Balloon Debate – What is the best treatment for recurrent anterior wall prolapse in patients with a prior hysterectomy?

Balloon Debate – What is the best treatment for recurrent anterior wall prolapse in patients with a prior hysterectomy?

Dr Rayan Mohamed-Ahmed

Urogynaecology Subspecialty Trainee, King’s College Hospital, London.

Moderator: Dr Ivalina Pandeva (Consultant Urogynaecologist, UK)
Anterior Vaginal Mesh – Dr Lucila Pavan (Consultant Urogynaecologist, Argentina)

Apical sling with native tissue repair or SSF with native tissue repair – Willy Davila
(Consultant Urogynaecologist, USA)

Sacrocolpopexy – Professor Barry O’Reilly (Consultant Urogynaecologist, Ireland)
Pessary – Dr Maura Seleme (Pelvic Physiotherapist, Netherlands)

At the most recent IUGA annual meeting, four leading experts took the stage for a lively balloon debate moderated by Dr Pandeva. The clinical case was to determine the optimal treatment for a 36-year-old female with Ehlers-Danlos syndrome and a recurrent stage III anterior wall prolapse with vault descent.
In Round 1, Dr Davila advocated for an apical sling with native tissue repair, highlighting the patient's scarred abdomen from endometriosis. However, he was the first voted out. Dr Seleme took an early lead by presenting the pessary as a "biologically smart support" that avoids surgical trauma and accommodates the patient's history of chronic pelvic pain. Round 2 saw Dr Pavan passionately defend transvaginal mesh (TVM) using ASPIRE trial data and a clever Stranger Things nod, declaring, "the real monster isn’t the mesh, it’s the fear surrounding it". Meanwhile, Professor O’Reilly argued for sacrocolpopexy, citing Cochrane evidence that sacrocolpopexy provides a long-term durable option and reduces recurrence risks by 50%. Despite a strong defense of mesh tolerability, Dr. Pavan was voted out. The final round came down to a classic clash between conservative management and definitive surgery. Dr Seleme maintained that "the safest strategy is the smartest strategy," emphasising realistic expectations. Professor O’Reilly countered that whilst post-operative physiotherapy is vital, sacrocolpopexy was the necessary definitive choice to address the multi-compartment prolapse. Ultimately, Professor O'Reilly and sacrocolpopexy won the day, edging out the pessary by 177 to 146 votes. Closing on a collaborative note, Dr. Seleme beautifully summarised the event's spirit: "We should work always together". It was an exceptional session filled with healthy competition and outstanding clinical learning!