Pelvic organ prolapse (POP) has an important impact on patients’ quality of life, urinary, vaginal, bowel and sexual function. At present time, POP repair may be done with native tissue (NTR) or with mesh (MR). POP repair allows the improvement of global patients’ quality of life, ameliorating symptoms. However, the role of mesh placement in POP repair is currently strongly questioned for their potential reported consequences as: dyspareunia, overactive bladder (OAB) symptoms, mesh related complications (1). 
Aim of our study is to compare the outcomes on sexual function and OAB symptoms after transvaginal POP repair with native tissue or with mesh placement.

Study is designed as a retrospective comparison between patients submitted to transvaginal POP repair. No power analysis or randomization was possible. Study was performed in accordance with Declaration of Helsinki and all patients provided informed consent for their participation. Data from sexually active women treated for anterior vaginal wall defect with transvaginal repair were prospectively collected and analysed in two tertiary referral centres with different expertise, as one centre was specialised on MR with commercial mesh kit (Group 1), while the other on NTR (Group 2). All surgical procedures were performed from senior skilled surgeons. Only commercial mesh kits were considered. POP was measured according to the POP-Q classification. Patients’ characteristics, operative and post-operative data were collected. Complications were reported according to Clavien-Dindo score. Follow-up was carried out at month 1, 6 and 12 and then yearly in each centre. Female Sexual Function Index (FSFI) and OAB-Screener questionnaires were administered before and after surgery, and at follow up. Patient Global Impression of Improvement (PGI-I) was used to evaluate global patients’ satisfaction and patients’ subjective surgery outcome. Statistical analysis was performed using Student’s T-Test and Chi-Square.

A total of 98 patients were enrolled. Group 1 consisted in 57 women (58,2%), and Group 2 in 41 (41,8%). Patients’ characteristics, outcomes at FSFI and OAB-screener questionnaires and OAB rate are reported in table 1. Group 2 consisted only in primary POP surgeries, while in Group 1 only 75.5% were surgery naïve for POP. Patients in both groups had pre-operative POP-Q stage III. Pre-operative patients’ characteristics were different for FSFI subdomains, OAB screener, age and recurrent POP. Mean follow up was 64 months (SD 32) and 22,3 months (SD 12,3) in Group 1 and Group 2 respectively. Complications were slightly higher in Group 1, but without a statistically significant difference. In Group 1 there were 6 (10,5%) 5 medical Clavien 2 and one surgical Clavien 2, and in Group 2 there were 3 (7,3%) complications, 2 Medical Clavien 2 and 1 medical Clavien 3. In both groups PGI-I proved a clear patients’ symptoms improvement with good subjective surgery outcomes, without statistically significant differences between them. Mean PGI-I was 1,8 (SD 1,5) in Group 1, while in Group 2 was 1,9 (SD 1,4), p>0.05. Mesh related complications occurred only in 1 (1,7%) patient (vaginal mesh extrusion successfully managed conservatively with Oestrogenic local therapy). OAB-Screener improved after surgery even at long term follow up in both groups (p<0.0001). OAB rate reduced after surgeries in both groups: 5 (45,5%) in Group 1 and 9 (56,3%) in Group 2. De novo OAB were 2 (3,5%) and 2 (4,9%) in Group 1 and Group 2 respectively. In each group, surgery did not significantly influenced FSFI total score, and the comparison between groups did not evidenced any difference (in total score and in sub-domains scores) at follow-up. Analysing the FSFI sub-domains of desire, arousal, satisfaction and pain significantly improved in Group 2. POP recurrence occurred in Group 1 in 2 (3,5%) patients, and in 3 (7,3%) patients of Group 2 (p>0.05).

POP repair and in particular mesh placement remains an important, thus controversial argument. In our study we found that sexually active patients who underwent NTR were younger and had a statistically significant improvement in sexuality FSFI domains but not in the global FSFI score. IN MR for anterior vaginal wall defect no improvement or worsening on sexuality was documented. This difference may be determined both from a preoperative lower level of sexual function in Group 2 respect Group 1, and from higher pre-operative age in Group 1. Ageing during follow up and menopause might also be further confounding factors. Both surgical techniques proved to be effective providing a good anatomical and subjective outcome. Surprisingly, complication rate was also similar between the two techniques, despite the possibility for mesh related complications. This data adds another point in the current debate in literature on MR for vaginal route POP (1-3). We also found another interesting result regarding OAB symptoms improvement after anterior compartment POP repair. Our study confirmed that in more than half cases OAB symptoms can significantly improve after POP surgery, despite De Novo OAB. 
Limitations of our study are the absence of randomization and the preoperative differences between groups, that clearly may have an impact on our outcomes.

NTR for women with anterior vaginal wall defect leads to important improvement in sexual life in terms of desire, arousal, satisfaction and pain. However, the overall female sexual function was comparable between two groups, and MR seems not to affect sexual function. Furthermore, anterior vaginal wall repair clearly improves OAB symptoms with both techniques.

Maher C, et al. Surgery for women with anterior compartment prolapse. Cochrane database Syst Rev. 2016 Nov;11:CD004014.
Balzarro M, et al .Long-term follow-up of anterior vaginal repair: A comparison among colporrhaphy, colporrhaphy with reinforcement by xenograft, and mesh. Neurourol Urodyn. 2018 Jan;37(1):278-283.
Glazener CM, et al (PROSPECT study group). Mesh, graft, or standard repair for women having primary transvaginal anterior or posterior compartment prolapse surgery: two parallel-group, multicentre, randomised, controlled trials(PROSPECT).. Lancet. 2017 Jan 28;389(10067):381-392