Anterior, posterior and apical vaginal reconstruction with and without bolsters

Pelvic-organ-prolapse repair presents unique challenges to the pelvic surgeon. Historically, the unacceptable failure rates with traditional procedures have instigated the many conceptual and technique changes. Critical analysis of the biomechanics of normal and altered anatomy has shifted the primary focus of surgeries from the midline of the distal vagina to the interspinous diameter. In addition, just as surgeons in other fields have begun to incorporate bolsters into various types of repairs, the field of prolapse repair has seen a proliferation of materials that are available to help strengthen repairs. Much effort, time and significant resources have been invested in improving these repairs, but much remains to be learned. The rapid pace of change has prevented the development of the type of evidence-based data that are needed to analyse accurately the specific risks and benefits of the various available approaches. Conceptual changes in the aetiology of pelvic organ prolapse, pelvic biodynamics and the specific nature of connective tissue damage have helped to fuel the rapid pace of change.