Discussion
prolapse
RECURRENCE, PROLAPSE, PROLAPSES, COMPLICATIONS

The present study evaluated the two most commonly performed surgical correction techniques, one of which is the reconstruction of the pelvic anatomy using native tissues, and the degree of objective (anatomical) and subjective (functional) success in achieving satisfactory results with respect to the most current recommendations on the surgical treatment of POP.

Systematic reviews, randomized trials and medical societies found no evidence to support the use of meshes to the detriment of native tissues.

Studies such as the present, which prove the effectiveness of surgical treatment with the application of traditional techniques in urogynecology, such as fixation of the vaginal vault to the sacrospinous ligament or suspension of the uterosacral ligament to correct even advanced apical prolapses, reinforce the prioritization of the choice and reproducibility of the classic technique in urogynecological surgery for POP.

Regarding the cure criteria, there is no consensus in the scientific community on success and failure in POP correction surgery. Barber et al.

In that context, the POP-Q enables more accurate descriptions of the POP stages for diagnosis and follow-up. Despite the fact that most patients are classified as stage II postoperatively, with a surgical outcome between the +1 and −1 range of the hymenal ring, they generally remain asymptomatic. Therefore, what would configure an anatomical failure (stage II according to the POP-Q) is classified as a cure according to the patient's subjective criteria, particularly when the prolapse is axial to the hymenal point.
Based on this scenario, the results of the present study (anterior compartment), showed questionable anatomical cure rates in both groups after one year of follow-up, when considering the cure criterion points of greater POP-Q prolapse below −1 (34.6% and 40%, for USLS and SSLF groups respectively). However, when adopting the hymenal ring as a reference point for healing (Ba ≤ 0), since these patients are asymptomatic, the cure rates were of 88.4% (USLS) and 88% (SSLF).
In the same direction, Barber et al.

However, Meyer et al.

The analysis of the apical compartment after the interventions points to the restoration of the anatomy in both groups, with no significant difference. These findings corroborate those of previous studies

On the other hand, in the posterior compartment, a better anatomical result was observed in the SSLF group, with a statistical difference, but no difference in terms of the subjective assessment. This was probably due to to posterior deviation of the vaginal axis: the greater the area of dissection of the posterior compartment, the better the anatomical correction.

In both groups, there was a significant decrease in the size and width of the genital hiatus after reconstruction of the posterior compartment and perineal body, which is considered a high-impact factor in surgical success and decreased recurrence. Inadequate correction of the genital hiatus can therefore impair the surgical outcome in addition to resulting in recurrence of the prolapse.

This randomized design, approved by ethics committees and clinical trials plataforms, highlights the methodological rigor and positive impact by offering reliability and resilience of site-specific surgical treatment in advanced POP, in a paradoxical technological appeal and numerous restrictions to synthetic meshes. Synthetic meshes may have their clinical applicability; however, it is increasingly limited due to the high rate of complications.

The recommendation to use classic techniques for POP correction is in line with reference medical societies, such as the IUGA,
On the other hand, sample size and sexual function data (most patients no longer had an active sexual life) may be limitations of the present study which may not compromise the scientific quality. The authors believe that the parity of positive cure outcomes analyzed by different anatomical methods, as well as the application of the P-QoL, reinforces the data and alleviates the limitation of the sample. Besides that, due to the objective being the comparison of cure criteria, not the assessment of the superiority or inferiority of a technique, the sample was sufficient according to the statistical recommendation.The authors point to the need for longer follow-up of patients (undergoing evaluations to provide data for future studies) with a more robust sample from multiple centers to really assess the potential for POP recurrence between the groups.Due to the current restrictions on the use of synthetic meshes by specialized medical societies, regulatory agencies and several authors, reconstructive pelvic surgery might be moving toward a return to the classic use of native tissues, even in cases o POP in advanced stages.