Native tissue alternative to the use of mesh in Sacral colpopexy

Dr Natharnia Young,

Monash Health Victoria Australia

Sacral colpopexy is considered the gold standard for vaginal vault prolapse however multiple regulatory bodies such as FDA, TGA and European Commission have placed warnings on the use of mesh in urogynaecology and increasingly women want mesh alternatives due to potential mesh complications.

Fascia Lata can be used as an alternative to Mesh for sacral colpopexy. This graft can be obtained from cadaver or autologous and harvested from the upper thigh. Biomechanical properties have been studied and found that cadaveric fascia lost 60-89% in strength and stiffness but there was minimal change with Autologous fascia.¹

Human fascia is an ideal biological graft with favourable tissue integration, large collagen content, improved tensile strength and angiogenesis.²

The Cochrane looked at 2 studies; sacral colpepexy: mesh compared to alternative graft. The risk of prolapse on examination (Stage 2 or above) was lower with mesh compared to fascia lata with a risk ratio 0.46 (0.19, 1.13).³  Culligan reported a higher anatomical failure rate that was predominantly in the anterior wall but there were no vault failures with use of cadaveric fascia.⁴ At 5 years follow up when re-analysed using clinical success – POP>0 and subjective awareness of bulge there was no difference between the groups.⁵

A prospective non-randomized study with autologous fascia lata versus mesh demonstrated no difference in success with a mean follow-up of 12 months (94.8 versus 97.8%). There was one anterior and apical failure in the fascia lata group with longer operating times.⁶

Harvest site complications are an additional risk to fascia lata sacral colpopexy. 14% had thigh bulge, 14% seroma, 53% parasthesia, 1 wound dehiscence, 1 infection and 1 difficulty with ambulation.⁷

In conclusion fascia lata is an alternative to mesh with a small risk of persistent leg complications.⁸

¹ Dora CD, Dimarco DS, Zobitz ME, Elliott DS. Time dependent variations in biomechanical properties of cadaveric fascia, porcine dermis, porcine small intestine submucosa, polypropylene mesh and autologous fascia in the rabbit model: implications for sling surgery. J Urol. 2004 May;171(5):1970-3. doi: 10.1097/01.ju.0000121377.61788.

² Hennes D. Biomechanical and immunobiological properties of human fascial ata vs TiMesh: implictions for pelvic reconstructive surgery. DOI: https//doi.org/10.33235/anzcj.29.4.110

³ Maher C, Yeung E, Haya N, Christmann-Schmid C, Mowat A, Chen Z, Baessler K. Surgery for women with apical vaginal prolapse. Cochrane Database of Systematic Reviews 2023, Issue 7. Art. No.: CD012376. DOI: 10.1002/14651858.CD012376.pub2.

⁴ Culligan PJ, Blackwell L, Goldsmith LJ, Graham CA, Rogers A, Heit MH. A randomized controlled trial comparing fascia lata and synthetic mesh for sacral colpopexy. Obstet Gynecol. 2005 Jul;106(1):29-37. doi: 10.1097/01.AOG.0000165824.62167.c1

⁵ Tate SB, Blackwell L, Lorenz DJ, Steptoe MM, Culligan PJ. Randomized trial of fascia lata and polypropylene mesh for abdominal sacrocolpopexy: 5-year follow-up. Int Urogynecol J. 2011 Feb;22(2):137-43. doi: 10.1007/s00192-010-1249-3. Epub 2010 Aug 27.

⁶ Bock ME, Nagle R, Soyster M, Song L, Tachibana I, Hathaway JK, Powell CR. Robotic Sacral Colpopexy Using Autologous Fascia Lata Compared with Mesh. J Endourol. 2021 Jun;35(6):801-807. doi: 10.1089/end.2020.0537. Epub 2020 Nov 26.

⁷ Delu AA, Terrani KF, Funk JT, Twiss CO. Harvest of large fascia lata autograft: Outcomes in 108 patients. Neurourol Urodyn. 2024 Jun;43(5):1179-1184. doi: 10.1002/nau.25464. Epub 2024 Apr 8.