Sacral colpohysteropexy (hereafter sacropexy) has become the gold standard for the surgical treatment of pelvic organ prolapse (POP). It allows the treatment of multicomportimental POP by placing an anterior vesico-vaginal and vaginal apex (or uterine isthmus) synthetic non-absorbable mesh attached to the anterior vertebral common ligament at the level of the sacral promontory. and a posterior recto-vaginal mesh. Based on historical habits, a prerectal mesh has been systematically placed in the rectovaginal space, in addition to the anterior and apical mesh, in order to prevent de-novo posterior prolapse. Indeed, retrospective comparative studies have not shown a higher risk of recurrence of POP especially rectocele with anterior salcropexy. However, the addition of posterior mesh may increase the risk of surgical complications and de-novo obstructed defecation. Current guidelines do not support systematic prophylactic posterior mesh placement in the absence of rectocele due to the lack of high-level evidence. The aim of is study is to compare reoperations for recurrence and serious complications after anterior sacropexy (ASP) versus double mesh sacropexy (DSP) for anterior and/or apical POP.

This analysis included patients enrolled in the French, multicenter, prospective VIGI-MESH register since February 2017 who received ASP or DSP for apical and/or anterior POP, excluding patients with rectocele or rectal prolapse or who received concomitant posterior vaginal repair. Follow-up continued until November 2022. All surgeons described each surgical procedure performed on a specific case report form. We checked the data collection by reviewing mesh deliveries from the hospital pharmacies and surgical procedure codes recorded by each hospital's medical data department. We defined serious complications using Clavien-Dindo classification: mesh placement cancelled due to peroperative injury (Grade III), subsequent surgical intervention related to a complication (Grade III), life-threatening complication (Grade IV), woman's death (Grade V). We collected also surgical revisions for prolapse recurrence. We used several sources to identify complications and revisions: the monitoring of surgical procedures by the data departments, surgeons' spontaneous reports, and a questionnaire sent to the women a year later. Serious complications and reoperations for recurrence were compared using Cox proportional hazard models including any associated surgery (hysterectomy or stress urinary incontinence surgery) and a frailty term to consider the center effect.

Between February 2017 and November 2022, 1966 women underwent a sacropexy in 30 centers and agreed to participate: 1313 underwent ASP and 653 DSP. Baseline characteristics did not differ between groups except for the history of hysterectomy, which was more common in patients undergoing DSP (Table). Concomitant hysterectomy (especially sub-total hysterectomy) and concomitant MUS surgery were more common during DSP (Table). The median follow up time was 26 months, IQR: 13 – 46.
Thirty-four patients (1.7%) underwent re-operation for recurrent POP (Figure 1). Of 25 women (1.9%) who required new surgery for POP recurrence after ASP, 20 had anterior and/or apical prolapse, 11 had rectocele and/or elytrocele, and one had rectal prolapse. In the DSP group, nine (1.4%) women required new surgery for POP recurrence: nine had anterior and/or apical prolapse, one had elytrocele, one had rectal prolapse. The route of reoperation was the laparoscopic in six patients, vaginal in 21 patients, both vaginal and laparoscopic in three patients, transanal in one patient and unknown in 3 patients. After adjusting for center effect and the associated surgery (hysterectomy or SUI surgery), the difference between the groups was not significanlty different (adjusted HR, 1.7; 95%CI 0.75, 3.8, p = 0.20). 
We observed twenty-eight (1.4%) serious complications (Figure 2) attributable to the sacropexy: 22 (1.7%) after ASP and 6 (0.9%) after DSP. Sacrocolpopexy was aborted in five women because of adhesions (one woman), vesical wound (one woman), or inaccessible promontory (3 women who benefited from pectopexy instead). Four patients had serious hemorrhage-related complications. Three patients underwent reoperation for gastrointestinal complications (one for appendicitis, one for ileal wound and one for bowel obstruction, all in the ASP group). Three women had serious urologic complications (two vesical wounds diagnosed postoperatively and one ureteral obstruction). Five patients had parietal eventration requiring surgery. One patient was reoperated for a pelvic abscess. One woman underwent pudendal nerve infiltration for painful vaginal granuloma. Seven women underwent reoperation for vaginal exposure of the mesh (five in the ASP group and two in the DSP group). At reoperation, six patients had partial or complete removal of the mesh (four after ASP and two after DSP).
After adjusting for center effect and the associated surgery, the difference between the groups was not significantly different (adjusted HR, 2.1; 95%CI 0.77, 6.0, p = 0.14).

Analysis of the results in our registry shows that the addition of a prophylactic posterior mesh is not associated with a higher risk of serious complications. The risk of reoperation for POP recurrence seems higher after ASP without reaching a statistically significant difference. One limitation of our study is that it only recorded recurrences requiring revision with a medium term follow up and may underestimate a potential benefit of DSP.

Serious complications and reoperation for POP recurrence after ASP and DSP are not significantly different. However, our results do not allow us to conclude that there is no inferiority with regard to the risk of recurrence. The risk of reoperation, either for recurrence or complication were reassuring and may help surgeons and patients in shared decision making regarding the addition of a prophylactic posterior mesh in the absence of rectocele.

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