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\begin{document}

\title{Sacrocolpopexy using autologous rectus fascia: cohort study of long-term
outcomes and complications}



\author[1]{Rui Wang}%
\author[2]{Krista Reagan}%
\author[3]{Sarah Boyd}%
\author[1]{Paul Tulikangas}%
\affil[1]{Hartford Hospital}%
\affil[2]{MultiCare Health System}%
\affil[3]{Penn State Health Milton S Hershey Medical Center}%


\vspace{-1em}



  
  \date{June 10, 2024}


\begingroup
\let\center\flushleft
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\selectlanguage{english}
\begin{abstract}
Objective: To evaluate objective and subjective outcomes of patients who
underwent sacrocolpopexy using autologous rectus fascia to provide more
data regarding non-mesh alternatives in pelvic organ prolapse surgery.
Design: Cohort study with retrospective and prospective data. Setting: A
single academic medical center. Population: Women who underwent
abdominal sacrocolpopexy using autologous rectus fascia between January
2010 and December 2019 Methods: Patients were recruited for a follow-up
visit including completing the Pelvic Floor Distress Inventory (PFDI)
and Pelvic Organ Prolapse Quantification (POPQ) exam. Demographic and
clinical characteristics were collected. Main Outcome Measures:
Composite failure, anatomic failure, symptomatic failure, and
retreatment. Results: During the study period, 132 women underwent
sacrocolpopexy using autologous rectus fascia. Median follow-up time was
2.2 years. Survival analysis showed that composite failure was 0.8\% (CI
0.1-5.9\%) at 12 months, 3.5\% (CI 1.1-10.7\%) at 2 years, 13.2\% (CI
7.0-24.3\%) at 3 years, and 28.3\% (CI 17.0-44.8\%) at 5 years. Anatomic
failure was 0\% at 12 months, 1.4\% (CI 0.2-9.2\%) at 2 years, 3.1\% (CI
0.8-12.0\%) at 3 years, and 6.8\% (CI 2.0-22.0\%) at 5 years.
Symptomatic failure rate was 0\% at 12 months, 1.3\% (CI 0.2-9.0\%) at 2
years, 2.9\% (CI 0.7-11.3\%) at 3 years, and 13.1\% (CI 5.3-30.3\%) at 5
years. Retreatment rate was 0.8\% (CI 0.1-5.9\%) at 12 months and 2
years, 9.4\% (CI 4.2-20.3\%) at 3 years, and 13.0\% (CI 6.0-27.2\%) at 5
years. Conclusions: Autologous rectus fascia sacrocolpopexy may be
considered a safe and effective alternative for patients who desire to
avoid synthetic mesh.%
\end{abstract}%



\sloppy


\textbf{Sacrocolpopexy using autologous rectus fascia: cohort study of
long-term outcomes and complications}

Rui Wang, MD\textsuperscript{1}, Krista Reagan, MD\textsuperscript{2},
Sarah Boyd, MD\textsuperscript{3}, Paul Tulikangas,
MD\textsuperscript{1}

\textsuperscript{1} Department of Obstetrics and Gynecology, Division of
Female Pelvic Medicine and Reconstructive Surgery, Hartford Hospital,
Hartford, CT

\textsuperscript{2} Department of Urogynecology and Pelvic
Reconstructive Surgery, MultiCare Health System, Tacoma, WA

\textsuperscript{3} Division of Female Pelvic Medicine and
Reconstructive Surgery, Penn State Health Milton S. Hershey Medical
Center, Hershey, PA

\textbf{Corresponding author}

Rui Wang

85 Seymour Street, Suite 525

Hartford, CT 06106

860-972-1908

Rui.Wang@hhchealth.org

\textbf{Conflict of interest}

The authors report no conflict of interest.

\textbf{Short Title:} Autologous rectus fascia sacrocolpopexy

\textbf{Word count}

Abstract: 248

Main text: 2,648



\textbf{Abstract}

\textbf{Objective:} To evaluate objective and subjective outcomes of
patients who underwent sacrocolpopexy using autologous rectus fascia to
provide more data regarding non-mesh alternatives in pelvic organ
prolapse surgery.

\textbf{Design:} Cohort study with retrospective and prospective data.

\textbf{Setting:} A single academic medical center.

\textbf{Population:} Women who underwent abdominal sacrocolpopexy using
autologous rectus fascia between January 2010 and December 2019

\textbf{Methods:} Patients were recruited for a follow-up visit
including completing the Pelvic Floor Distress Inventory (PFDI) and
Pelvic Organ Prolapse Quantification (POPQ) exam. Demographic and
clinical characteristics were collected.

\textbf{Main Outcome Measures:} Composite failure, anatomic failure,
symptomatic failure, and retreatment.

\textbf{Results:} During the study period, 132 women underwent
sacrocolpopexy using autologous rectus fascia. Median follow-up time was
2.2 years. Survival analysis showed that composite failure was 0.8\% (CI
0.1-5.9\%) at 12 months, 3.5\% (CI 1.1-10.7\%) at 2 years, 13.2\% (CI
7.0-24.3\%) at 3 years, and 28.3\% (CI 17.0-44.8\%) at 5 years. Anatomic
failure was 0\% at 12 months, 1.4\% (CI 0.2-9.2\%) at 2 years, 3.1\% (CI
0.8-12.0\%) at 3 years, and 6.8\% (CI 2.0-22.0\%) at 5 years.
Symptomatic failure rate was 0\% at 12 months, 1.3\% (CI 0.2-9.0\%) at 2
years, 2.9\% (CI 0.7-11.3\%) at 3 years, and 13.1\% (CI 5.3-30.3\%) at 5
years. Retreatment rate was 0.8\% (CI 0.1-5.9\%) at 12 months and 2
years, 9.4\% (CI 4.2-20.3\%) at 3 years, and 13.0\% (CI 6.0-27.2\%) at 5
years.

\textbf{Conclusions:} Autologous rectus fascia sacrocolpopexy may be
considered a safe and effective alternative for patients who desire to
avoid synthetic mesh.

\textbf{Funding} : internal departmental research funding

\textbf{Tweetable abstract:} Sacrocolpopexy using autologous rectus
fascia is a safe and effective alternative to synthetic mesh\textbf{.}

\textbf{Keywords:} autologous fascia, complications, sacrocolpopexy,
surgical outcomes



\textbf{INTRODUCTION}

Pelvic organ prolapse is a common condition. Each year, over 300,000
surgeries are performed in the U.S. for pelvic organ
prolapse.\textsuperscript{1,2} Abdominal sacrocolpopexy is an effective
technique with several studies demonstrating long-term
effectiveness.\textsuperscript{3} Sacrocolpopexy is most often performed
using a synthetic mesh to suspend the vaginal apex to the anterior
longitudinal ligament of the sacrum. However, there is a risk of
mesh-related complications associated with this procedure. The Colpopexy
and Urinary Reduction Efforts (CARE) trial showed an estimated rate of
mesh complications of 10.5\%.\textsuperscript{4}

Prior studies using alternatives to mesh for sacrocolpopexy have had
mixed results. In a randomized trial that evaluated the use of a porcine
dermal xenograft versus synthetic mesh, durability was similar at 1
year.\textsuperscript{5} The porcine graft is no longer commercially
available. In another randomized trial of sacrocolpopexy using cadaveric
fascia lata versus synthetic mesh, synthetic mesh resulted in better
outcomes at 5 years.\textsuperscript{6}

Given patient and provider concerns surrounding mesh use in pelvic
reconstructive surgeries, more data is needed regarding non-mesh
alternatives. Abdominal sacrocolpopexy using autologous rectus fascia
may provide an effective and safe alternative to sacrocolpopexy using
synthetic mesh. Although case series have been published with patients
undergoing autologous rectus fascia
sacrocolpopexies,\textsuperscript{7,8} no large cohort studies have been
conducted with long-term follow-up. The aim of this study is to evaluate
objective and subjective outcomes of patients who underwent
sacrocolpopexy using autologous rectus fascia.

\textbf{METHODS}

\textbf{Study design}

This study was reviewed and approved by the Hartford Hospital
Institutional Review Board. Our cohort study included all women who
underwent abdominal sacrocolpopexy using autologous rectus fascia
between January 2010 and December 2019 at a single academic medical
center. While we most commonly performed minimally invasive
sacrocolpopexy using synthetic mesh, patients were offered a non-mesh
alternative using autologous tissue. Patients were thoroughly counseling
regarding limited available data on the outcomes of this procedure.
Patients were eligible for the study if they were female, [?]18 years old
and underwent abdominal sacrocolpopexy using autologous rectus fascia.
Patients were excluded if they had a history of a prior sacrocolpopexy
or if synthetic mesh was used for the procedure. Eligible patients were
identified by review of operative log books and billing records, and
surgical procedures were confirmed by review of the full operative
notes. As part of standard practice, all patients were asked
preoperatively to complete a validated prolapse symptom questionnaire
(Pelvic Floor Dysfunction Inventory, PFDI-20) and this data was also
collected. Pre- and post-operative pelvic organ quantification (POP-Q)
measurements were recorded.

Patients were recruited for a follow-up visit including completing the
PFDI-20 and POP-Q exam. Over the course of 2015 to 2020, eligible
patients were called and offered to return to the office for an
examination and complete the follow-up PFDI questionnaire and if unable
or unwilling to come for a visit, were asked to complete the
questionnaire by phone. Examinations were performed by an author not
involved in the initial surgery. For patients who did not return to the
office for a study visit, their most recent POP-Q examination from
routine postop follow-up was used. Follow-up time was defined as the
time between surgery and the date of the last post-operative POP-Q
examination or PFDI-20 questionnaire.

Our primary outcomes were subjective symptoms as measured by PFDI-20 and
anatomic prolapse staging as measured by POP-Q examinations. We reported
a composite measure of treatment failure that included retreatment for
prolapse (pessary or surgery), anatomic outcomes as defined by any POP-Q
measure beyond the hymen, and symptomatic outcome defined as a positive
response (with any degree of bother other than ''not at all'') to the
PFDI question ''Do you usually have a bulge or something falling out
that you can see or feel in your vaginal area?''. Secondary outcomes
included post-operative complications including readmission,
transfusion, reoperation and infections. Demographic and medical data
included age, race, ethnicity, body mass index, previous hysterectomy,
prior incontinence surgery, prior prolapse surgery, smoking status,
parity, history of diabetes mellitus, hypertension, hyperlipidemia, and
asthma. Surgical data included concomitant surgeries, operative time,
postoperative hematocrit level, length of stay, and postoperative
complications within 30 days.

\textbf{Analysis}

Descriptive statistics were calculated with the use of standard methods
for means, medians, and proportions. Categorical data were analyzed
using chi-square or Fisher's exact test where appropriate. Continuous
variables were analyzed using paired or one-sample t-tests where
appropriate. Statistical analysis was performed with Stata software
(version 12; StataCorp, College Station, TX). All analyses were
considered statistically significant at p-values \textless{}0.05.

\textbf{Surgical technique}

All procedures were performed through a low transverse or low vertical
incision to harvest a strip of rectus fascia approximately 10cm in
length by 2cm in width. The rectus fascia was either attached to the
anterior vaginal wall or reconstructed in Y configuration and secured to
the anterior and posterior vaginal walls with delayed absorbable or
permanent sutures depending on surgeon preference. The apex of the
rectus fascia strip was attached to the anterior longitudinal ligament
at the sacrum with permanent sutures. The peritoneum was closed over the
exposed length of rectus fascia.

\textbf{RESULTS}

There were a total of 132 patients who underwent sacrocolpopexy using
autologous rectus fascia during the study period. Patient
characteristics are shown on Table 1. Mean age was 59.0 (range 32-83)
years. Mean body mass index was 25.9 kg/m\textsuperscript{2} (SD 3.8
kg/m\textsuperscript{2}). Preoperatively, 23.7\% of patients presented
with stage II prolapse, 71.0\% with stage III prolapse and 4.6\% with
stage IV prolapse. This was the initial prolapse repair for 75.8\% of
the patients. Concomitant surgeries performed included: total
hysterectomy (47.7\%), supracervical hysterectomy (11.4\%), Burch
colposuspension (61.4\%), posterior colporrhaphy (50.8\%). Mean
operative time was 258 minutes (SD 104). The mean post-operative
hematocrit was 33.0 g/dL (SD 3.1 g/dL). Two patients (1.5\%) received
blood transfusion. Mean length of stay was 2.2 days (SD 1.1 days). The
length of stay was significantly lower for patients who underwent
surgery after the implementation of Enhanced Recovery After Surgery
(ERAS) protocol compared to before ERAS (1.8 \selectlanguage{ngerman}± 0.6 days vs. 2.4 ± 1.3
days, respectively; P=0.008).

Out of all 132 eligible patients, 95 (72\%) consented to have additional
follow up for the purposes of this study. For patients who were not able
to have additional follow up during the study period, follow up data
were collected from chart review. A total of 128 (97\%) of patients had
postoperative POPQ exams either as part of routine care or follow up
during the study.

Median follow-up time was 2.2 years, ranging from 1 month to 6.2 years.
Survival analyses showed that the probability of composite failure was
0.8\% (CI 0.1-5.9\%) at 12 months, 3.5\% (CI 1.1-10.7\%) at 2 years,
13.2\% (CI 7.0-24.3\%) at 3 years, and 28.3\% (CI 17.0-44.8\%) at 5
years (Figure 1). The probability of anatomic failure was 0\% at 12
months, 1.4\% (CI 0.2-9.2\%) at 2 years, 3.1\% (CI 0.8-12.0\%) at 3
years, and 6.8\% (CI 2.0-22.0\%) at 5 years (Figure 2). The probability
of symptomatic failure was 0\% at 12 months, 1.3\% (CI 0.2-9.0\%) at 2
years, 2.9\% (CI 0.7-11.3\%) at 3 years, and 13.1\% (CI 5.3-30.3\%) at 5
years (Figure 3). The probability of retreatment was 0.8\% (CI
0.1-5.9\%) at 12 months and 2 years, 9.4\% (CI 4.2-20.3\%) at 3 years,
and 13.0\% (CI 6.0-27.2\%) at 5 years (Figure 4). A total of 7 patients
underwent surgical retreatment for prolapse, 3 patients had an anterior
and posterior colporrhaphy, 2 patients had only a posterior
colporrhaphy, 1 patient had posterior colporrhaphy with a sacrospinous
ligament fixation, and 1 patient had an anterior and posterior
colporrhaphy with a sacrospinous ligament fixation.

On follow-up, 7.7\% of patients had stage 0, 63.1\% had stage I, 28.5\%
had stage II, and 0.8\% had stage III prolapse. None had stage IV
prolapse. All POP-Q measurements except for total vaginal length were
significantly improved from baseline (P\textless{}0.001). In terms of
subjective outcomes, PFDI scores were significantly improved from
baseline (99.8, CI 86.7-112.9) to follow-up (52.3, CI 42.0-62.6;
P\textless{}0.001).

In terms of post-operative complications, 13.6\% of patients were
treated for post-operative infections other than urinary tract
infections. Of these, 6.1\% of patients had surgical site infections and
3.8\% had pneumonia. Rate of readmission within 30 days of surgery was
9.1\%. This included 5.3\% of patients readmitted with ileus or small
bowel obstruction (0.8\% requiring surgical intervention), and 1.5\% of
patients readmitted for pain. There were no patients with post-operative
venous thromboembolism and no other patient requiring reoperation within
30 days.

Postoperative voiding dysfunction was present in 4.5\% of patients
beyond the immediate postoperative period. The rate of overactive
bladder symptoms was 35.6\% post-operatively and 12.9\% received
medications. Although 32.6\% of all patients reported stress urinary
incontinence symptoms post-operatively, 10.6\% had positive cough stress
test, and 13.6\% underwent subsequent treatment for stress urinary
incontinence. The rate of subsequent mid-urethral slings was 5.3\%, the
rate of subsequent pubovaginal slings was 3.8\%, and the rate of
subsequent urethral bulking was 7.6\%, with 3.0\% of patients undergoing
both urethral bulking and mid-urethral slings. Overall 19.7\% of
patients received physical therapy post-operatively. No patients were
diagnosed or treated for incision site hernia.

\textbf{DISCUSSION}

\textbf{Main Findings}

We showed in a cohort of patients that sacrocolpopexy using autologous
rectus fascia was an effective treatment for pelvic organ prolapse with
subjective and objective outcomes that were sustained for up to three
years. PFDI scores remained decreased by almost half for patients with
over three years of follow-up. Over 63\% of patients had stage I or less
prolapse on exam at last follow-up. And only 5\% of patients underwent
reoperation for prolapse recurrence. In addition, the use of autologous
fascia eliminated the up to 10.5\% mesh complications noted in the CARE
trial follow-up.\textsuperscript{4}

\textbf{Interpretation}

The use of mesh for pelvic reconstructive surgery has come under intense
scrutiny over the last decade. Mesh complications have become an
increasing concern for patients. In 2008, the Food and Drug
Administration (FDA) issued a Public Health Notification regarding the
adverse events related to the use of surgical mesh in
urogynecology.\textsuperscript{2} In 2011, the FDA issued an update
noting that serious complications associated with surgical mesh for
transvaginal repair of prolapse is not
rare.\textsuperscript{2}Subsequently, in 2012, the FDA issued orders to
conduct post-market surveillance studies to address the safety and
effectiveness of transvaginal mesh prolapse repairs. In 2016, surgical
mesh for transvaginal prolapse repair was reclassified from Class II to
Class III. In 2017, all urogynecologic mesh was reclassified from Class
I to Class II. Finally, in 2019, vaginal mesh kits were removed from the
market.\textsuperscript{9} Although this did not include mesh used for
sacrocolpopexy and mid-urethral slings, studies have shown that the
rates of prolapse and incontinence surgeries using mesh have decreased
during this time.\textsuperscript{10}

A recent review of the available literature on autologous fascia
prolapse repairs showed that there have been only six case
series.\textsuperscript{7} Several series reported on the use of
pedicled rectus fascia flaps.\textsuperscript{11--13} One retrospective
study that included free rectus fascia graft compared outcomes between
mesh, Pelvicol xenograft, and autologous fascia for abdominal
sacrocolpopexy but only had 15 patients in the autologous fascia
group.\textsuperscript{8} The authors concluded that recurrence was more
likely with a Pelvicol graft but was equivalent for mesh and autologous
graft. Oliver et al. reported a series of 19 patients with excision of
sacrocolpopexy mesh with replacement of a free rectus fascia
graft.\textsuperscript{14} Seth et al. reported a case series of 7
patients who underwent autologous rectus fascia sacrocolpopexy and
sacrohysteropexy with free Y grafts. Mean follow-up was 16 months with
all patients having durable results at last
follow-up.\textsuperscript{7} Another alternative to mesh sacrocolpopexy
is allograft fascia. However, there have been studies that reported
significant early failure rates with sacrocolpopexy using allograft
fascia.\textsuperscript{15,16} Antigenicity, immune response, and
post-harvest preservation techniques are all factors that affect graft
remodeling and thus the success and function of an allograft, but that
do not negatively affect autologous fascia grafts.

This cohort provided subjective and objective outcome data on an
alternative to mesh sacrocolpopexy. To our knowledge, this was the
largest cohort available with long-term follow-up. Our low retreatment
rate for prolapse was consistent with those noted in studies using mesh
graft.~Our postoperative ileus or SBO rate was comparable to slightly
lower than that seen in the 2 year data from the CARE trial (5.3\% vs
6.8\%). In addition, the use of this autologous graft eliminated the
10.5\% complication rate of mesh erosion noted in the CARE
trial.\textsuperscript{4} One concern with harvesting autologous rectus
fascia is the risk of incisional hernias. In the~SISTer~trial, hernias
occurred in 1.2\% of patients who underwent a rectus
fascia~pubovaginal~sling~for treatment of
incontinence.\textsuperscript{17}~There were no cases of incisional
hernias in our cohort.~Mean length of stay in our cohort was 2.2 days
and this is a notable disadvantage of the procedure compared to
minimally invasive sacrocolpopexy with mesh grafts with a mean length of
stay less than 24 hours.\textsuperscript{18} Prolonged length of stay
has been associated with increased hospital-acquired infections,
decreased mobility and longer postoperative recovery
time.\textsuperscript{19,20} As such, there has been a trend across all
surgical specialties to develop protocols and techniques that aid in
shortening length of stay.\textsuperscript{21,22} The ongoing COVID-19
pandemic has further pushed this goal to decrease hospital exposures and
led to same-day discharge after pelvic reconstructive surgery with good
outcomes.\textsuperscript{23} The advent of ERAS programs have aided in
this goal. We did see a decrease in length of stay in patients that
underwent surgery after standardized ERAS protocols were initiated at
our hospital.

\textbf{Strengths and Limitations}

The strengths of our study include the prospective collection of primary
outcomes, the size of our population, and the duration of follow-up. We
included both subjective and objective outcome measures as either type
of outcome measure alone may not capture the patient's true experience
and quality of life after pelvic reconstructive surgery. PFDI-20 is a
validated measure of patient's pelvic floor symptoms, which we were able
to compare across time for each patient. We present the largest cohort
of patients who underwent sacrocolpopexy using autologous rectus fascia
in the literature and our results provide valuable information for
providers and patients seeking alternatives to mesh sacrocolpopexy. We
were able to recruit patients for follow-up assessment up to over 6
years from the time of surgery, which allowed us to analyze the outcomes
for patients who had at least 3 years of follow-up.

Our results are limited by the fact that some data are collected
retrospectively, the range of follow-up time, and single institution
data. Certain demographic and medical history data were collected
retrospectively and may be limited by the accuracy of medical records.
Patients chose their surgical treatment after extensive counseling and
there is likely to be selection bias. However, our study is targeted at
this group of patients, who did not desire mesh material in their
prolapse surgery, in order to provide long-term outcomes data for a
non-mesh alternative to sacrocolpopexy. Due to the wide range of years
during which this procedure was performed and in order to collect a
large cohort of patients, some patients did not have long-term follow-up
available. We were able to analyze the subgroup of patients who had
long-term follow-up, which demonstrated similar outcomes and supported
our main results. Because this study was conducted at a single
institution, our patient population may not be generalizable to other
regions or countries.

Although our results showed that sacrocolpopexy using autologous rectus
fascia resulted in significant prolapse improvements and low rates of
retreatment, our cohort was subject to selection bias as described. Our
findings support future research utilizing randomized controlled trials
to provide more robust evidence for sacrocolpopexy using autologous
rectus fascia for patients who desire a non-mesh alternative.

\textbf{CONCLUSION}

Sacrocolpopexy using autologous rectus fascia may be considered a safe
and effective alternative to synthetic mesh. Our results showed
significant improvements in objective and subjective outcomes that were
sustained over several years. Our results contribute significantly to
the evidence in the literature regarding autologous rectus fascia as an
alternative to mesh sacrocolpopexy.

\textbf{Contribution to Authorship:}

RW: data collection, data analysis, manuscript writing, manuscript
editing, final approval

KR: study design, data collection, manuscript writing, manuscript
editing, final approval

SB: data collection, manuscript editing, final approval

PT: study design, manuscript editing, final approval

\textbf{Funding:}

This study was funded through internal division research funds.

\textbf{Institutional Review:}

This study was reviewed and approved by the Hartford Hospital
Institutional Review Board. Initial approval date: 08/25/2014. Last
approval date: 04/24/2020.

\textbf{Acknowledgements}

The authors are thankful for the assistance in accommodating study
patients for office visits by the Hartford Hospital Urogynecology office
staff, and especially for Colleen Mellen, APRN, for her contribution to
performing a portion of the study visits.

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Figure 1. Kaplan-Meier curve for composite failure

Figure 2. Kaplan-Meier curve for anatomic failure

Figure 3. Kaplan-Meier curve for symptomatic failure

Figure 4. Kaplan-Meier curve for retreatment

Table 1. Characteristics of study population

Table 2. Composite failure, retreatment, anatomic failure, and
symptomatic failure outcomes

Table 3. Secondary subjective and objective outcomes

Table 4. Post-operative complications (N=132)\selectlanguage{english}
\begin{figure}[H]
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\includegraphics[width=0.70\columnwidth]{figures/Figure1-KM-composite/Figure1-KM-composite}

\end{center}
\end{figure}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/Figure2-KM-anatomic/Figure2-KM-anatomic}

\end{center}
\end{figure}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/Figure3-KM-symptomatic/Figure3-KM-symptomatic}

\end{center}
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\includegraphics[width=0.70\columnwidth]{figures/Figure4-KM-retreatment/Figure4-KM-retreatment}

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\textbf{Hosted file}

\verb`Table 1.docx`  available at \url{https://authorea.com/users/435817/articles/538579-sacrocolpopexy-using-autologous-rectus-fascia-cohort-study-of-long-term-outcomes-and-complications}

\textbf{Hosted file}

\verb`Table 2.docx`  available at \url{https://authorea.com/users/435817/articles/538579-sacrocolpopexy-using-autologous-rectus-fascia-cohort-study-of-long-term-outcomes-and-complications}

\textbf{Hosted file}

\verb`Table 3.docx`  available at \url{https://authorea.com/users/435817/articles/538579-sacrocolpopexy-using-autologous-rectus-fascia-cohort-study-of-long-term-outcomes-and-complications}

\textbf{Hosted file}

\verb`Table 4.docx`  available at \url{https://authorea.com/users/435817/articles/538579-sacrocolpopexy-using-autologous-rectus-fascia-cohort-study-of-long-term-outcomes-and-complications}

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