Biological Grafts for the Surgical Management of Uterovaginal Prolapse: A Narrative Overview of the Evolution of Biomaterials.

Uterovaginal prolapse (U-POP) affects the lives of millions of women worldwide. This narrative review was performed as part of the Global Consensus on controversies and best practices in the surgical management of U-POP. The committee on augmenting and alternative materials for primary U-POP repair addressed three questions: (1) Is there a preferred material for augmentation of primary uterovaginal prolapse repair? (2) What are the critical outcomes for the assessment of augmented repair? and (3) Could novel biomaterials be used preventatively, to avoid the need for surgical intervention for U-POP? We provide a narrative overview of the evolution of biomaterials used in POP repair, from autologous grafts, allografts and xenografts to synthetic mesh and to the engineering and preclinical validation of next-generation smart biomaterials. Each option available today requires a trade-off. Native-tissue repair avoids graft-related complications, but recurrence remains an important problem for some patients. Permanent synthetic implants provide durable structural support, but can cause material-specific complications. Biological grafts have not consistently improved long-term outcomes. New materials are therefore needed that balance mechanical support, tissue integration, and biologic compatibility. We conclude by focusing the attention of the clinical and scientific communities on the scarcity of rigorous comparative trials and on this unmet need in the field of female pelvic medicine.