this method, following the widespread suspension of synthetic sling procedures. However, reports of autologous fascial support of the vaginal vault are limited to a few shortterm case series. This series involves 132 women, followed up for a median of 2.2 years; the authors present 5year data with comparable success rates to those reported in the landmark CARE study (Nygaard et al. JAMA 2013;309:201624) without the complication of mesh erosion. The mixed bag of patient types and concomitant surgery in this study underscores the myriad of pathologies and presenting symptoms to the pelvic floor surgeon; sadly, this reality hinders forensic evaluation of a single procedure. It is noted that around threequarters of the women in the study were having primary prolapse surgery, with a similar proportion undergoing some form of hysterectomy coupled with autologous fascial vault support. Other sacrocolpopexy series have involved women, the majority of whom have already had primary procedures, are without a uterus and represent an already failed and perhaps more difficult to treat group successfully (Maher et al. Cochrane Database Syst Rev 2016; CD012376). The addition of hysterectomy, as well as the harvesting of autologous fascia, inevitably means a lengthening of procedure times compared with those usually quoted for women undergoing laparoscopic vault suspension procedures of hysteropexy or sacrocolpopexy. The complexities of pelvic f loor patients and their symptoms mean that additionally nearly twothirds of the patients had Burch colposuspensions performed at the time of index surgery. The unpredictability of pelvic f loor surgery on bladder symptoms is amply demonstrated, as around onethird of women complain of stress incontinence and a third suffer overactive bladder symptoms following the procedure. It is clear that functional improvements do not always go hand in hand with anatomical correction for the pelvic f loor patient. Many women remain alarmed by the adverse reports of mesh augmentation surgery in gynaecology (IzettKay et al. BJOG 2021;128:1319). Contemporary best practice involves incorporating irrefutable principles such as recognising the importance of appropriate apical support, which is usually optimally achieved abdominally, as well as an awareness of risks of surgery, careful counselling regarding mesh, and being able to offer evidencebased alternatives. This paper provides valuable longterm data for a future promising meshless surgical technique.