Ultrasound Obstet Gynecol 2012; 40: 495503

Published online in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/uog.12272

Opinion
Mesh in prolapse surgery: an imaging perspective

Introduction
Recurrence after female pelvic organ prolapse surgery is
common, with up to a third of all procedures performed
for recurrence1 . Anterior compartment recurrence seems
to be a particular problem2 . It is not surprising, therefore,
that there is constant striving to improve outcomes.
While mesh implants have been used for decades in an
attempt to reduce recurrence rates, it was only after the
worldwide success of midurethral slings made of wideweave polypropylene mesh, developed in the early 1990s,
that surgeons became more comfortable with using such
implants3 . The introduction of transobturator slings4 set
off a new wave of innovation when anterior vaginal wall
meshes anchored via the transobturator route (Perigee
and Anterior Prolift) were developed in 20032004.
At the same time, posterior meshes anchored through the
ischiorectal fossa were introduced (Posterior Prolift and
Apogee). Essentially, all current commercial meshes
sold and used specifically for prolapse repair are derivatives of those mesh devices. Biological meshes, on the
other hand, are often not properly anchored, and there
are no solid data on outcomes. Sonographically they are
invisible, and owing to the lack of available information
they will not be considered any further in this review. At
present, the use of biological meshes has to be regarded as
experimental.
Synthetic prolapse meshes are commonly used in conjunction with suburethral slings to treat concomitant
urodynamic stress incontinence. Ultrasound has played
a major role in the evaluation of sling function and placement, since such implants are as echogenic as polypropylene meshes used for prolapse surgery5 9 . Initially there
was some concern about simultaneous insertion, especially if both implants use a transobturator path. However, there are generally no technical difficulties, and the
two different procedures (suburethral sling and anterior
compartment mesh) seem to have very little, if any, effect
on each other, as shown in a paper published in this issue
of the journal10 . The only exception seems to be cases
where both mesh and sling are inserted through the same
anterior vaginal incision, which can either be deliberate
or a result of inadvertent extension of one incision to the
other. This can result in a mechanical union between sling
and mesh, making dynamic compression of the urethra
less likely and potentially leading to sling failure. Such
an effect is easily demonstrable on translabial ultrasound,
since the sling is directly adjacent to the mesh implant
and shows no mobility relative to the mesh on Valsalva
maneuver.

Copyright 2012 ISUOG. Published by John Wiley & Sons, Ltd.

While industry marketing has increased the use of mesh

kits for prolapse repair, it would be hard to argue that
there was no need for such innovation. After all, recurrent
prolapse is common, especially in the anterior compartment, with estimates of recurrence rates ranging from 5 to
60%. In fact, it may be possible to identify preoperatively
patients in whom recurrence is highly probable. A focus
on patient selection is becoming increasingly urgent.

Methodology
Pelvic floor assessment by imaging is best performed
by translabial or transperineal ultrasound, which has a
number of advantages over magnetic resonance imaging
(MRI), as it is cheaper and more easily available, and
provides information in real time at 30 Hz or higher11 .
Even with four-dimensional (4D) imaging using systems
originally developed for fetal assessment, temporal
resolution is higher than for single-plane dynamic MRI.
The advantages of ultrasound are particularly obvious
when it comes to assessing mesh implants, since modern
wide-weave polypropylene meshes are highly echogenic,
but invisible on plain X-ray or MRI12,13 . As a result, both
intravaginal and perineal ultrasound have been introduced
for the imaging of mesh implants14 18 .
Modern 4D ultrasound systems designed for prenatal
diagnosis are perfectly suited for pelvic floor assessment.
A 7090 aperture and an 8090 acquisition angle
allow visualization of the entire levator hiatus with
levator ani, urethra, vagina, rectal ampulla and anal
canal at the same time, in real time, requiring very little
transducer manipulation (Figure 1). The method has
been comprehensively described in two recent review
articles11,19 . Its main limitation in terms of implant imaging is that cranial aspects of prolapse meshes are difficult
or impossible to visualize, especially if there is recurrent
posterior prolapse. However, these limitations are rarely
relevant clinically, since suspension failure will invariably
make the mesh descend and become clearly visible.
This article will be limited to those applications of pelvic
floor ultrasound that are useful for surgeons contemplating the use of mesh in pelvic reconstructive surgery, and
for those dealing with patients after mesh implantation.
The imaging of suburethral slings is covered elsewhere11 .

Predicting recurrence: towards better patient selection

The probability of recurrence after prolapse surgery is
likely to vary from one patient to another. As anterior

OPINION

Dietz

496

Figure 1 Translabial three-dimensional ultrasound representation

of pelvic floor structures in a patient with normal findings,
showing: (a) the midsagittal plane, (b) the coronal plane, (c) the
axial plane and (d) a rendered volume, i.e. a semitransparent
representation of all volume pixels located in the region of interest
(the box seen in (ac)). L, levator ani; R, rectum; SP, symphysis
pubis; U, urethra; V, vagina.

compartment mesh seems to be associated with substantially reduced recurrence rates20 , it is probable that the
risk : benefit ratio of mesh use vs traditional surgery in
some women should favor the use of mesh, regardless of
mesh-related complications. This is most likely in women
at high risk for prolapse recurrence after conventional
surgery. Hence, it seems prudent to consider individual
recurrence risk prior to prolapse surgery.
A number of authors have investigated risk factors
for recurrence. Younger age21,22 , a family history of
prolapse23 , prolapse grade21 24 , poor pelvic floor muscle contractility25 , previous hysterectomy, body mass
index21 , previous prolapse surgery, a larger genital
hiatus25 , levator avulsion (Figure 2)23,26 28 and hiatal
ballooning29 , that is, excessive distensibility of the levator
hiatus (Figure 3)30 , all seem to be associated with recurrence. Whiteside et al.22 , in a series of 176 women seen
1 year after prolapse surgery, found stage 2+ prolapse in
58%, associated with younger age and higher preoperative stage. In 292 women seen on average 5 months after
prolapse repair, Vakili et al.25 found recurrent stage 2+
prolapse in 35%, and this occurred more commonly in
women with a large genital hiatus and poor levator contractility. More recently, levator avulsion, a major defect

Figure 2 Right-sided levator avulsion ( ) after normal vaginal delivery at term (as seen from caudally) on: (a) a rendered ultrasound volume
similar to that in Figure 1d, (b) magnetic resonance imaging (axial plane) and (c) tomographic ultrasound imaging, 3 months postpartum.

Figure 3 Ultrasound images showing different degrees of hiatal distensibility on maximal Valsalva maneuver. The limit of normality
(mean + 2 SD in nulliparae60 , or as predictor of symptoms of prolapse30 ) is 25 cm2 .

Copyright 2012 ISUOG. Published by John Wiley & Sons, Ltd.

Ultrasound Obstet Gynecol 2012; 40: 495503.

Opinion

497

of the levator ani muscle after vaginal childbirth31,32 ,

has been shown to be a predictor of anterior compartment recurrence23,26,27 , even after mesh use28 . The author
reported on 83 women, seen on average 4.5 years after
anterior colporrhaphy, with a recurrence rate (stage 2+
cystocele) of 40% and a relative risk of 2.9 in women with
avulsion26 . Using the same ultrasound methodology32,33 ,
Weemhoff et al.23 found an odds ratio of 2.4 for recurrence in 156 women seen on average 31 months after anterior colporrhaphy, with an overall recurrence rate of 51%.
Other risk factors were advanced preoperative stage, family history of prolapse and sacrospinous fixation23 .
The impact of levator avulsion has been confirmed
with MRI: Morgan et al.34 reported on a series of 83
women 6 weeks after vaginal prolapse surgery and found
poorer support in those with avulsion. This predictive
effect of avulsion on prolapse recurrence applies even
in women after the use of anterior compartment mesh,
as Wong et al.28 showed in a series of 219 women
on average 2.1 years after Anterior Prolift or Perigee
mesh. In our own recurrence modeling29 , which included
334 patients on average 2.5 years after cystocele repair,
avulsion was associated with an odds ratio of 2.95 for
recurrence, while hiatal area on Valsalva conveyed an
additional 7% per cm2 for the likelihood of recurrence.
This effect of ballooning seems largely independent of
the risk conveyed by avulsion, implying that both factors
in combination may effectively identify patients in whom
conventional surgery is likely to fail. The likelihood of
recurrence may vary from 12 to 95% in a patient with
a given degree of cystocele, depending on avulsion and
hiatal ballooning29 (Figure 4).
Imaging, especially using modern 4D pelvic floor ultrasound, can contribute to patient selection by diagnosing
levator avulsion and excessive hiatal distensibility or

Probability

(a) 1.0
0.8
0.6
0.4
0.2
0.0
10

20

30

40

50

60

70

Hiatal area on Valsalva maneuver (cm2)

Probability

(b) 1.0
0.8
0.6
0.4
0.2
0.0
10

20

30

40

50

60

70

Hiatal area on Valsalva maneuver (cm2)

Figure 4 Risk of prolapse recurrence 2.5 years after anterior

colporrhaphy in women with (a) and without (b) avulsion, relative
, no mesh;
, mesh.
to hiatal area and mesh use (n = 334).

Copyright 2012 ISUOG. Published by John Wiley & Sons, Ltd.

ballooning, but both these main predictors of recurrence can be obtained on clinical examination35,36 . In
view of the acrimonious discussion regarding the use of
mesh and the increasing medicolegal relevance of mesh
complications it seems prudent to limit mesh use to the
anterior compartment, and to patients at high risk of
prolapse recurrence. Unfortunately, the need for better
patient selection and identification of those at a high risk
of recurrence is being ignored by bureaucrats and senior
clinicians involved in this debate37 39 .

Dealing with complications: shrinkage and erosion

There are substantial downsides to mesh use. Meshrelated chronic pain and erosion are complications that
have attracted considerable attention40 . The prevalence
of chronic pain syndromes is unclear and probably
depends on surgical technique, but together with de
novo dyspareunia they may affect over 5% of patients,
substantially impacting on their quality of life. Mesh
erosion is better defined, in that a prevalence of 510%
over the first few years after mesh implantation seems
to be generally accepted41 . Previous vaginal surgery42 ,
concurrent hysterectomy43 and smoking44 are risk
factors; the amount of mesh implanted and the extent
of dissection may also be relevant. Imaging seems to be
largely irrelevant to the diagnosis and management of
erosion since it is clinically obvious.
Chronic pain syndromes are a substantial potential
management problem, and their etiology is uncertain45 .
Some authors have suggested a connection between a
thick, indurated mesh on palpation and chronic pain. It is
plain that in some women mesh implants are completely
smooth and flat (Figure 5), but in others folded and thickened (Figure 6). Animal data suggest that meshes shrink in
vivo46 , but to date all claims of mesh shrinkage, retraction
or contraction have been based on studies employing single time points, i.e. not on longitudinal observation14,15,47 .
From an anatomical point of view, it is unreasonable to expect that an 8-cm mesh will remain flat once
implanted into the anterior vaginal wall between the bladder neck and apex. Even under optimal conditions this
implies a length of 5 cm, and even if the mesh is optimally fixated with sutures it is very likely that it will fold
on implantation, reducing dimensions. Any true postoperative shrinkage would require the analysis of mesh
dimensions at different postoperative time points in the
same patient. It is curious that authors claiming evidence
of mesh contraction on comparing in vitro and in vivo
measurements did not arrive at the more probable conclusion that they inserted too much mesh in the first place.
Unfortunately, the concept of mesh contraction has
been adopted enthusiastically40 . Retraction/contraction
after mesh implantation in the context of prolapse surgery
may well exist, but it remains unproven to date, and its
magnitude and clinical relevance are by no means certain.
Two studies employing multiple time points concluded
that mesh shrinkage is probably limited to the period
of physiological wound healing, and that mesh surface

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Dietz

Figure 5 Identification of transobturator armed mesh on Valsalva maneuver in midsagittal (a), coronal (b) and axial (c) planes. Arrows show
mesh length. Horizontal line in (a) is a line of reference placed through the inferior symphyseal margin; vertical line illustrates maximum
descent of caudal mesh margin on Valsalva maneuver. B, bladder; L, levator ani; R, rectum; S, symphysis.

Assessing anchoring mechanisms: towards better mesh

engineering

Figure 6 Example of distally folded, thickened anterior

compartment mesh (arrows) in midsagittal view (a) and rendered
volume axial view (b). A, anal canal; B, bladder; R, rectum;
S, symphysis pubis.

reduction is much more likely to be caused by folding,

that is, too much mesh, or mesh that has not been
sufficiently fixed to the underlying tissues16,48 . In short,
the appearances of shrinkage are likely to be due to
surgical technique and suboptimal implant design, not
the patients immune system. This implies that we should
be able to reduce the likelihood of this complication by
adjusting mesh design and surgical technique. Mesh area
should be minimized, and implants need to be anchored
solidly, both to underlying tissues and the pelvic sidewall.

Another area in which modern imaging can be of help

to the pelvic reconstructive surgeon and to engineers
involved in the design of mesh implants is the analysis
of implant failure. It is high time we realized that mesh
anchoring is a crucial factor for success or failure. At
the present time, sonographic imaging is the only way
of assessing mesh anchoring objectively, since these
implants are radiolucent and very difficult to demonstrate
on MRI. Fortunately, modern polypropylene mesh
implants, both suburethral slings and prolapse meshes,
are highly echogenic49,50 . Prolapse meshes have been
imaged with translabial and endovaginal ultrasound for
about 8 years, mainly to document mesh placement and
configuration14,16,17,48 . A multitude of different anchoring techniques have been developed, from sling arms sited
through the obturator foramen to barbed plastic anchors
and suture-based methods. In my unit we have accumulated substantial data on mesh anchoring, relying on the
assumption that a mesh that moves several cm during
a Valsalva maneuver is unlikely to still be anchored to
the pelvic sidewall or the sacrospinous ligament. Figure 7
comprises ultrasound images showing a midsagittal
plane at rest (a), on mild Valsalva maneuver (b) and on

Figure 7 Typical appearance on ultrasound of transobturator mesh (M) in a case of dislodgment of superior transobturator anchoring arms,
resulting in a high cystocele as observed after colposuspension or fascial sling: midsagittal views at rest (a), on half Valsalva (b) and on
maximum Valsalva maneuver (c). The cranial aspect of the mesh is unsupported and highly mobile. B, bladder; S, suburethral sling;
SP, symphysis pubis.

Copyright 2012 ISUOG. Published by John Wiley & Sons, Ltd.

Ultrasound Obstet Gynecol 2012; 40: 495503.

Opinion
maximal Valsalva (c), demonstrating apical failure, i.e.
dislodgment of apical anchoring structures, resulting in
excessive mobility of cranial aspects of the implant.
In a single midsagittal slice it is possible to document
both prolapse recurrence and mesh anchoring failure.
Patterns of failure vary substantially between different
mesh kits and anchoring methods. The most solid form of
lateral anchoring seems to be provided by transobturator
arms. Dislodgment of inferior arms seems to be least
likely. Sidewall fixation by plastic anchors may be less
effective51 . Just placing a mesh and expecting it to scar
into place over a few weeks with some form of vaginal
splinting seems unlikely to provide anything but increased
complication rates compared with traditional anterior
colporrhaphy. The effectiveness of apical anchoring seems
to vary between implants, with barbed anchors adding less
support than expected51 .
It is likely that some anchoring methods are better
than others, and that some anchors are at increased risk
of being dislodged. In a series of 296 women, seen on
average 1.8 years after anchored anterior compartment
mesh (Perigee, Prolift, Anterior Elevate), we found a
large percentage of anatomical situations indicative of
anchoring failure52 . A recurrent cystocele was found in
38% of patients. Three different patterns of cystocele
recurrence were observed, associated with distinctive
mesh mobility on Valsalva: (1) anterior failure (3%):
cystocele ventral and caudal to well supported mesh; (2)
apical failure (8%): high cystocele dorsal and caudal to
mesh with high mobility of the cranial mesh aspect; and
(3) global failure (27%): cystocele with high mobility of
the entire mesh on Valsalva (Figure 8). Anterior failures
occur because of dislodgment of the bladder base from a
well supported mesh (Figure 8a). Apical failures are not
uncommon in armed transobturator meshes, implying
dislodgment of superior arms, as seen in Figures 7 and
8b. Most common are global failures (Figure 8c) in which
the entire mesh has become highly mobile, implying a
complete absence of effective mesh anchoring. A global
recurrence may occur after placement of any of the five
different mesh types we have audited to date, but it
seems particularly common after non-anchored meshes
and Anterior Elevate. Apical and global anchoring failures

499

seem to be associated with hiatal area on Valsalva

maneuver and avulsion, implying that these forms of
prolapse recurrence are due to excessive loading of mesh
anchoring structures51 . This suggests that current implant
designs are suboptimal as regards anchoring, and that
there may be substantial room for improvement. This
could be achieved relatively easily by optimizing current
technology, for instance, by widening anchoring arms, or
by providing greater grip through the use of Velcro-like
mesh surfaces.

Dealing with recurrence after mesh: using the implant

as an asset
Imaging is particularly useful in recurrence after mesh
placement, mainly because in some instances the implant
can be converted from a liability to an asset, depending on
the type of recurrence and associated findings as discussed
above. The cases shown in Figures 7 and 8b, apical recurrences according to the above classification, clearly need
their implant resuspended cranially. This is most conveniently achieved by bilaterally extending the mesh to the
sacrospinous ligaments, as is routine with certain secondgeneration mesh implants. Such a procedure may require
a mesh extension, and one has to take great care to leave
a sufficiently large gap between the mesh arms and the
sacrum in order to avoid intestinal obstruction. Another
approach would be to obtain access to the cranial,
unsupported margin of the original mesh abdominally
and suspend it in the form of a sacrocolpopexy.
Relatively uncommonly, a recurrent cystocele occurs
anterior/inferior to a mesh that is well anchored to the
sidewall but has become dislodged from the bladder neck
(Figure 8a). This particular situation is often associated
with a larger gap between the mesh and symphysis
pubis, and with recurrent or de novo stress incontinence
in those women who have not undergone concomitant
suburethral sling placement18 . Cystocele recurrence due
to dislodgment of the mesh from the bladder neck is easily
treated by dissecting the recurrent cystocele and inferior
mesh margin and reattaching the bladder neck to the mesh.
Global support failure, that is, dislodgment of all lateral
and cranial supports as seen in Figure 8c, seems to be the

Figure 8 Ultrasound images showing types of mesh anchoring/cystocele recurrence after application of anterior compartment meshes: (a)
anterior recurrence, (b) apical recurrence and (c) global recurrence. Dots indicate outline of meshes, with arrows indicating cranial and
caudal mesh margins. A, anal canal; B, bladder; R, rectum; SP, symphysis pubis; U, urethra.

Copyright 2012 ISUOG. Published by John Wiley & Sons, Ltd.

Ultrasound Obstet Gynecol 2012; 40: 495503.

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500
80
70
60
Force (N)

most common form of failure. Currently there are no data

on how to deal with such a situation. So far, the literature
contains no description of a successful re-suspension of
an existing mesh to the sidewall. Cranial dislodgment of
a second-generation mesh, such as the Anterior Elevate or
Uphold, will require cranial re-suspension, and depending
on the degree of scarring this may be undertaken vaginally
or abdominally. In the current climate, insertion of a
second mesh (after partial or complete removal of the
first) would have to be considered with particular caution.

50
40
30
20

Investigating pathophysiology: towards treatment of

causes, not effects
From a pathophysiological point of view it appears
reasonable to regard female pelvic organ prolapse as
a hernia. This is most obvious for true rectocele, a
herniation of anterior rectal wall and rectal contents
through a defect in the rectovaginal septum. However,
the model can also be applied to other forms of
prolapse, possibly including rectal intussusception and
prolapse, with the hernial portal defined as the levator
hiatus. This assumption is supported by the fact that
the size of the hiatus is associated with prolapse30 ,
independent of levator avulsion53 , and with prolapse
recurrence25,29 . While imaging suggests that intravaginal
mesh design could be improved by enhancing the loadbearing capabilities of anchoring structures such as
transobturator arms or pelvic sidewall anchors, it also
opens up entirely new therapeutic possibilities.
Firstly, since levator avulsion is a major risk factor for
prolapse and prolapse recurrence, it appears reasonable
to reconstruct the levator by reconnecting the torn muscle
to its insertion on the os pubis. This is unlikely to be
successful as a primary procedure postpartum owing to
the state of the tissues at the time, but most avulsions are
occult and not accessible without dissection in the delivery
suite54 . Levator reconstruction seems to be technically
possible as an adjunct to prolapse surgery, through a
lateral colpotomy, but the effect on hiatal reduction and
prolapse recurrence has been disappointing in the hands
of the author55 . This may be partly because frequently
an avulsed muscle is not just torn off its insertion,
but also overdistended and damaged on a microscopic
or ultrastructural level, and this may also apply to a
macroscopically normal contralateral side. A more global
approach may be needed to develop a method of pelvic
floor reconstruction that is applicable to most or all of
our prolapse patients, not just the small minority with an
isolated unilateral levator defect.
Female pelvic organ prolapse is a hernia through the
levator hiatus, and recurrence is associated with the size
of the hernial portal25,29 . Basic physical considerations
suggest that the forces acting on pelvic support structures
are directly proportional to the size of the hiatus. Since
pressure (p) = F/A, that is, force per unit area, a given
pressure, say, 100 cmH2 O, will generate twice the force
perpendicular to the surface of the hiatus in one person
than in someone else with double the hiatal area. In our

Copyright 2012 ISUOG. Published by John Wiley & Sons, Ltd.

10
0
0

10

20

30

40

50

60

70

Hiatal area on Valsalva (cm2)

Figure 9 Modeling of pelvic floor loading relative to abdominal

pressure and hiatal area on Valsalva maneuver. The force generated
by a given intra-abdominal pressure will vary enormously,
depending on hiatal area on Valsalva. Commonly, patients with
prolapse present with a hiatal area of between 30 and 60 cm2 ,
and most patients are able to generate Valsalva pressures in excess
, 20 cmH2 O;
, 40 cmH2 O;
,
of 80 cmH2 O30,61 .
, 80 cmH2 O;
, 100 cmH2 O.
60 cmH2 O;

(admittedly simplistic) modeling, a hiatal area of 50 cm2

will expose hiatal structures to forces of 50 N at a pressure
of 100 cmH2 O (Figure 9). To provide a perspective on
the magnitude of such forces it helps to consider the
mechanical properties of modern implant materials. The
tension-free vaginal tape fails at 6070 N, Gynemesh
at 46.3 N, AMS IntePro Lite at 27.2 N and Gynecare
Ultrapro at 7.8 N56,57 . Hence, some lightweight meshes
may disintegrate at forces that are likely to be reached in
vivo in women with a highly abnormal pelvic floor.
If hiatal area is indeed an important factor in the
pathophysiology of prolapse, then we should try to target
it in pelvic floor reconstruction. This particular hernial
portal cannot be closed off without highly deleterious
implications for function, since it is traversed by the
urethra, vagina and anorectum. However, we may be
able to reduce its size. Until recently, there was only one
procedure documented in the world literature that was
designed to achieve this goal the Zacharin abdominoperineal levatorplasty, which has not found widespread
adoption owing to morbidity and complications58 . We
have developed a minimally invasive levatorplasty, the
puborectalis sling, which allows a substantial reduction
of the hiatus through placement of a corset-like band
of mesh through the ischiorectal fossa, anchored to the
inferior pubic rami, surrounding the hiatus laterally and
postanally59 . In the first 50 patients followed up for more
than 6 months, we documented hiatal reduction from an
average of 43.5 to 31 cm2 (P < 0.0001; see Figure 10
for a typical comparison of pre- and postoperative hiatal
imaging). The effect of such a procedure on prolapse
recurrence is uncertain and requires a randomized
controlled trial, which commenced at four sites in
Australia in mid-2012.

Ultrasound Obstet Gynecol 2012; 40: 495503.

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501

reconstruction and hiatal reduction levatorplasty. The

likelihood of substantial innovation in this field within
the next 5 years is very high unless regulators and
administrators shut down clinical research in the field.
This is starting to appear a distinct possibility in some
jurisdictions.

Acknowledgment
I would like to thank Mr Poul Nielsen, Auckland
Bioengineering Institute, for help with the modeling of
pelvic floor loading as shown in Figure 9.

Disclosures
Within the last 2 years, Dr Dietz has received an
educational grant from GE Medical (value USD 9000)
and has received equipment support from GE Medical
and Siemens for workshops. He also acted as consultant
for Materna Medical (San Francisco, USA).

Figure 10 Ultrasound images comparing pre- and postoperative

imaging in a patient after prolapse surgery, showing a hiatal
reduction from 35 to 22 cm2 3 months after insertion of a
puborectalis sling. Midsagittal (a) and axial (b) views on Valsalva
maneuver before anterior repair, transobturator sling and
sacrospinous fixation; midsagittal (c) and axial (d) views on
Valsalva 3 months after the procedure. B, bladder; L, levator ani;
S, symphysis pubis.

Conclusions
The current debate surrounding the use of mesh in pelvic
reconstructive surgery has to date largely missed the
point. Accurate diagnosis has to come before surgery,
and much of the confusion at present is due to a lack of
diagnostic effort, both before and after mesh surgery. Any
further attempts at optimizing prolapse surgery should
be preceded by a conscious effort to first improve the
assessment of such patients, and imaging has a major role
to play in this regard.
Anchored anterior compartment meshes do seem to
lower recurrence rates, but owing to substantial meshrelated complications they are probably only indicated in
women at high risk of prolapse recurrence. Such patients
can be identified on clinical examination and pelvic floor
imaging. Women with a highly abnormal levator ani
muscle are unlikely to be permanently cured of their
prolapse by conventional means, and should probably be
offered mesh surgery.
Even with mesh use, however, recurrence rates
(while substantially lower than without mesh) are still
unacceptably high, suggesting that current implant design
is suboptimal. Imaging shows distinct patterns of mesh
failure and suggests equally distinct surgical approaches,
as well as improvements in implant design. Imaging also
allows entirely new surgical approaches, such as levator

Copyright 2012 ISUOG. Published by John Wiley & Sons, Ltd.

H. P. Dietz
Discipline of Obstetrics, Gynaecology and Neonatology,
Sydney Medical School Nepean, Penrith,
New South Wales, Australia
(e-mail: hpdietz@bigpond.com)

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