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\title{Management of recurrent pelvic organ prolapse. (Mini-commentary on
BJOG-19-1139.R1)}



\author[1]{Katie Propst}%
\affil[1]{Cleveland Clinic}%


\vspace{-1em}



  
  \date{May 18, 2024}


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Mini-commentary on BJOG-19-1139.R1: Mesh inlay, mesh kit or native
tissue repair for women having repeat anterior or posterior prolapse
surgery: randomised controlled trial (PROSPECT)

\textbf{Management of recurrent pelvic organ prolapse}

Katie Propst,

Urogynecology and Reconstructive Pelvic Surgery, OB/Gyn \& Women's
Health Institute, Cleveland Clinic, 9500 Euclid Avenue, Desk A-81,
Cleveland, OH

PropstK@ccf.org

Recurrent pelvic organ prolapse (POP) is not clearly defined and its
management is not as well understood as primary POP (Ismail et al, Int
Urogynecol J, 2016, 27:1619-1632). Management of recurrent POP entails
consideration of patient-specific risk factors, duration of time since
the primary repair was performed, degree of patient bother,
patient-specific goals, and review of complications of the initial POP
surgery. In addition to patient considerations, the planned surgical
procedure must be determined. Evidence for procedure selection in
recurrent POP is limited. Vaginal mesh repairs were introduced to reduce
the recurrence of POP; however, it is unclear if the use of mesh in
vaginal repair of recurrent POP would lead to better outcomes.

In this issue, Glazener and colleagues provide evidence on the
management of women with recurrent POP who desire surgical intervention
(BJOG 2020 xxxx). As part of the PROSPECT study (Glazener et al, Lancet,
2016, 389:318-392), two parallel randomized controlled trials were
performed: the Mesh Inlay Trial comparing native tissue repair to mesh
inlay and the Mesh Kit Trial comparing native tissue repair to mesh kit.
The study included 59 surgeons from 33 centers in the UK. Surgeons were
allowed to perform procedures based on their usual technique and to use
graft materials that they would normally use.

Limitations of available data and concerning complication rates have led
to widespread unavailability of mesh kits making questions related to
their use in the treatment of recurrent POP even more difficult to
answer. As an alternative to mesh kits, pelvic reconstructive surgeons
have the option to use a mesh inlay which can be fashioned from
polypropylene mesh making the mesh inlay arm an important component of
the study. The patient-centered primary outcome, change in Pelvic Organ
Prolapse Symptom Score (POP-SS) at one year, did not differ between
native tissue and mesh kit repairs or between native tissue and mesh
inlay repairs. POP-SS did not differ at two years either.

The study was powered based on a 30\% recurrence rate of surgical repair
of anterior and/or posterior compartment POP. This plan led to an
estimated 1240 study candidates. Assumption of 50\% study acceptance was
made and enrollment of 620 women was planned. While the design of this
study reflects surgeons' usual practice allowing generalizability,
recruitment targets were not reached limiting the ability to make
conclusions.

Despite the limitations of results, this work informs future trial
planning. Simpler study design with more realistic recruitment
expectations is prudent. It is clear that not all POP recurrences are
due to the same factors. Recurrences may occur due to the surgical
approach, lifestyle factors, and changes in tissue quality due to aging.
In future studies, it would be useful to better understand the surgical
history of the study sample and the timing of POP recurrence.

The Mesh Inlay and Mesh Kit Trials illustrate the need for evidence
regarding the management of women with recurrent POP and provide
valuable information in the planning of future trials.

\textbf{Conflicts of interest:} None to report. A completed disclosure
of interest form is available to view online as supporting information.

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