A comparison of native vaginal and ligament surgery for cure of pelvic organ prolapse and overactive bladder.

The key messages from the Shkarupa et al. native cardinal/uterosacral ligament (CL/USL) study, was that, in premenopausal women, ligament repair alone is sufficient for cure of pelvic organ prolapse (POP) and urgency, achieving cure rates of 85.7% for POP and 81.6% for urgency at 12 months. However, in postmenopausal women, the cure rates were 20.5% for POP and 33.3% for urge at 12 months. The Lancet Prospect Trial recorded 21% for native vaginal repair at 12 months. The poor POP cure rate in the Prospect Trial, and the rapid deterioration in the post-menopausal CL/USL repair group, can be explained by known biomechanics. The vagina has little structural strength. Ligaments, with a much higher breaking strain, are the main structural support of pelvic organs. Yet, even native ligament repair reported very low cure rates at 12 months. The poor results in postmenopausal women with native ligament repair can be explained by collagen breakdown after the menopause, as collagen is the key structural component of ligaments. An important question posed in the ligament repair study was, "What happens to women cured by ligament repair after the menopause when the collagen leaches out of the ligaments?". One recommendation was that collagen creating tapes be routinely applied in prolapse surgery and OAB, at least in postmenopausal women. The recommendation for routine collagen-creating ligament repair methods, especially in older women, are supported by high 5-year surgical cure rates in 70-year-old Japanese women, 91.2% for POP, at 12 months, falling to 79.0 at 60 months, using collagen creating Tissue Fixation System (TFS) minislings.