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Mesh & Graft-Augmented Prolapse Repair

Mesh and graft-augmented vaginal repairs reinforce a transvaginal repair of pelvic organ prolapse (POP) with synthetic mesh or a biologic graft. Transvaginal synthetic mesh improves anterior-compartment anatomic outcomes but adds mesh-specific morbidity. Biologic grafts probably reduce examination-detected anterior recurrence at 1–2 years, but have not shown a clear advantage in prolapse awareness or repeat prolapse surgery over native-tissue repair.[28] Since April 2019, no FDA-approved transvaginal mesh products for POP repair remain available in the United States.[1][2][3]

Sacrocolpopexy, in which mesh is placed abdominally, is a separate operation, and midurethral slings for SUI were not removed from the US market by the 2019 FDA POP-mesh order.[23]

Current U.S. context​

The FDA states that no FDA-approved mesh products are currently marketed in the United States for transvaginal POP repair. Its April 16, 2019 stop-sale order concerns this category, not abdominal sacrocolpopexy mesh or SUI mesh slings. A prior implant does not itself require removal: people without complications can continue routine care, while new bleeding, discharge, pain or dyspareunia warrants assessment.[23]

Material Types​

MaterialExamplesCurrent role
Synthetic nonabsorbable meshType I macroporous monofilament polypropyleneMost studied material; improves anterior anatomic cure but adds exposure, pain, bladder injury, de novo SUI, and repeat-surgery risk.[1][3]
Synthetic absorbable meshPolyglactin / Vicryl-type materialsIn anterior repair, absorbable synthetic mesh probably reduces examination-detected recurrence at 1–2 years, but benefit for prolapse awareness, repeat surgery, or longer-term outcomes has not been established.[3][28]
Autologous biologic graftRectus fasciaAvoids permanent synthetic material but adds donor-site morbidity and lacks strong POP benefit data.
Allograft / homologous graftCadaveric fascia lataStudied historically; no consistent durable advantage over native repair.[2][3]
XenograftPorcine dermis, porcine small intestinal submucosaNo meaningful benefit over native tissue in contemporary reviews; posterior-compartment outcomes may be worse in some trials.[1][3]

Efficacy by Compartment​

CompartmentSynthetic meshBiologic graftPractical conclusion
AnteriorPolypropylene mesh improves anatomic and some subjective outcomes compared with native-tissue repair but increases morbidity (ACOG/AUGS, Level A).[1] In the Society of Gynecologic Surgeons review, anterior mesh improved anatomic and bulge-symptom outcomes, while other subjective outcomes, including urinary incontinence and dyspareunia, generally did not differ; a later meta-analysis also found higher anatomic cure.[2][4] In PROSPECT (primary anterior or posterior repair), prolapse symptom and prolapse-related quality-of-life scores did not differ from standard repair at 1 and 2 years.[5]Biologic grafts probably lower examined anterior recurrence at 1–2 years versus native tissue (native versus graft RR 1.53; 8 RCTs, 707 women), while prolapse awareness is similar and benefit for repeat prolapse surgery remains uncertain.[1][3][28]In the US, no approved TVM POP product remains available.
PosteriorDoes not improve outcomes.[1][3]Does not improve outcomes and may worsen anatomic results in some trials.[1][3]Do not routinely use mesh or biologic grafts for posterior colporrhaphy.
ApicalNative-tissue vaginal repairs have similar prolapse awareness and reoperation compared with TVM in some analyses, while TVM adds mesh complications.[6] ASPIRe met its prespecified TVM-versus-SCP noninferiority comparison for post-hysterectomy vault prolapse, without establishing equivalence or TVM superiority over native tissue.[7] In the distinct ten-year SUPeR follow-up of uterovaginal prolapse, vaginal mesh sacrospinous hysteropexy had fewer composite failures than vaginal hysterectomy with uterosacral suspension (35/88 versus 46/87), without a demonstrated difference in patient-reported prolapse symptoms; 112/175 analyzed women entered the six- to ten-year extension.[30]No clear durable role.Sacrocolpopexy is usually the mesh-based durability benchmark.

Trial Anchors​

PROSPECT​

The PROSPECT trials randomized 1,352 women (1,348 analyzed) undergoing primary transvaginal anterior or posterior compartment prolapse surgery to standard repair alone or standard repair augmented with synthetic mesh or a biologic graft. Augmentation did not improve prolapse symptom scores or prolapse-related quality of life at 1 or 2 years. Among women who received synthetic mesh, 51 of 434 (12%) had a mesh complication within 2 years.[5] At six years, with 65% retained for the primary outcome and no examination-based anatomy assessment, prolapse symptom scores and the symptom-based functional-cure composite were similar across randomized comparisons.[31] Complete satisfaction was lower after mesh inlay than native repair (115/268 [42.9%] versus 144/260 [55.4%]), and 22/263 mesh-inlay respondents (8.4%) reported mesh-removal surgery.[31]

Three-year mesh versus native-tissue trial​

A double-blind multicenter trial randomized 65 women with POP-Q stage 2–4 prolapse to vaginal colpopexy repair with mesh (33) or traditional vaginal repair without mesh (32); enrollment stopped early because of a 15.6% mesh exposure rate. At 3 years, with 51 women completing questionnaires and 41 examined, prolapse stage, symptom scores and cure rates under several definitions did not differ between groups. Anatomic cure was lowest in the anterior compartment, and all three reoperations for recurrent prolapse were in the mesh group. The early stop left the trial small.[25]

Recurrent prolapse trial​

A trial limited to recurrent prolapse randomized 194 women with stage II or higher prolapse (190 operated) to trocar-guided polypropylene mesh or conventional vaginal repair. At 12 months, anatomic failure in the treated compartment was 9.6% (8 of 83) after mesh and 45.2% (38 of 84) after conventional repair (OR 7.7, 95% CI 3.3–18), assessed by an unblinded surgeon. Subjective improvement was similar (81% versus 80%), and mesh exposure occurred in 14 of 83 (16.9%). The trocar-guided kit belongs to a product category no longer marketed in the United States.[26]

FDA 522 study​

A prospective, nonrandomized FDA-mandated 522 study comparing transvaginal mesh with native tissue repair reported 36-month composite success of 89.3% for mesh versus 80.2% for native tissue, demonstrating noninferiority but not superiority on the primary endpoint.[8] These study endpoints did not establish a favorable FDA benefit-risk determination or restore U.S. marketing availability.[8][24]

PROSPERE​

The PROSPERE multicenter trial comparing laparoscopic sacrocolpopexy with transvaginal mesh for primary cystocele showed similar composite success rates at 4 years, but grade III or higher complications were more common after TVM (8.7% versus 2%).[9]

ASPIRe: post-hysterectomy vault prolapse​

ASPIRe randomized 376 women, of whom 360 underwent study surgery, to native-tissue repair, sacrocolpopexy or transvaginal mesh. Modeled 36-month composite failure was 43%, 28% and 29%, respectively. Sacrocolpopexy was superior to native tissue; the transvaginal-mesh comparison with native tissue did not meet the trial's adjusted superiority threshold. TVM met a prespecified noninferiority margin versus sacrocolpopexy. Most failures were anatomical rather than repeat operations.[7]

ASPIRe used the now-unmarketed Uphold LITE vaginal product. The prolapse principles page contains the corrected endpoint and analysis details.

Mesh-Specific Complications​

For the canonical complications and removal reference (IUGA / ICS classification, complete-vs-partial removal evidence, surgical-approach algorithm, ACOG Committee Opinion 694 management framework), see Mesh Complications & Removal. The summary below is the indication-and-augmentation-context view.

The 2024 Cochrane review included 51 trials. Its estimates combine different products, compartments and follow-up periods.[3]

ComplicationSignal
Vaginal mesh exposureAmong women who had mesh repair, 11.8% had mesh exposure and 6.1% underwent surgery for mesh exposure.[3]
Repeat surgeryTotal repeat surgery for prolapse, SUI, or mesh exposure is higher with mesh (RR 1.56, 95% CI 1.07-2.26; 27 trials; low-certainty evidence), although repeat surgery for prolapse alone is lower.[3]
De novo SUIIncreased after mesh-augmented repair.[3]
Bladder injuryHigher with mesh placement.[3]
Dyspareunia / painPain and dyspareunia are reported complications; rates depend on baseline symptoms, sexual activity, implant and follow-up.[3][10]
Erosion range by compartment burdenReported erosion rates range from 1.4-19% after anterior wall placement and 3-36% when mesh spans multiple compartments.[2]

A retrospective study examined associations between mesh erosion and patient or procedure features. Counseling considers smoking, tissue health and the precise operation.[11] The host response to polypropylene is shaped by the vaginal hormonal and microbial environment, implant porosity, surface area, and chronic immune activation.[12]

U.S. regulatory timeline​

YearEvent
2008FDA public-health notification about complications of urogynecologic mesh.
2011Additional FDA safety communication about serious transvaginal POP mesh complications.
2016Transvaginal POP mesh reclassified as Class III devices.
2019FDA ordered the remaining transvaginal POP mesh manufacturers to stop sales and distribution.

In an NSQIP analysis, transvaginal mesh use for apical prolapse repair fell from 35.0% to 11.0% between 2008 and 2017, with a decrease of 4.4% per quarter in the year after the 2011 safety communication.[13] These events and subsequent 522-study assessments are summarized by the FDA. Regulatory availability outside the United States is jurisdiction- and product-specific.[23][24]

Technique and selection context​

Native-tissue vaginal repair and abdominal or minimally invasive sacrocolpopexy are the main reconstructive alternatives discussed for new U.S. cases, alongside conservative management. Vaginal POP mesh kits remain unavailable for new U.S. cases despite historical recommendations. Synthetic or biologic augmentation has not established a routine advantage for posterior vaginal wall repair.[1][3][14][23] For anterior or apical prolapse reconstruction, the AUGS consensus recommends intraoperative cystoscopy to inspect the bladder and urethra and confirm ureteral efflux; posterior-only repair is the exception.[32]

When reviewing a previous augmented repair, record the material, operative route, compartment, fixation pattern and any concomitant surgery. Manufacturer documentation and the original operative report identify the device and its placement. Whether a particular augmentation improves outcomes enough to justify its harms is a separate question that only comparative studies answer.

Mesh and Graft Complication Management​

ACOG / AUGS guidance on mesh and graft complications emphasizes symptom-driven management and specialist referral for complex pain, erosion, urinary tract involvement, or failed prior excision.[15]

PresentationManagement frame
Asymptomatic small exposureExpectant management is acceptable for monofilament macroporous mesh.[15]
Small symptomatic exposure (< 0.5 cm)A 6–12-week trial of topical vaginal estrogen with local care and observation may be reasonable before excision; reassess if symptoms persist, since comparative evidence is limited.[15]
Bleeding, discharge, partner pain, or recurrent exposureFor type I polypropylene transvaginal POP mesh exposure, office trimming often fails; if the treating surgeon lacks mesh-revision expertise, refer to an experienced surgeon. For such exposure without pelvic pain, partial vaginal excision is recommended when surgery is chosen; complete vaginal excision may be considered for recurrence. Counsel that symptoms may persist and prolapse or incontinence may recur.[15][16][33]
Pain / dyspareunia without visible exposuremesh removal may not resolve pain. In one series, complete pain resolution occurred in only about half after operative management.[17]
Urinary tract erosion, fistula, abscess, severe pain, or complex prior excisionRefer to FPMRS / reconstructive specialist; evaluate with cystoscopy, imaging, and multidisciplinary pain care when indicated.[15]

For an asymptomatic person, the presence of an implant alone is not an indication for removal. For symptoms, match treatment to the identified problem and explain that removal may not resolve pain and may introduce recurrent prolapse or incontinence.[15]

Sacrocolpopexy vs. Transvaginal Mesh​

Sacrocolpopexy and transvaginal mesh use different routes, dissection and fixation. A 2021 systematic review suggested fewer mesh complications and similar anatomic and subjective success with sacrocolpopexy compared with transvaginal mesh, based on very low-certainty evidence.[18] A 2026 anterior-compartment Cochrane review found more de novo dyspareunia with permanent vaginal mesh than abdominal sacrocolpopexy at one year (RR 2.15, 95% CI 1.17–3.98; 2 RCTs, 248 women; moderate certainty).[28] The VIGI-MESH registry similarly found fewer serious complications after laparoscopic sacrocolpopexy than TVM at 1 year, with low recurrence reoperation rates.[19]

Long-term data are more mixed. A Finnish nationwide cohort with mean 7.4-year follow-up found similar prolapse reoperation rates across native tissue, transvaginal mesh, and abdominal mesh, with differences in recurrence site; observational comparisons can be confounded by procedure selection.[20]

Long-Term Outcomes​

A New York State observational cohort included 54,194 women; among 12,284 propensity score-matched pairs, transvaginal mesh POP repair was associated with higher 5-year reintervention risk than vaginal repair without mesh (8.8% versus 6.3%; HR 1.40).[21] Long-term follow-up cohorts confirm that recurrence, reoperation, and mesh complications remain surveillance issues years after the index procedure.[20]

At 7 years in the recurrent prolapse trial, with 127 women evaluable for the primary outcome, composite success (no prolapse beyond the hymen, no bulge symptoms and no retreatment) was 53% after trocar-guided mesh and 54% after native-tissue repair.[27] Repeat prolapse surgery was 25% versus 16% (difference 9%, 95% CI −5 to 23) and occurred in untreated compartments after mesh and in treated compartments after native-tissue repair.[27] Mesh exposure was 42% at seven years; pain and dyspareunia did not differ significantly between groups.[27] At twelve years, among 45 mesh and 43 native-tissue questionnaire respondents, additional operations for recurrent POP, SUI, or exposure had occurred in 18/45 (40%) versus 8/43 (19%); patient-reported improvement did not differ significantly.[29]

Future Directions​

Biologic and biomimetic graft materials aim to reproduce the mechanical advantages of synthetic mesh while improving tissue integration and reducing chronic host response.[22] Preclinical promise has not yet produced a durable, low-morbidity vaginal graft that clearly outperforms native tissue repair.[22] The 2024 Cochrane review concludes that transvaginal mesh has limited utility in primary surgery and that any ongoing use should occur with ethical oversight and outcomes reported to regulatory bodies.[3]

See Also​

Videos​

Transvaginal Rectocele Repair Reinforced with Biological Mesh
Colorectal Disease Journal (2021)

References​

1. Committee on Practice Bulletins—Gynecology and American Urogynecologic Society. Pelvic organ prolapse: ACOG Practice Bulletin, Number 214. Obstet Gynecol. 2019;134(5):e126-e142. doi:10.1097/AOG.0000000000003519

2. Schimpf MO, Abed H, Sanses T, et al. Graft and mesh use in transvaginal prolapse repair: a systematic review. Obstet Gynecol. 2016;128(1):81-91. doi:10.1097/AOG.0000000000001451

3. Yeung E, Baessler K, Christmann-Schmid C, et al. Transvaginal mesh or grafts or native tissue repair for vaginal prolapse. Cochrane Database Syst Rev. 2024;3:CD012079. doi:10.1002/14651858.CD012079.pub2

4. Capobianco G, Sechi I, Muresu N, et al. Native tissue repair versus transvaginal mesh interventions for the treatment of anterior vaginal prolapse: systematic review and meta-analysis. Maturitas. 2022;165:104-112. doi:10.1016/j.maturitas.2022.07.013

5. Glazener CM, Breeman S, Elders A, et al. 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;389(10067):381-392. doi:10.1016/S0140-6736(16)31596-3

6. Maher C, Yeung E, Haya N, et al. Surgery for women with apical vaginal prolapse. Cochrane Database Syst Rev. 2023;7:CD012376. doi:10.1002/14651858.CD012376.pub2

7. Menefee SA, Richter HE, Myers D, et al. Apical suspension repair for vaginal vault prolapse: a randomized clinical trial. JAMA Surg. 2024;159(8):845-855. doi:10.1001/jamasurg.2024.1206

8. Kahn B, Varner RE, Murphy M, et al. Transvaginal mesh compared with native tissue repair for pelvic organ prolapse. Obstet Gynecol. 2022;139(6):975-985. doi:10.1097/AOG.0000000000004794

9. Lucot JP, Cosson M, Verdun S, et al. Long-term outcomes of primary cystocele repair by transvaginal mesh surgery versus laparoscopic mesh sacropexy: extended follow up of the PROSPERE multicentre randomised trial. BJOG. 2022;129(1):127-137. doi:10.1111/1471-0528.16847

10. Yang J, Zhang K, Han J, et al. Long-term observation on postoperative recurrence and complications of transvaginal mesh surgery for pelvic organ prolapse. Gynecol Obstet Invest. 2022;87(1):30-37. doi:10.1159/000520979

11. Cetin Arslan H, Arslan K. Risk factors and outcomes of vaginal mesh erosions after pelvic reconstructive surgery: a retrospective cohort study. Medicine (Baltimore). 2025;104(19):e42442. doi:10.1097/MD.0000000000042442

12. Abhari RE, Izett-Kay ML, Morris HL, Cartwright R, Snelling SJB. Host-biomaterial interactions in mesh complications after pelvic floor reconstructive surgery. Nat Rev Urol. 2021;18(12):725-738. doi:10.1038/s41585-021-00511-y

13. Winkelman WD, Modest AM, Richardson ML. U.S. Food and Drug Administration statements about transvaginal mesh and changes in apical prolapse surgery. Obstet Gynecol. 2019;134(4):745-752. doi:10.1097/AOG.0000000000003488

14. American College of Obstetricians and Gynecologists and American Urogynecologic Society. Pelvic organ prolapse (joint publication of ACOG Practice Bulletin No. 214). Female Pelvic Med Reconstr Surg. 2019;25(6):397-408. doi:10.1097/SPV.0000000000000794

15. American College of Obstetricians and Gynecologists / American Urogynecologic Society. Management of mesh and graft complications in gynecologic surgery. Committee Opinion No. 694. 2017. Accessed September 20, 2026.

16. Abbott S, Unger CA, Evans JM, et al. Evaluation and management of complications from synthetic mesh after pelvic reconstructive surgery: a multicenter study. Am J Obstet Gynecol. 2014;210(2):163.e1-163.e8. doi:10.1016/j.ajog.2013.10.012

17. Crosby EC, Abernethy M, Berger MB, et al. Symptom resolution after operative management of complications from transvaginal mesh. Obstet Gynecol. 2014;123(1):134-139. doi:10.1097/AOG.0000000000000042

18. Zhang CY, Sun ZJ, Yang J, et al. Sacrocolpopexy compared with transvaginal mesh surgery: a systematic review and meta-analysis. BJOG. 2021;128(1):14-23. doi:10.1111/1471-0528.16324

19. Fritel X, de Tayrac R, de Keizer J, et al. Serious complications and recurrences after pelvic organ prolapse surgery for 2309 women in the VIGI-MESH registry. BJOG. 2022;129(4):656-663. doi:10.1111/1471-0528.16892

20. Wihersaari O, Karjalainen P, Tolppanen AM, et al. Prolapse recurrence, methods of reoperation, and long-term mesh complications: a nationwide follow-up study. Acta Obstet Gynecol Scand. 2025. doi:10.1111/aogs.70083

21. Chughtai B, Mao J, Asfaw TS, et al. Long-term device outcomes of mesh implants in pelvic organ prolapse repairs. Obstet Gynecol. 2020;135(3):591-598. doi:10.1097/AOG.0000000000003689

22. Whooley J, Cunnane EM, Do Amaral R, et al. Stress urinary incontinence and pelvic organ prolapse: biologic graft materials revisited. Tissue Eng Part B Rev. 2020;26(5):475-483. doi:10.1089/ten.TEB.2020.0024

23. U.S. Food and Drug Administration. Urogynecologic surgical mesh implants. Accessed September 20, 2026.

24. U.S. Food and Drug Administration. FDA activities: urogynecologic surgical mesh. Accessed September 20, 2026.

25. Gutman RE, Nosti PA, Sokol AI, Sokol ER, Peterson JL, Wang H, et al. "Three-year outcomes of vaginal mesh for prolapse: a randomized controlled trial." Obstet Gynecol. 2013;122(4):770-777. doi:10.1097/AOG.0b013e3182a49dac

26. Withagen MI, Milani AL, den Boon J, Vervest HA, Vierhout ME. "Trocar-guided mesh compared with conventional vaginal repair in recurrent prolapse: a randomized controlled trial." Obstet Gynecol. 2011;117(2 Pt 1):242-250. doi:10.1097/AOG.0b013e318203e6a5

27. Milani AL, Damoiseaux A, IntHout J, Kluivers KB, Withagen MIJ. "Long-term outcome of vaginal mesh or native tissue in recurrent prolapse: a randomized controlled trial." Int Urogynecol J. 2018;29(6):847-858. doi:10.1007/s00192-017-3512-3

28. Christmann-Schmid C, Baessler K, Yeung E, et al. "Surgery for women with anterior compartment prolapse." Cochrane Database Syst Rev. 2026;4:CD004014. doi:10.1002/14651858.CD004014.pub7

29. Kluivers KB, Kamping M, Milani AL, IntHout J, Withagen MI. "Subjective outcomes 12 years after transvaginal mesh versus native tissue repair in women with recurrent pelvic organ prolapse; a randomized controlled trial." Int Urogynecol J. 2023;34(7):1645-1651. doi:10.1007/s00192-022-05442-9

30. Nager CW, Visco AG, Richter HE, et al. "Sacrospinous hysteropexy with mesh vs vaginal hysterectomy for treatment of uterovaginal prolapse: 10-year results of a randomized clinical trial." JAMA Surg. 2026;161(8):764-774. doi:10.1001/jamasurg.2026.2263

31. Reid FM, Aucott L, Glazener CMA, et al. "PROSPECT: 4- and 6-year follow-up of a randomised trial of surgery for vaginal prolapse." Int Urogynecol J. 2023;34(1):67–78. doi:10.1007/s00192-022-05308-0

32. Cohen SA, Carberry CL, Smilen SW. "American Urogynecologic Society consensus statement: cystoscopy at the time of prolapse repair." Female Pelvic Med Reconstr Surg. 2018;24(4):258–259. doi:10.1097/SPV.0000000000000529

33. Joint Writing Group of the American Urogynecologic Society and the International Urogynecological Association. "Joint position statement on the management of mesh-related complications for the FPMRS specialist." Female Pelvic Med Reconstr Surg. 2020;26(4):219–232. doi:10.1097/SPV.0000000000000853