Volume 63, Number 4

OBSTETRICAL AND GYNECOLOGICAL SURVEY

Copyright © 2008
by Lippincott Williams & Wilkins CME REVIEWARTICLE 11
CHIEF EDITOR’S NOTE: This article is part of a series of continuing education activities in this Journal through which a total
of 36 AMA/PRA Category 1 CreditsTM can be earned in 2008. Instructions for how CME credits can be earned appear on the
last page of the Table of Contents.

Biologic and Synthetic Graft Use in

Pelvic Surgery: A Review
Sharon M. Jakus, MD, MPH,* Alex Shapiro, MD,† and
Cynthia D. Hall, MD‡
*Fellow, Urogynecology and Pelvic Reconstructive Surgery, Cedars-Sinai Medical Center, Los Angeles,
California; †Fellow, Urogynecology and Pelvic Reconstructive Surgery, Women’s Hospital Memorial Medical
Center, Long Beach, California; and ‡Director, Division of Urogynecology and Pelvic Reconstructive Surgery,
Co-Director, Center for Women’s Continence and Pelvic Health, Cedars-Sinai Medical Center and Assistant
Professor, David Geffen School of Medicine at UCLA, Los Angeles, California

Urinary incontinence and pelvic organ prolapse are some of the most commonly treated condi-
tions in postmenopausal women. Surgical cure rates vary greatly depending on surgical technique
and the type of materials used, if any, to supplement the native tissue. Traditional colporrhaphy
relies on adequate tissue for a successful repair. The main concern associated with traditional
plication or needle suspension type repairs is that the use of intrinsic attenuated tissue may provide
a weak, constricted, or an anatomically incorrect result. Graft use allows for a broader base of
support and eliminates the need to rely on the existing weakened fascia and musculature. A review
of the existing literature on success rates and complications with various synthetic and biologic
graft materials yielded the following conclusions. The superiority of graft use over traditional suture
suspensions for abdominal sacrocolpopexy and suburethral sling procedures has clearly been shown
in the literature. Macroporous monofilament synthetic grafts and non-cross-linked biologic grafts
appear to have the best integration into native tissues. Solvent dehydration and irradiation of biologic
grafts may weaken the integrity of the material and may prevent proper tissue integration. Technical
factors related to surgical technique may impact success rates, such as tension on suture line or failure
to use vaginal packing. The perfect graft material has not yet been created. Suggestions for further
research include more prospective, randomized trials comparing synthetic and biologic grafts, tension-
free versus secured mesh, and absorbable versus nonabsorbable mesh.
Target Audience: Obstetricians & Gynecologists, Family Physicians
Learning Objectives: After completion of this article, the reader should be able to recall how common
urinary incontinence is, explain the historical considerations for diagnosis and treatment, and summarize
the updated methods of treatment based upon anatomical structures and pathophysiology.

Pelvic organ prolapse is a common condition af-
fecting 15% to 30% of women over the age of 50 (1).
The likelihood of undergoing prolapse or inconti-
nence surgery in the United Sates is quoted as 1 in 11
with up to a 30% recurrence rate (2).
Normal pelvic anatomy relies upon muscular sup-
port and intact endopelvic fascia. The levator ani
musculature is tonically contracted to close the gen-
ital hiatus and provides support to the pelvic organs.
When neuromuscular injury weakens the levators,
253
this puts strain on the surrounding connective tissue.
The endopelvic fascia provides a continuous frame-
work of support, including the pubocervical fascia
for the anterior vaginal wall and the rectovaginal
fascia for the posterior vaginal wall. Reconstructive
pelvic floor surgery is based on the anatomic princi-
ple of repairing defects in the endopelvic fascia or
compensating for these defects (3). Historically,
these defects were classified as a distension type
defect (stretching or attenuation of the pubovaginal
254 Obstetrical and Gynecological Survey
or rectovaginal fascia) or a displacement type defect
(detachment from the arcus tendineus). The Del-
ancey Classification delineates the contribution of
connective tissue attachments to pelvic organ sup-
port. “Level I” refers to the upper one-fourth of the
vagina, which is suspended by the uterosacral/cardi-
nal ligament complex maintaining the cervix above
the level of the ischial spines. Lateral paravaginal
support to the arcus tendineus fascia pelvis provides
support to “Level II,” the middle one-half of the
vagina, which keeps the vagina midline over the
rectum. The most distal or inferior level, “Level III”
or the lower one-fourth of the vagina, is supported by
the perineal body, perineal membrane, superficial
and deep perineal muscles, and endopelvic fascia.
The latter attachments maintain the normal position
of the lower vagina and are critical to the proper
function of the anal canal.
Cure rates and mesh-related complications have been
described for many urogynecologic procedures, such as
suburethral slings, anterior and posterior repairs, and
abdominal sacrocolpopexies (ASCs). Long-term suc-
cess rates with biologic or synthetic mesh vary from
61% to 100% for suburethral slings, from 68% to 100%
for ASCs, and from 84% to 100% for posterior repairs
(4–6). Anterior repairs, however, have more inconsis-
tent results (37%–100%) (6). Superior success rates
with graft use have been confirmed by meta-analysis
for ASCs and suburethral slings (7–11).
Traditionally, surgical correction of stress urinary
incontinence involves reinforcing the periurethral tis-
sue, such as with a Kelly plication, and providing
support to the suburethral hammock, such as with a
needle suspension or a Burch procedure. Traditional
anterior or posterior colporrhaphy relies on adequate
tissue for a successful repair. There are 2 main con-
cerns associated with traditional plication type re-
pairs. One is that the use of intrinsic attenuated tissue
may provide a weak repair. Indeed, histologic exam-
ination in at least one study demonstrated that tissue
The authors have disclosed that they have no financial relation-
ships with or interests in any commercial companies pertaining to
this educational activity.
The Faculty and Staff in a position to control the content of this
CME activity have disclosed that they have no financial relation-
ships with, or financial interests in, any commercial companies
pertaining to this educational activity.
Lippincott CME Institute, Inc. has identified and resolved all
faculty and staff conflicts of interest regarding this educational
activity.
Reprint requests to: Cynthia D. Hall, MD, Division of Urogyne-
cology and Pelvic Reconstructive Surgery, Department of Obstet-
rics and Gynecology, Cedars-Sinai Medical Center, 8635 West 3rd
Street, Suite 160W, Los Angeles, CA 90048. E-mail: hallc@cshs.
org.
identified as “fascia” at the time of colporrhaphy may
actually consist of part of the vaginal wall, possibly
an artifact of the surgical dissection itself (12).
Risk of reoperation after failed prolapse surgery
has been quoted as high as 29.2% (2). Another con-
cern of traditional repairs is that the surgeon may
attempt to use stronger lateral or nonanatomic tissues
for repair and suspension, which can result in con-
striction or foreshortening of the vagina. This in turn
may result in pelvic pain, dyspareunia, and urinary
retention. Furthermore, the wisdom of relying on
native tissue that has already failed the patient in
providing adequate support is questioned by some
authors (3).
Graft use allows for a broader base of support and
eliminates the need to be dependent on existing
weakened fascia and musculature. The use of grafts
to augment pelvic reconstructive surgery must be
tailored to maintain continence, vaginal capacity, and
coital function in addition to pelvic organ support.
Some proposed criteria for graft use are: patients who
have failed previous reconstructive surgery, those in
whom intraoperative dissection reveals inadequate
tissue, and patients with congenital collagen defi-
ciency (13). Relative contraindications to the use of
grafts include: history of previous irradiation; severe
urogenital atrophy; immunosuppressed patient; ac-
tive pelvic or vaginal infection; systemic steroid use;
and conditions which impair healing, such as morbid
obesity, poorly controlled diabetes, and heavy ciga-
rette smoking (14).
Cure rates and mesh-related complications have
been described for various urogynecologic proce-
dures, such as suburethral slings, anterior and poste-
rior repairs, and ASCs. Long-term success rates of
suburethral slings with synthetic mesh vary from
61% to 100% (5). Long-term outcomes for ASCs and
posterior repairs with synthetic grafts are similarly
favorable (68%–100% and 84%–100%, respectively)
(5,15–17). Anterior repairs, however, seem to have
more inconsistent results, between 37% and 100%
(6). Technical factors related to surgical technique
such as tension on the suture line or failure to use
vaginal packing may impact success rates.
Overall, there are few prospective, randomized tri-
als addressing the success rates and complications of
graft use in pelvic reconstructive surgery. Most of the
existing literature consists of retrospective case series
with small numbers and inconsistent outcome mea-
sures. There is also considerable variation in the way
that prolapse and success rates are defined. The 2
standard means of objectively quantifying pelvic or-
gan prolapse are: the Baden-Walker Half-Way
 Biologic and Synthetic Grafts in Pelvic Surgery Y CME Review Article
Graded System and the International Continence So-
ciety Pelvic Organ Questionnaire (POP-Q) Stages.
Outcomes are often described as “recurrence” or
“failures” if found to be stage II or grade II on
follow-up examination, although some studies only
use “anatomic success” (without specific docu-
mented measurements) or need for reoperation in the
assessment of their results. Multiple validated quality
of life questionnaires can also be used to quantify the
impact of these surgeries on activities of daily living,
recurrence of incontinence or prolapse symptoms,
and sexual function. Unfortunately, however, many
studies omit these questionnaires and instead only
report subjective patient impressions (6,18). Mesh-
related complications are also not always reported
and often are not clearly defined. The literature con-
tains terminology that varies from mesh “exposure”
and “extrusion” to “erosion” or “rejection.”
This review will begin with an overview of the
properties of the grafts available for use in pelvic
surgery, including ideal characteristics of grafts as
well as the biomechanics of existing biologic and
synthetic grafts. This will be followed by an account
of current experience with graft use for particular
pelvic reconstructive surgeries, including suburethral
slings, ASC, anterior and posterior repairs, and total
vaginal mesh repairs. Finally, an evidence-based
summary and recommendations will be provided for
the use of grafts in urogynecologic surgery.
IDEAL GRAFTS
The principle of using grafts in reconstructive sur-
gery is to reinforce existing tissue with a material that
is safe, biologically compatible, and provides an an-
atomically appropriate result. The ideal graft should
be inert, noncarcinogenic, have tensile strength and
flexibility, nonallergenic, noninflammatory, able to
be sterilized, nonmodifiable by body tissue, and con-
venient and affordable (19). However, no existing
graft has all of these properties. Natural biologic
graft materials, including autographs, allographs, and
xenographs, can be costly or in limited supply and
may carry risks of perioperative morbidity or, theo-
retically, disease transmission. Concerns regarding
synthetic mesh center on the risk of erosion, encapsu-
lation, and poor tissue function. Both natural and bio-
logic materials have long been employed successfully
for hernia and prolapse surgeries. Mesh-augmented re-
pairs have become the accepted standard of care for
inguinal hernia repairs with clearly demonstrated im-
provement in success rates over suture repair alone
255
(20). However, with vaginal reconstructive surgeries,
there are additional hurdles to overcome, such as the
proximity to bladder and bowel, and the pliability nec-
essary for coital function.
IMMUNOLOGIC RESPONSE TO GRAFTS
The ideal prosthesis should incur minimal initial
inflammatory and cellular reactions followed by vas-
cular and fibroblastic ingrowth. The inflammatory
process is different in response to synthetic versus
biologic grafts. Biologic grafts induce a T helper type
2 (Th2) humoral immune response. Th2 pathways
typically correspond to a graft acceptance type reac-
tion in transplant patients (21). Synthetic grafts acti-
vate leukocytes and generate a cytokine profile
largely consisting of tumor necrosis factor (TNF)-␤,
interferon (IFN)-␥, and interleukin (IL)-12, which is
classified as a T helper type 1 (Th1) response. These
cytokines are proinflammatory with the activation of
macrophages that may then initiate a rejection pro-
cess. The time sequence of the histologic response to
grafts is classically described in stages. Stage 1, the
first 7 days, includes intense inflammation with the
infiltration of capillaries, granular tissue, and giant
cells. In stage 2, after 14 days, granular tissue persists
and the number of giant cells increases. In stage 3,
after 28 days, the acute phase reaction ends and
histiocytes and giant cells predominate. Finally, stage
4 begins with the presence of giant cells and dense
fibrous tissue on the external surface of the implant.
Wound healing is characterized by collagen deposi-
tion with tissue integration (resulting in good long-
term durability). Encapsulation of grafts with fibrous
tissue alone can result in hardening, shrinkage, and
erosion, which may result in dyspareunia, alteration
of normal anatomy, and increased failure rates (14).
BIOLOGIC GRAFTS
Biologic grafts, whether autografts, allografts, or
xenografts, have several theoretical advantages and
disadvantages. Due to histologic similarities with
native tissues at the surgical site, the grafts are more
likely to undergo tissue remodeling and less likely to
cause erosion. Biologic grafts may be preferred for
patients with severe vaginal atrophy, history of local
radiation, or immunosuppression because of their in-
creased risk of delayed healing or infection. Drawbacks
of biologic grafts are limited availability; high cost;
inconsistent strength between specimens; possible at-
tenuation due to chemical processing; and concerns for
disease transmission via viruses, prions, or zoons.
256 Obstetrical and Gynecological Survey
Harvesting of autologous grafts, such as fascia lata,
rectus fascia, or skin graft (such as Repliform™;
Boston Scientific, Natick, MA) increases operative
time and carries a risk of increased perioperative
morbidity and incisional hernia. It may also result in
poor cosmesis at the harvesting site. However, they
are well incorporated into the native tissues and are
less likely to cause a foreign body reaction. These
grafts may also be the safest for use in an infected
area. The durability of autologous grafts may be
limited, given the intrinsic strength of this tissue, the
physiologic absorption process, and eventual re-
placement with local connective tissue.
Allografts can be taken from dura matter, rectus
sheath, or fascia lata. Several techniques are used
in the preparation of allograft specimens includ-
ing: ethanol extraction, high-pressure agitation,
lyophilization (freeze-drying), and gamma irradia-
tion. Allografts, such as dermis and cadaveric fas-
cia, have been shown to have similar tensile
strength and tissue stiffness to fresh, unprocessed
tissue if processed by solvent dehydration (22).
The risk of HIV transmission from allografts has
been estimated at 1 in 1.67 million, although in
actuality there have been no reported cases of
transmission in the literature (23). The freeze-
drying technique was designed to decrease the
antigenicity of the tissue, but has also been shown
to result in a graft that is weaker than solvent-
dehydrated fascia (24,25). Cross-linkage of bio-
logic grafts may also result in decreased durability
due to decreased potential for collagen ingrowth,
limited revascularization, and an increased risk of
encapsulation (14).
The proposed mechanism of allograft breakdown is
a graft-versus-host type autolysis reaction caused by
residual antigenicity of the graft. Some early failure
rates due to autolysis with cadaveric fascia lata slings
have been quoted as high as 20% (26). A small,
retrospective comparison of autologous pubovaginal
slings (N ⫽ 17) to solvent-dehydrated allograft slings
(N ⫽ 12) found similar rates of subjective improve-
ment in stress incontinence (92.3% vs. 90.5%) al-
though a significant number of allograft patients
(41.7%) had positive urodynamic findings of stress
incontinence that was not seen at all in the autolo-
gous graft patients (9). Although most studies ob-
served no erosion or graft-related complications with
use of biologic grafts in the anterior or posterior
compartments (27–33), one study by Drake et al
reported an extrusion rate of 10.9% using a dermal
allograft for anterior and posterior colporrhaphies.
This study reported a median time to discovery of 4
weeks and a full healing time of 13 weeks with
conservative management using vaginal estrogen
(34). In a study of ASC, Culligan reported 11% of
patients in the fascia lata arm with wound break
down but no erosions (35). In a similar study, Greg-
ory had no mesh-related complications (36).
Some xenograft materials have also been shown to
have favorable results with efficacy similar to autol-
ogous fascia (37). Xenografts can be prepared from
porcine dermis (Pelvicol™ and Pelvisoft™; CR
Bard, Branston, RI), porcine small intestinal submu-
cosa (SIS™; Cook Medical Inc., Bloomington, IN)
or bovine pericardium (Veritas™; Synovis Surgical,
St Paul, MN). Porcine collagen has a 95% homology
to human collagen and is easy to handle because it
rehydrates rapidly. Xenograft degradation, with
respect to both integrity and strength, has been
noted after implantation in human studies (26).
Similar to human allografts, xenografts are strictly
regulated by the FDA.
SYNTHETIC GRAFTS
Historically, the use of prosthetic materials in pel-
vic surgery dates back to the turn of the century.
Silver mesh was used as early as 1903, followed by
the introduction of nylon in the 1938, Dacron (Mer-
silene™; Ethicon, Somerville, NJ) in the 1956,
polypropylene (Marlex™; CR Bard) in 1958, and
most recently absorbable products such as polygla-
ctin 910 (Vypro I and II™; Ethicon) (38). Synthetic
mesh is typically classified by filament number and
pore size (Table 1) with tensile strength dependent on
fiber type, weight-to-area ratio and the weave (39).
Type I meshes [e.g., Marlex, Atrium™ (American
Medical Systems, Minnetonka, MN), Gynemesh™
(Ethicon), Pelvitex™ (CR Bard)] are polypropylene,
monofilament meshes that are macroporous (⬎75
␮m). Type II (e.g., Gore-tex™; WL Gore Associates,
Flagstaff, AZ) and type III [e.g., Teflon™ (DuPont
de Nemours, Wilmington, DE), Mersilene, IVS™
(TYCO Healthcare, Michelin, Belgium)] meshes are
both multifilamentous, although type II are micro-
porous (⬍10 ␮m) and type III have both macro-
porous and microporous components. Type IV
meshes, polypropylene sheets, have a pore size ⬍1
micrometer [e.g., Silastic™ (CR Bard) Cellgard™
(Hoechst Cellanese Corp., NY)]. Mechanical and
biologic properties of mesh types I, II, and III were
studied by Brun et al, and found to be comparable
with similarly high tensile strengths (⬎50 N) (40).
The surgical literature reveals improved success rates
with low weight, large pore monofilament meshes
 Biologic and Synthetic Grafts in Pelvic Surgery Y CME Review Article 257

TABLE 1
Graft and mesh characteristics
Rigidity Thickness
Type of Mesh Material Trade Name Manufacturer Knitted (mg/cm) (cm)
I. Monofilament Polypropylene Marlex CR Bard, Branston, RI Yes 540 0.066
macroporous Atrium American Medical Systems, Yes 185 0.048
Minnetonka, MN
Prolene Ethicon, Somerville, NJ Yes 465 0.065
Gynemesh Ethicon, Somerville, NJ Yes 177 0.041
Pelvitex CR Bard, Branston, RI Yes ? 0.04
Multifilament Polyglactin 910 Vicryl/VyproI, II Ethicon, Somerville, NJ Yes ? 0.49
II. Multifilament Polytetrafluoroethylene Goretex WL Gore Associates, No ? 1.1
microporous Flagstaff, AZ
III. Multifilament macro- ⫹ Polyethylene Terephthalate Mersilene Ethicon, Somerville, NJ Yes 17 0.025
microporous Polytetrafluoroethylene Teflon DuPont de Nemours, Yes ? 0.068
Wilmington, DE
Polypropylene IVS TYCO Healthcare Yes ? 0.04
International, Mechelin,
Belgium

with elasticity between 20% and 35% (21). This
degree of elasticity matches the compliance of sur-
rounding tissues. Marlex, a type I mesh, is stiffer
than several of the type II meshes, Mersilene and
Teflon, could increase the risk of injury to surround-
ing tissues (41). Atrium polypropylene mesh is more
pliable and lighter than Marlex or Prolene™ (5).
High erosion rates have been reported for vaginally
placed mesh, ranging from 9% to 11% for polypro-
pylene mesh (42,43) to 25% for Marlex mesh (44) in
anterior repairs and up to 40% with the use of Mer-
silene and Goretex mesh in posterior repairs (45).
One study comparing abdominally and vaginally
placed mesh also reported a significantly greater
erosion rate with the vaginal route (3%–4% for the
abdominal route vs. 16%–40% for the transvaginally
placed mesh) (45). Experience with the use of syn-
thetic materials for suburethral slings illustrates the
impact of the biomechanical properties of the mesh
on postoperative morbidity. Erosion rates with the
polypropylene mesh used for a transvaginal tape
(TVT) (⬍1%) are lower than those reported with
Goretex (6%–12%) (46), Mersilene (4%–6%) (47) or
Marlex (3%) (48).
Monofilament macroporous type I meshes have the
lowest reported incidence of infection and erosion.
This supports the theory that the small interstices
of multifilament meshes (⬍10 ␮m) that are the
root of the problem. Small interstices permit the
entry of bacteria (⬍1 ␮m), but block the migration
of larger macrophages (16–20 ␮m) and polymor-
phonuclear leukocytes (9–15 ␮m) that might coun-
teract bacterial colonization. It also seems best to
select knitted monofilament prosthesis over woven
monofilaments whose interstices are smaller, akin
to those a microporous mesh. The number, size and
shape of the pores also correlate with the develop-
ment of collagen and fibrous tissue. Monofilament
macroporous grafts permit collagen deposition be-
tween fibers whereas multifilament microporous
grafts are more likely to engender encapsulation of
the entire graft with collagen (49). This may be
due to a shorter lasting acute inflammatory re-
sponse to multifilament materials that results in a
more pronounced chronic inflammatory response
as compared to the reaction to monofilament ma-
terials. Heavier meshes, such as Prolene (85 g/m2)
and Marlex (95 g/m2), have a greater weight and
tighter weave than lighter meshes, such as Gy-
nemesh (43 g/m2) and Polyform™ (Boston Scien-
tific) (40 g/m2).
Other newer light meshes with combined absorb-
able and nonabsorbable components have also been
introduced recently. For example, Vypro I and II
meshes contain 50% Polyglactin 910 (absorbable,
used for abdominal hernia repairs) and 50% Polypro-
pylene with the addition of a combined polyglactin-
polypropylene violet thread for added stiffness in
Vypro II. Lym et al looked at 78 patients who un-
derwent posterior colporrhaphy with Vypro II, and
found an unacceptably high rate of complications
at 3 years of follow-up with 27% de novo dyspa-
reunia and 30% of mesh erosion (16). De Tayrac
cites experience in the posterior compartment with
a light (38 g/m2), macroporous (1.5 mm) polyester
mesh, Ugytex™ (Sofradim, Rhone-Alps, France)
coated with collagen, polyethylene and glycol.
Mesh erosion is cited at 6.3% and de novo dyspa-
258 Obstetrical and Gynecological Survey
reunia at 12.8%. However, this author also reports
a high anatomical success rate of 92% at 10
months after surgery (50).
GRAFTS IN SPECIFIC GYNECOLOGIC
PROCEDURES
The following sections will review the current pub-
lished experience with biologic and synthetic grafts
for particular urogynecologic procedures, including
suburethral slings, ASC, anterior repair, posterior
repair, and total vaginal mesh. Level I and II evi-
dence to support the use of graft materials in pelvic
reconstructive surgery exists for both suburethral
slings and ASCs. A Cochrane review by Maher et al
illustrates the significant benefits of graft use for
continence procedures (with a RR of 5.5 for recurrent
stress urinary incontinence after endofascial plication
compared to TVT sling) and ASC (RR ⫽ 0.23 for
recurrent prolapse of the vaginal vault with ASC
compared to vaginal sacrospinous fixation) (6). The
published literature on anterior and posterior colpor-
rhaphy is mixed with respect to success rates and
complications and does not conclusively support the
use of grafts over site-specific or plication-type re-
pair with native tissues. The Cochrane review re-
ported a RR of 1.39 for cystocele recurrence after a
simple plication repair compared to a repair with
mesh and a RR of 0.24 for rectocele recurrence with
a transvaginal repair compared to a transanal repair
(there was insufficient evidence for a comparison
with and without mesh) (6). Finally, there are no
peer-reviewed studies on the use of total vaginal
mesh procedures. Acquiring Level II evidence with
sufficient power to demonstrate the superiority of
mesh use is most challenging for rectocele repair due
to the high success rates (80%–90%) with traditional
plication and site-specific repair (10).
Suburethral Slings
The original, gold-standard urethral suspension
procedures were developed by Marshall, Marchetti,
and Krantz (MMK) in the 1950s and Burch in the
1960s. The first use of a sling suspension was de-
scribed by Aldridge in the 1940s using autologous
rectus fascia. High cure rates were reported with both
the Burch procedure and fascial slings, although
postoperative voiding dysfunction was less common
with the Burch procedure (51,52). MMK procedures
had similar success rates, but fell out of favor with
most gynecologists after reports of osteitis pubis in
some patients due to suture placement in the perios-
teum of the pubic symphysis.
Retrospective studies have shown autologous grafts
have better success rates with pubovaginal slings than
allografts. In one case control study, patients who re-
ceived autologous fascial slings (N ⫽ 39) had similar
quality of life measures to those patients who received
a Tutoplast™ (Tutogen Medical, Neunkiichen, Ger-
many), a solvent-dehydrated fascial sling; however, the
rate of objective stress incontinence symptoms was
much higher in the allograft group (42% vs. 0%, re-
spectively) (9). A second retrospective study found
higher failure rates (recurrent findings of stress incon-
tinence at 6 months on urodynamics) in patients who
received allografts (67%) compared to those who re-
ceived autologous grafts (11).
There is also a long history of the use of synthetic
slings for the treatment of stress urinary incontinence
(Table 2). The first synthetic materials used for blad-
der neck suspensions were Mersilene by Williams in
1962 and Marlex mesh by Morgan et al in 1970
(48,53). With these early slings, high rates of ero-
sions, infections, and fistula formation were noted.
For example, Mersilene mesh use for suburethral
slings has a high reported success rate of 93% at 30
months, but is complicated by a 4% erosion rate (47).
The “tension-free” mid-urethral slings, made of
polypropylene mesh, were first introduced by Ulm-
sten and Petros in the late 1990s (54). These were
placed with an introducer and a plastic overlying
sheath, and were made of a stretchy 1-cm wide
segment of polypropylene which did not move ap-
preciably in the tissues once the overlying sheath was
removed. The design allowed for minimal dissection,
no need to anchor the sling, and the potential added
benefit of the sheath protecting the sling itself from
contamination. Multicenter randomized studies com-
paring the TVT to the Burch procedure show com-
parable results with the added benefit of decreased
morbidity and hospitalization rates with the TVT
(55). Long-term follow-up data for the TVT sling
show high success rate (84.7%) at 56 months (56).
In 2001, Delorme first described the transobturator
suburethral tape (TOT) placement with a 90% cure
rate and no perioperative complications or voiding
dysfunction (57). The theoretical advantages of the
TOT are the avoidance of intrapelvic and retropubic
passage of the instruments (thereby decreasing the
complication rate) and decreased postoperative void-
ing dysfunction (due to a more transverse mesh
placement compared to the TVT). In one study by
DeTayrac et al (2004), TOT procedures had lower
mean operative time, no bladder injury, decreased
 Biologic and Synthetic Grafts in Pelvic Surgery Y CME Review Article 259

TABLE 2
Slings
Follow-Up Cure Rate
Author Yr No. Patients Type of Mesh (mo) (%) Complications
Nilsson (56) 2001 85 TVT (Prolene) 56 84.7
Young (47) 2001 136 Mersilene 30 93 4% erosion
McBride (9) 2005 39 Autologous 24 100
32 Allograft 24 58
Meschia (60) 2006 95 TVT (Prolene) 24 87 No erosions
95 IVS (Prolene—Multifilament) 24 78 9% erosions
Soergel (11) 2001 33 Autologous 33 78.8
12 Allograft 12 33
deTayrac (50) 2004 31 TVT (Prolene) 12 83.9 No erosions
30 TOT (Prolene) 12 90 No erosions
Moore (59) 2005 5 TOT (Prolene) after failed TVT 17 100 No erosions
Meschia (60) 2006 95 TVT 24 87 None
95 IVS tape 24 78 9% erosion
Yamada (63) 2006 67 Mentor ObTape 36 13.4% erosion
56 Monarc None

postoperative urinary retention, and similar rates of Abdominal Sacrocolpopexies

cure (90%), improvement, and failures compared to
the TVT group (50).
The TOT has also been shown to have a signifi-
cantly lower rate of de novo detrusor overactivity
compared to a retropubic approach such as the TVT
or SPARC sling (8% vs. 33% and 17%, respectively)
(58). A recent study has reported that failure rates for
TOT slings may be higher for patients with intrinsic
sphincter deficiency. Failures may be corrected by
subsequent placement of a TVT sling (59).
Even with similar technique, different materials
may yield different erosion rates. One prospective,
randomized study of TVT (monofilament, macro-
porous mesh) versus IVS (microporous, multifila-
ment mesh) showed similar efficacy in the treatment
of SUI. However, the IVS tape had a lower incidence
of postoperative voiding dysfunction but a higher
rate (9%) of vaginal erosion (60). Another study
showed similar rates of erosion (7.5%) and need for
reoperation (7%) due to postoperative symptoms of
stress and urge incontinence (61). The severe mesh
complications with the IVS tape are even more con-
cerning. Indications for mesh removal with the IVS
tape listed in the literature include intractable mesh
infections, retropubic abscesses, cutaneous and vesi-
covaginal fistulas, voiding difficulties, and chronic
pain syndrome (62). Comparison of the Mentor Ob-
Tape™ (a nonwoven minimally elastic, microporous,
monofilament polypropylene mesh) with the Monarc
Sling™ (a woven, elastic, macroporous, monofila-
ment polypropylene mesh), similarly revealed a
marked difference in erosion rates (13.4% vs. 0%,
respectively) (63).
ASCs are currently the gold standard to correct
apical vaginal prolapse and may also correct high
cystoceles or rectoceles. The most common tech-
nique involves mesh sewn to both the anterior and
posterior walls of the vagina and anchored to the
anterior sacrum. A review article by Nygaard et al
reported an average follow-up of 6 months to 3 years
with success rates of 78% to 100%, a reoperation rate
of 4.4%, mesh erosion rate of 3.4%, and an incidence
of small bowel obstruction of 1.1% requiring reop-
eration (7). Long-term follow-up up to 13.7 years
after ASC maintained a 74% success rate (8). In
terms of technique, concurrent hysterectomy may be
a risk factor for mesh erosion, particularly if a total
hysterectomy is performed (64) with erosion rates
increased up to 27% compared to 1.3% without a
hysterectomy (35). However, another retrospective
study did not support this finding (65). Some surgeons,
therefore, advocate supracervical hysterectomy at the
time of ASC in the absence of cervical dysplasia or a
malignancy. Enterocele and abdominal paravaginal re-
pair at the time of ASC have not been shown to con-
sistently improve outcomes. The median rate of bowel
obstruction requiring surgery after an ASC without
reperitonealization of mesh is only 1.1% (7). A recent
case series report also showed no increased risk of
bowel complications up to 19 months of follow-up with
ASC not accompanied by burial of mesh (66).
Allogenic graft material use in ASC is complicated
by high short-term failure rates (26). A case series
report by Fitzgerald et al describes a 12% reoperation
rate for ASC using freeze-dried fascia lata allografts
260 Obstetrical and Gynecological Survey

with failure evident at a mean time of 7 to 11 months. Anterior Repairs

Histologic analysis of the retrieved material demon-
strated areas of disorganized remodeling, graft de-
generation, and some instances of immune reactions
(26). The same author was only able to actually
locate the remains of the fascia in 3 of the 21 repeat
sacrocolpopexies.
There are prospective trials that have compared
synthetic and biologic meshes for ASC (Table 3).
Culligan et al compared 54 patients who underwent
ASC with Trelex polypropylene mesh to 46 patients
who received solvent-dehydrated fascial grafts. Fail-
ure rates (prolapse greater than stage II, by POP-Q
quantification) 6 months postoperatively were signif-
icantly higher in the allograft group (32%) than in
those who received mesh (9%) (35). The superiority
of synthetic mesh for ASC was also confirmed by a
retrospective cohort study comparing synthetic mesh
to freeze-dried cadaveric fascia with higher optimal
surgical outcomes by POP-Q examination when
mesh was used (89%) compared to when the fascia
was used (61%) (36). Another retrospective cohort
study by Altman et al also found a trend toward
increased rate of recurrence by anatomic and subjec-
tive measures with porcine dermal grafts compared
to synthetic mesh (29% vs. 24%, respectively) (67).
Similar to the experience with other procedures,
erosion rates with synthetic mesh used for ASC vary
by the properties of the mesh used. Vaginal mesh
erosion has been reported in 2% of patients who
received polypropylene mesh (66,68). These rates are
higher (up to 11%) with microporous multifilament
meshes, such as Gore-Tex and Mersilene (69). The
treatment of vaginal mesh erosion varies from trans-
vaginal excision plus antibiotics for monofilament
macroporous meshes to complete abdominal and
vaginal excision for infected multifilament micro-
porous meshes (4,9).
The earliest described anterior vaginal wall repair,
designed to correct stress incontinence, was the Kelly
plication of the urethral sphincter muscle in 1913.
Anterior colporrhaphy to correct primary and recur-
rent cystoceles have traditionally involved a similar
type of plication technique. One of the earlier reports
of an anterior repair augmented by prosthesis was
described by Julian in 1996 (44). This prospective
study randomly allocated 24 patients to anterior
repair alone or with the addition of Marlex monofil-
ament polypropylene mesh. This prosthesis was an-
chored proximally to the vaginal apex and to the
levator fascia as lateral attachments over the standard
fascial repair. The success rate for the correction of
prolapse (defined as less than grade I) was higher in
those patients with the graft (100%) compared to
66% at 24 months. Compared to the use of synthetic
meshes for ASC, however, vaginal placement of
synthetic mesh seems to have a much higher rate of
erosions in most studies (25% in Julian’s study) (44).
Another polypropylene mesh, Gynemesh, was stud-
ied by DeTayrac in a larger patient sample (87
women) with a similarly high success rate of 92% at
24 months and a lower erosion rate of 8.3% (70). A
prospective, observational study by Milani et al had
a 94% success rate with Prolene mesh in 63 patients
at a 17-month follow-up examination, but was ac-
companied by an erosion rate of 13% (71). There has
been at least one retrospective case series, however,
showing a 100% success rate with Marlex mesh in
142 patients at 3 years with a low incidence of
erosion (2%) (72) (Table 4).
In addition to the high risk of erosion, functional
outcomes may also be worse with the use of nonab-
sorbable mesh during anterior repair. Salvatore et al
reported not only an erosion rate of 13% using Pro-
lene mesh, but also an increase in overactive bladder
symptoms (28%–⬎56%) and an increase in dyspa-

TABLE 3
Abdominal sacrocolpopexy
Author Follow-Up Cure Rate
(Biologic vs. Synthetic) Yr No. Patients Type of Mesh (mo) (%) Complications
Gregory (36) 2004 28 Marlex/Mersilene 26.3 89
Culligan (35) 2005 54 Polypropylene 12 91 26% graft complications
46 Fascia lata 68 15% graft complications
Altman (67) 2006 25 Prolene 7.4 24
27 Porcine collagen 7.1 29
Fitzgerald (26) 2004 67 Freeze-dried fascia 12 57 ?
Elneil (66) 2005 128 Prolene
 Biologic and Synthetic Grafts in Pelvic Surgery Y CME Review Article 261

TABLE 4
Anterior repair
Follow-Up Cure Rate
Author Yr No. Patients Type of Mesh (mo) (%) Complications
Synthetic
Sand (15) 2004 161 Polyglactin 910 13 75
Dwyer (49) 2004 64 Atrium polypropylene 29 94 9% erosion
Milani (71) 2005 32 Prolene 17 94 13% erosion
20% dyspareunia
Julian (44) 1996 24 Marlex 12 100 25% erosion
Flood (72) 1998 142 Marlex 38 100 2% erosion
Weber (74) 2001 26 Polyglactin 23.3 42
Tension free
Eglin (87) 2003 103 Polypropylene 16 97 ⬍1% erosion
DeTayrac (70) 2005 87 Polypropylene 24 92 8.3% erosion
Bader (86) 2004 40 Polypropylene 16 95 ⬍1% erosion
Biologic
Gandhi (31) 2005 76 Fascia lata 13 79
Gomellski (75) 2004 70 Porcine dermis 24 91 1.4% wound separation
Groutz (32) 2001 21 Solvent-dehydrated fascia 20 100
Salomon (33) 2004 27 Porcine 14 81

reunia (18%–⬎78%) (73). In general, nonabsorbable Ghandi et al performed a prospective, randomized

mesh use for anterior repairs seems to result in high
success rates when combined with traditional fascia
repair, but may be accompanied by unacceptably
high erosion rates.
Absorbable mesh use was adopted in order to at-
tempt to achieve equivalent success rates with fewer
complications. Polyglactin 910 is an absorbable
mesh that has been studied in several large, prospec-
tive, randomized controlled trials. In one study by
Sand et al, the mesh was used as a patch on top of the
standard fascial repair in 161 patients (21 with recur-
rent cystoceles) with a significantly decreased recur-
rence rate at 12 months compared to the suture-only
controls (25% vs. 43%) (15). A review by Maher et
al reported similar success rates with Polyglactin 910
compared to fascial repair alone (75% vs. 57%) at
1-year follow-up (17). Another large, prospective,
randomized study compared 3 different techniques,
including standard anterior colporrhaphy, ultralateral
anterior repair with dissection to the lateral pubic
ramus, and anterior repair reinforced with Polygla-
ctin 910 use, showed no significant differences in
recurrence rates or mesh complications among the
different groups at a 2-year follow-up (74). It is
important to note, however, that this study was not
powered for a ⬍30% difference in success rates.
The best available level I and II evidence indicates
that anterior repair with the addition of any mesh is
more effective than anterior repair alone, but that ab-
sorbable mesh may have lower complication rates (6).
Biologic grafts have shown good success rate for
anterior repairs with virtually no mention of erosions.
trial revealing a trend toward decreased recurrence
rates with the use of cadaveric fascia lata versus
standard colporrhaphy to repair recurrent anterior
vaginal wall prolapse (21% vs. 29%, respectively) at
13 months (31). A retrospective case series of high-
grade cystocele repair with porcine dermis similarly
showed an 87% success rate at 24 months (75).
Transobturator placement of a porcine collagen im-
plant showed an 81% anatomic cure rate at 14-month
follow-up, with concomitant improvement in quality
of life and urinary discomfort scores (33). Finally, a
small, prospective series of anterior repairs with
solvent-dehydrated fascia-lata grafts did not docu-
ment any recurrences at a follow-up of 20 months
(32). These studies seem to support higher success
rates using biologic grafts to augment anterior repair,
although none was a comparative trial.
Posterior Repairs
Posterior repairs should correct associated symptoms
of defecatory dysfunction in addition to prolapse symp-
toms. Rectocele repair has been performed with varied
approaches from transanal to transvaginal placation re-
pairs, site-specific repair of the rectovaginal fascia, to
plication of both the rectovaginal fascia and levator
muscles. Randomized controlled trials have confirmed
the superiority of transvaginal repairs over transanal
procedures (76). Traditional levator ani plication has
been shown to have good anatomic success rates (76%–
96%), but can be complicated by dyspareunia up to
50% of the time (6). One retrospective, observational
study of posterior colporrhaphy reported a success
262 Obstetrical and Gynecological Survey

rate of 76% at 42 months, but was associated with
an increase in dyspareunia (18%–⬎27%), consti-
pation (22%–⬎33%), incomplete bowel emptying
(27%–⬎38%), fecal incontinence (4%–⬎11%),
and sexual dysfunction (18%–⬎27%) (77). In the
mid 1990s, site-specific repairs became popular in
an attempt to lessen dyspareunia by theoretically re-
storing normal anatomy. Early studies seemed to sup-
port this contention (3,78,79). However, a retrospective
comparison of site-specific repair and fascial reapproxi-
mation indicates a significantly higher recurrence rate
with site-specific repair (44% vs. 18%, respectively) at
1 year (80). A recent prospective, randomized study,
however, found similar anatomic and functional out-
comes comparing traditional posterior repair, site-
specific rectocele repair, and posterior repair with
porcine graft at up to 18 months average follow-up (81).
Although the baseline success rates of posterior
repairs are reasonably good, the addition of a graft or
mesh might ameliorate shortening or narrowing of
the vagina that could contribute to dyspareunia. Syn-
thetic mesh use for posterior repairs maintains high
anatomic cure rates, but has been associated with a
significant incidence of dyspareunia and vaginal ero-
sion when nonabsorbable meshes are used. A retrospec-
tive, observational study with Atrium polypropylene
mesh had a 100% success rate at 29 months with mesh
erosion in 9% of patients (42). An ambiperspective
(retrospective chart review and prospective observa-
tional) study with combined vicryl/Prolene mesh had an
83.9% cure rate at 6 months with mesh protrusion in
12.9% at 6 months (82). One prospective, observational
study by Milani using Prolene mesh demonstrated a
6.5% erosion rate and an alarming 63% increase in
dyspareunia (71). On the other hand, a prospective,
randomized trial with polyglactin 910 absorbable mesh
had an anatomic cure rate (90%) equivalent to repairs
without mesh and the authors reported no adverse
events (15) (Table 5).
Biologic grafts for rectocele repair have produced
inconsistent results with many of the same compli-
cations seen with nonabsorbable synthetic meshes.
One prospective study using a porcine collagen xeno-
graft without underlying plication or repair of native
tissues had a high rate of recurrence, 38% at 1-year
follow-up and 41% at 2 years, with a 13% reopera-
tion rate and ⬍50% of patients reporting relief of
rectal trapping. Although Altman theorized that the
high rate of failure with this xenograft might result
from premature degradation of the biologic grafts, he
concluded that the addition of site-specific repair
might improve the success rate when biologic grafts
are used (30). Another prospective, observational
study combining site-specific repair with a dermal
allograft showed a success rate of 93% at 12 months
without any documented complications (28). Finally,
a second prospective, observational series combining
site-specific repair with a porcine acellular collagen
matrix had a high wound separation rate of 15% (29).
The authors concluded that devascularization of the
vaginal mucosa and lack of contact with the under-
lying rectovaginal septum may have contributed to
the high degree of wound breakdown. The addition
of fenestrations to the graft may increase the surface
area in contact with the vaginal mucosa and improve
outcomes. One study using a fenestrated graft (Pel-
visoft) did indeed find less sloughing of the vaginal
mucosa and quicker healing (29).
TENSION-FREE PLACEMENT OF
GRAFTS VAGINALLY
There has been a literal explosion of new products
which utilize grafts (mostly synthetic nonabsorbable)

TABLE 5
Posterior repair
Cure Rate
Author Yr No. Patients Type of Mesh Follow-Up (%) Complications
Synthetic
Lim (82) 2005 90 Vicryl-Prolene 6 mo–1 yr 83.9 7.8% erosion
Sand (15) 2001 161 Polyglactin 910 13 mo 90
Dwyer (49) 2004 50 Atrium polypropylene 29 mo 100 9% erosion
Milani (71) 2005 31 Prolene 17 mo 94 6.5% erosion
Biologic
Kohli (13) 2003 30 Dermal allograft 12.9 mo 93
Dell (29) 2005 35 Pelvisoft 12 mo
Altman (30) 2005 33 Porcine collagen 12 mo 61
Tension free
Farnsworth (84) 2002 IVS Tunneler 91
Biertho (85) 2004 34 IVS Tunneler 12 mo 92.2 2.9% erosion
 Biologic and Synthetic Grafts in Pelvic Surgery Y CME Review Article 263

placed with a “tension-free” technique, having exten-
sions that pass through the obturator space or the
pararectal space and are not secured with any sutures.
The first such procedure was the posterior intravag-
inal slingplasty (IVS) introduced by Petros in 1997
for the treatment of vault prolapse (83). The IVS
Tunneller™ (Tyco Healthcare) is used to insert an
8-mm polypropylene tape (not a macroporous
polypropylene mesh) between the perineum and the
vaginal vault. It was not attached to another graft that
covered the posterior or anterior wall. The thin syn-
thetic strip of mesh acts like an artificial ligament to
reinforce weakened uterosacral ligaments. A small,
prospective, observational study by Farnsworth et al
describes a symptomatic prolapse cure rate of 91%
(84). Another small, prospective series described an
8.8% recurrence rate over a 1-year follow-up period
(85). Potential complications with this procedure
and/or this particular mesh were elucidated in a case
series by Baessler et al describing mesh infections,
retropubic abscesses, vesicovaginal fistulas, intraves-
ical mesh, voiding difficulties, and pain syndromes in
patients requiring sling removal at 24-months post-
operatively from the IVS procedure (62).
Since then, other procedures have been developed
which utilize these same tension-free extensions but
connected to other graft materials. The Apogee™
and Perigee™ devices (American Medical Systems)
were designed to correct posterior/apical and anterior
prolapse, respectively, using this technique with a
macroporous polypropylene mesh. Posterior dissec-
tion must proceed to the level of the ischial spines
with an introducer needle inserted inferior and lateral
to the anus. The 2 anterior support extensions are
passed through the obturator membrane. There is
some data on tension-free support of the anterior
vaginal wall. Several prospective, observational se-
ries using polypropylene meshes have shown high
success rates of 91% to 97% and moderate erosion
rates 5% to 8.3% at 16 to 24-month follow-up
(50,86,87). The data on posterior intravaginal sling-
plasty is limited by small numbers and short
follow-up periods. One retrospective study assessing
posterior IVS combined with posterior repair had a
high recurrence rate of 29% with a reoperation rate of
14%. The erosion rate was not reported (88). A
short-term follow-up study showed a low erosion rate
of 2.9% with a moderate rate of recurrence of 8.8%
(85). The ProLift™ (Gynecare/Ethicon) system con-
sists of a complete vaginal mesh with 3 sets of
extensions. We have some older data on total vaginal
mesh repair using Marlex (without the tension-free
extensions) that showed a 10% reoperation and 5%
mesh erosion rate during 10 years of follow-up (89).
However, there are currently only a few case series
evaluating this newer technique. One case series re-
porting the experience with total vaginal mesh, using
Marlex, over a 10-year period cited a 5% erosion rate

TABLE 6
Summary of findings
1) Synthetic grafts have been shown to be superior to biologic grafts for abdominal sacrocolpopexy and suburethral sling
procedures in the literature through prospective randomized trials and prospective case series.
2) Macroporous monofilament synthetic grafts and non-cross linked biologic grafts appear to have the best integration into native tissues.
Microporous synthetic grafts are more likely to become infected.
3) Solvent dehydration and irradiation of biologic grafts appear to weaken the integrity of the material and may prevent proper
tissue integration.
4) Technical factors related to surgical technique may impact success rates, such as tension on suture line or failure to use
vaginal packing.
5) Level I and II data seem to support the use of grafts (biologic or synthetic) for anterior repair but erosion rates are higher,
especially with the non-absorbable meshes.
6) There is no conclusive data to recommend the use of grafts posteriorly or the new “tension-free” vaginal mesh procedures.

TABLE 7
Recommendations for future research
1) Classification of graft-related healing abnormalities, because the current terminology of “erosion”, “rejection” and “exposure” are
non-specific.
2) Standardized outcome measures for all studies, using quality-of-life (QOL) validated questionnaires, urodynamic (UDS)
parameters, and pelvic-organ-prolapse-quantification (POPQ) measurements.
3) Consideration of the long-term implications of graft implantation, particularly following total graft suspensions (with respect to
erosion rates and management of erosion).
4) Comparison of synthetic and biologic meshes in prospective randomized studies.
5) Prospective comparison of tension-free vs. secured mesh.
6) Prospective comparison of absorbable vs. non-absorbable mesh.
264 Obstetrical and Gynecological Survey
and high rates of reoperation, 36% for bladder func-
tion and 28% for anorectal function, although with
reported high patient satisfaction rates, as much as
74% (89). A retrospective chart review of polypro-
pylene mesh over a shorter period of time of 2.5
years showed a recurrence rate of 5.2% and a 7%
erosion rate (90).
POSTOPERATIVE CARE
Postoperative surveillance for mesh erosions must
be performed for any surgery involving grafts or
mesh. Examinations should be performed at regular
intervals beginning a week or 2 after surgery and
extending to at least 2 years of follow-up. Studies
have shown that most erosions occur within the first
year of surgery, but may occur many years later.
Erosions generally present with bleeding, vaginal
discharge, and pain. Many mesh exposures can be
treated with topical estrogens and broad spectrum
antibiotics. Larger extrusions may need to be surgi-
cally excised with mobilization of the lateral tissue to
cover the defect. Some authors recommend that type
I mesh usually need not be removed in the case of
infection, whereas complete removal is often re-
quired for type II and type III mesh.
Continuous vaginal estrogens are recommended
for at least 1-month preoperatively and at least 3
months postoperatively, if not indefinitely. It is also
important to counsel patients to avoid all strenuous
activity, heavy lifting, and straining for at least 2
months postoperatively. The best means of ensuring
long-term success is preventing the recurrence or
persistence of factors that predispose to prolapse,
such as obesity and constipation. There is no consis-
tent recommendation with respect to antibiotic pro-
phylaxis with the use of vaginal or abdominal mesh
for pelvic reconstructive surgery, although it is stan-
dard practice for other procedures involving mesh
such as hernia repair.
CONCLUSION
The conclusions of the review are summarized
in Table 6. However, there are few prospective, ran-
domized trials addressing the success rates and
complications of graft use in pelvic reconstructive
surgery. Most of the existing literature consists of
retrospective case series with small numbers and
inconsistent outcome measures. Suggestions for fur-
ther research include more prospective, randomized
trials comparing synthetic and biologic mesh, tension-
free versus secured mesh, and absorbable versus non-
absorbable mesh (Table 7). These studies should also
standardize outcome measures based on pelvic exami-
nation and validated questionnaires. Finally, long-term
implications of graft implantation, particularly total
graft suspensions, need to be further studied.
REFERENCES
1. Hendrix SL, Clark A, Nygaard I, et al. Pelvic organ prolapse in
the Women’s Health Initiative: gravity and gravidity. Am J
Obstet Gynecol 2002;186:1160–1166.
2. Olsen AL, Smith VJ, Bergstrom JO, et al. Epidemiology of
surgically managed pelvic organ prolapse and urinary incon-
tinence. Obstet Gynecol 1997;89:501–506.
3. Cundiff GW, Weidner AC, Visco AG, et al. An anatomic and
functional assessment of the discrete defect rectocele repair.
Am J Obstet Gynecol 1998;179:1451–1456.
4. Griffis K, Hale DS. Grafts in pelvic surgery. Clin Obstet Gy-
necol 2005;48:713–723.
5. Iglesia CB, Fenner DE, Brubaker, L. The use of mesh in
gynecologic surgery. Int Urogynecol J 1997;8:105–115.
6. Maher C, Baessler K, Glazener, CMA, et al. Surgical manage-
ment of pelvic organ prolapse in women. Cochrane Database
Syst Rev 2007;(3):CD004014.
7. Nygaard IE, McCreery R, Brubaker L, et al. Abdominal sacro-
colpopexy: a comprehensive review. Obstet Gynecol 2004;
104:805–823.
8. Hilger WS, Poulson M, Norton PA. Long-term results of ab-
dominal sacrocolpopexy. Am J Obstet Gynecol 2003;189:
1606–1610.
9. McBride AW, Ellerkmann RM, Bent AE, et al. Comparison of
long-term outcomes of autologous fascia lata slings with Sus-
pend Tutoplast fascia lata allograft slings for stress inconti-
nence. Am J Obstet Gynecol 2005;192:1677–1681.
10. Walters MD. The use and misuse of prosthetic materials in
reconstructive pelvic surgery: does the evidence support our
surgical practice? Int Urogynecol J Pelvic Floor Dysfunct
2003;14:365–366.
11. Soergel TM, Schott S, Heit M. Poor surgical outcomes after
fascia lata allograft slings. Int Urogynecol J Pelvic Floor Dys-
funct 2001;12:247–253.
12. Farrel SA, Dempsey T, Geldenhuys L. Histologic examination
of “fascia” used in colporrhaphy. Obstet Gynecol 2001;98:
794–798.
13. Kohli N, Goldberg R, Maccarone J. Augmenting pelvic floor
repairs. OBG Manage 2006;S1–S8.
14. Davila GW, Drutz H, Deprest J. Clinical implications of the
biology of grafts: conclusions of the 2005 IUGA Grafts Round-
table. Int Urogynecol J 2006;17:S51–S55.
15. Sand PK, Koduri S, Lobel RW, et al. Prospective randomized
controlled trial of polyglactin mesh to prevent recurrence of
cystoceles and rectoceles. Obstet Gynecol 2001;184:1357–
1364.
16. Lym YN, Muller R, Corstiaans A, et al. A long-term review of
posterior colporrhaphy with Vypro 2 mesh. Int Urogynecol J
Pelvic Floor Dysfunct 2007;18:1053–1057.
17. Maher C, Baessler K. Surgical management of anterior vaginal
wall prolapse: an evidence-based literature review. Int Urogy-
necol J 2005;17:84–88.
18. Huebner M, Hsu Y, Fenner DE. The use of graft materials in
vaginal pelvic floor surgery. Int J Gynaecol Obstet 2006;92:
279–288.
19. Silva WA, Karram MM. Scientific basis for use of grafts during
vaginal reconstructive procedures. Curr Opin Obstet Gynecol
2005;17:519–529.
20. Luijendij R. A comparison of suture repair with mesh repair for
incisional hernias. N Engl J Med 2000;243:292–298.
 Biologic and Synthetic Grafts in Pelvic Surgery Y CME Review Article
21. Deprest J, Zheng F, Konstantinovic M, et al. The biology
behind fascial defects and the use of implants in pelvic organ
prolapse repair. Int Urogynecol J 2006;17:S16–S25.
22. Lemer ML, Chaikin DC, Blaivas JG. Tissue strength analysis of
autologous and cadaveric allografts for the pubovaginal sling.
Neurourol Urodyn 1999;18:497–503.
23. Birch C, Fynes MM. The role of synthetic and biological pros-
theses in reconstructive pelvic floor surgery. Curr Opin Obstet
Gynecol 2002;14:527–535.
24. Hinton R, Jinnah RH, Johnson C, et al. A biomechanical
analysis of solvent-dehydrated and freeze-dried human fascia
lata allografts. A preliminary report. Am J Sports Med 1992;
20:607–612.
25. O’Reilly KJ, Govier FE. Intermediate term failure of pubovagi-
nal slings using cadaveric fascia lata: A case series. J Urol
2002;167:1356.
26. Fitzgerald MP, Mollenhauser J, Bitterman P et al. Functional
failure of fascia lata allografts. Am J Obstet Gynecol 1999;
181:1339–1345.
27. Oster S, Astrup A. A new vaginal operation for recurrent and
large rectocele using dermis transplant. Acta Obstet Gynecol
Scand 1981;60:493–495.
28. Kohli N, Miklos JR. Dermal graft-augmented rectocele repair.
Int Urogynecol J 2003;14:146–149.
29. Dell JR, O’Kelley KR. Pelvisoft biomesh augmentation of rec-
tocele repair: the initial clinical experience in 35 patients. Int
Urogynecol J 2005;16:44–46.
30. Altman D, Lopez A, Gustafsson C, et al. Anatomical outcome
and quality of life following posterior vaginal wall prolapse
repair using collagen xenograft. Int Urogynecol J 2005;16:
298–303.
31. Gandhi S, Goldberg RP, Kwon C, et al. A prospective ran-
domized trial using solvent dehydrated fascia lata for the
prevention of recurrent anterior vaginal wall prolapse. Am J
Obstet Gynecol 2005;192:1649–1654.
32. Groutz A, Chaikin DC, Theusen E, et al. Use of cadaveric
solvent-dehydrated fascia lata for cystocele repair—
preliminary results. Urology 2001;58:179–183.
33. Salomon LJ, Detchev R, Barranger E, et al. Treatment of
anterior vaginal wall prolapse with porcine skin collagen im-
plant by the transobturator route: preliminary results. Eur Urol
2004;45:219–225.
34. Drake NL, Weidner AC, Webster GD, et al. Patient character-
istics and management of dermal allograft extrusions. Int Uro-
gynecol J Pelvic Floor Dysfunct 2005;16:375–377.
35. Culligan PJ, Murphy M, Blackwell L, et al. Long term success
of abdominal sacral colpopexy using synthetic mesh. Am J
Obstet Gynecol 2002;187:1473–1480.
36. Gregory WT, Otto LN, Bergstrom JO, et al. Surgical outcome
of abdominal sacrocolpopexy with synthetic mesh versus ab-
dominal sacrocolpopexy with cadaveric fascia lata. Int Uro-
gynecol J 2005;16:369–374.
37. Nicholsen SC, Brown ADG. The long term success of abdomi-
novaginal sling operations for genuine stress incontinence
and a cystocele—a questionnaire based study. J Obstet Gy-
necol 2001;21:162.
38. Birch C. The use of prosthetics in pelvic reconstructive sur-
gery. Best Pract Res Clin Obstet Gynaecol 2005;19:979–991.
39. Amid PK. Classification of biomaterials and their related com-
plication in abdominal wall surgery. Hernia 1997;1:15–21.
40. Brun JL, Bordenave L, Lefabvre F, et al. Physical and biolog-
ical characteristics of the main biomaterials used in pelvic
surgery. Bio Med Mat Eng 1992;2:203–225.
41. Chu CC, Welch L. Characterization of morphological and me-
chanical properties of surgical mesh fabrics. J Biomed Mater
Res 1985;19:903–916.
42. Dwyer PL, O’Reilly BA. Transvaginal repair of anterior and
posterior compartment prolapse with Atrium polypropylene
mesh. BJOG 2004;111:831–836.
43. Hung MJ, Liu FS, Shen PS, et al. Factors that affect recur-
265
rence after anterior colporrhaphy procedure reinforced with
four corner anchored polypropylene mesh. Int Urogynecol J
Pelvic Floor Dysfunct 2004;15:399–406.
44. Julian T. The efficacy of Marlex mesh in the repair of severe,
recurrent vaginal prolapse of the anterior mid-vaginal wall.
Am J Obstet Gynecol 1996;175:1472–1475.
45. Visco AG, Weidner AC, Barber MD, et al. Vaginal mesh ero-
sion after abdominal sacral colpopexy. Am J Obstet Gynecol
2001;184:297–302.
46. Bent AE, Ostergard DR, Zwick-Zaffuto M. Tissue reaction to
expanded polytetrafluorethylene suburethral sling for urinary
incontinence: clinical and histological study. Am J Obstet
Gynecol 1993;169:1198–1204.
47. Young SB, Howard AE, Baker SP. Mersilene mesh sling: short
and long-term clinical and urodynamic outcomes. Am J Ob-
stet Gynecol 2001;185:32–40.
48. Morgan JE, Farrow GA, Stewart FE. The Marlex sling opera-
tion for the treatment of recurrent stress incontinence: a 16
year review. Am J Obstet Gynecol 1985;151:224–226.
49. Dwyer PL. Evolution of biological and synthetic grafts in re-
constructive pelvic surgery. Int Urogynecol J 2006;17:S10–
S15.
50. DeTayrac R, Deffieux X, Droupy S, et al. A prospective ran-
domized trial comparing tension-free vaginal tape and tran-
sobturator suburethral tape for surgical treatment of stress
urinary incontinence. Am J Obtet Gynecol 2004;190:602–608.
51. Aldridge AH. Transplantation of fascia for relief of urinary
stress incontinence. Am J Obstet Gynecol 1942;44:398.
52. Burch JC. Cooper’s ligament urethrovesical suspension for
stress incontinence. Nine years’ experience, results, compli-
cations, technique. Am J Obstet Gyncol 1968;100:764–774.
53. Williams TJ, TeLinde RW. The sling operation for urinary in-
continence using the mersilene ribbon. Obstet Gynecol 1962;
19:241–245.
54. Ulmsten U, Petros P. Intravaginal sling: an ambulatory surgi-
cal procedure for treatment of female urinary incontinence.
Scand J Urol Nephrol 1995;29:75–82.
55. Ward KL, Hilton P. A prospective multicenter randomized trial
of tension-free vaginal tape and colposuspension for primary
urodynamic stress incontinence: two year follow-up. Am J
Obstet Gynecol 2004;190:324–331.
56. Nilsson CG, Kuuva N, Falconer C, et al. Long-term results of
the tension free vaginal tape for surgical treatment of female
stress incontinence. BJOG 1999;106:345–350.
57. Delorme E, Droupy S, DeTayrac R, et al. Transobturator tape
(Uratape). A new minimally invasive method in the treatment
of urinary incontinence in women. Prog Urol 2003;13:656–
659.
58. Botros SM, Miller JJ, Goldberg RP, et al. Detrusor overactivity
and urge incontinence following trans-obturator versus mi-
durethral slings. Neurourol Urodyn 2007;26:42–45.
59. Moore RD, Gamble K, Miklos JR. Tension-free vaginal tape
sling for recurrent stress incontinence after transobturator
tape sling failure. Int Urogynecol J Pelvic Floor Dysfunct 2007;
18:309–313.
60. Meschia M, Pifarotti P, Bernasconi F, et al. Tension-free vag-
inal tape and intravaginal slingplasty for stress urinary incon-
tinence: A multicenter randomized trial. Am J Obstet Gynecol
2006;195:1338–1342.
61. Bafghi A, Benizri EI, Trastour C, et al. Multifilament propylene
mesh for urinary incontinence: 10 cases of infections requiring
removal of the sling. BJOG 2005;112:376–378.
62. Baessler K, Hewson AD, Tunn R, et al. Severe mesh compli-
cations following intravaginal slingplasty. Obstet Gynecol
2005;106:713–716.
63. Yamada BS, Govier FE, Stefanovic KB, et al. High rate of
vaginal erosions associated with the mentor ObTape. J Urol
2006;176:651–654.
64. Barrington JW, Calvert JP. Vaginal vault suspencion for pro-
266 Obstetrical and Gynecological Survey
lapse after hysterectomy using autologous fascial sling of
rectus sheath. BJOG 1998;105:83–86.
65. Brizzolara S, Pillai-Allen A. Risk of mesh erosion with sacral
colpopexy and concurrent hysterectomy. Obstet Gynecol
2003;102:306–310.
66. Elneil S, Cutner AS, Remy M, et al. Abdominal sacrocol-
popexy for vault prolapse without burial of mesh: a case
series. BJOG 2005;112:486–489.
67. Altman D, Anzen B, Brismar S, et al. Long-term outcome of
abdominal sacrocolpopexy using xenograft compared with
synthetic mesh. Urology 2006;67:719–724.
68. Fynes M, Goh JTW, Chong C, et al. Abdominal sacrocol-
popexy for vaginal vault prolapse. Int Urogynecol J Pelvic
Floor Dysfunct 2001;12:14–17.
69. Cervigni M. The use of synthetics in the treatment of pelvic
organ prolapse. Curr Opin Urol 2001;11:429–435.
70. DeTayrac R, Gervaise A, Chauveaud A, et al. Tension-free
polypropylene mesh for vaginal repair of anterior vaginal wall
prolapse. J Reprod Med 2005;50:75–80.
71. Milani R, Salvatore S, Soligo M, et al. Functional and anatom-
ical outcome of anterior and posterior vaginal prolapse repair
with prolene mesh. BJOG 2005;112:107–111.
72. Flood CG, Drutz HP, Waja L. Anterior colporrhaphy reinforced
with marlex mesh for the treatment of cystoceles. Int Urogy-
necol J Pelvic Floor Dysfunct 198l;9:200–204.
73. Salvatore S, Soligo M, Meschia M, et al. Prosthetic surgery for
genital prolapse: functional outcome. Neurourol Urodyn 2002;
21:296–297.
74. Weber AM, Walters MD, Piedmonte MR, et al. Anterior col-
porraphy: a randomized trial of three surgical techniques.
Am J Obstet Gynecol 2001;185:1299–1306.
75. Gomelsky A, Rudy DC, Dmochowski RR. Porcine dermis in-
terposition graft for repair of high grade anterior compartment
defects with or without concomitant pelvic organ prolapse
procedures. J Urol 2004;171:1581–1584.
76. Nieminen K, Hiltunen KM, Oksala J, et al. Transanal or vaginal
approach to rectocele repair: a prospective randomized pilot
study. Dis Colon Rectum 2004;47:1636–1642.
77. Kahn MA, Stanton SL. Posterior colporrhaphy: its effects on
bowel and sexual function. BJOG 1997;104:82–86.
78. Singh K, Cortes E, Reid WMN. Evaluation of the fascial tech-
nique for surgical repair of isolated posterior vaginal wall
prolapse. Obstet Gynecol 2003;101:320–324.
79. Kenton K, Shott S, Brobaker L. Outcome after rectovaginal
fascia reattachment for rectocele repair. Am J Obstet Gynecol
1999;181:1360–1364.
80. Abramov Y, Kwon C, Gandhi S, et al. Long-term anatomic
outcome of discrete site-specific defect repair versus stan-
dard posterior colporrhaphy for the correction of advanced
rectocele: a 1-year follow-up analysis. Neurourol Urodyn
2003;22:520–521.
81. Paraiso MF, Barber MD, Muir TW, et al. Rectocele repair: a
randomized trial of three surgical techniques including graft
augmentation. Am J Obstet Gynecol 2006;195:1762–1771.
82. Lim YN, Rane A, Muller R. An ambispective observational
study in the safety and efficacy of posterior colporrhaphy with
composite vicryl-prolene mesh. Int Urogynecol J 2005;16:
126–131.
83. Petros PP. Medium-term follow-up of the intravaginal sling-
plasty operation indicates minimal deterioration of urinary
continence with time. Aust N Z J Obstet Gynaecol 1999;39:
354–356.
84. Farnsworth BN. Posterior intravaginal slingplasty (infracoccy-
geal sacropexy) for severe posthysterectomy vaginal vault
prolapse—a preliminary report on efficacy and safety. Int
Uro7gynecol J Pelvic Floor Dysfunct 2002;13:4–8.
85. Biertho I, Dallemagne JM, Markiewicz S, et al. Intravaginal
slingpalsty: short-term results. Acta Chir Belg 2004;104:700–
706.
86. Bader G, Fauconnier A, Roger N, et al. Cystocele repair by
vaginal approach with a tension-free transversal polypro-
pylene mesh. technique and results. Gynecol Obstet Fertil
2004;32:280–284.
87. Eglin G, Ska JM, Serres X. Transobturator subvesical mesh.
Tolerance and short term results of a 103 case continuous
series. Gynecol Obstet Fertil 2003;31:14–19.
88. Jordaan DJ, Prollius A, Cronje HS, et al. Posterior intravaginal
slingplasty for vaginal prolapse. Int Urogynecol J Pelvic Floor
Dysfunct 2006;17:326–329.
89. Sullivan ES, Longaker CJ, Lee PY. Total pelvic mesh repair: a
ten year experience. Dis Colon Rectum 2001;44:857–863.
90. Amrute KV, Badlani GH. Female incontinence: a review of
biomaterials and minimally invasive techniques. Curr Opinion
Urol 2006;16:54–59.