We read with interest the article by Larson et al, which states that the superior suspension points for anterior wall mesh operations are below the normal upper vagina. They imply that the limited ability to correct for apical support by these anterior mesh kits may explain operative failure.

Although we concur with the primary anatomic conclusions, we would like to challenge an important premise apparently underlying the research question. Specifically, we believe anterior mesh kits were never designed to offer apical support; on the contrary, at least in 1 instance with which we are very familiar, an anterior mesh kit was designed to treat residual or recurrent cystoceles that developed after sacrospinous-ligament fixations or sacrocolpopexies. We agree that the apex is often involved in high-grade cystoceles. In those patients it is essential to surgically address the involvement of the middle compartment appropriately. This was exemplified by our study in which 5 of 22 patients with an isolated anterior mesh underwent a concomitant sacrospinous-ligament fixation. Therefore, a total mesh kit, including the fixation point at the level of the sacrospinous ligaments, should have been considered in this magnetic resonance imaging study to examine apical support. It must also be noted that in total mesh kits, the mesh will overlay the vaginal apex at a level higher than these fixed points. Tissue ingrowth above the level of these fixed points will add to securing the vaginal apex in posthysterectomy patients.

Secondly, we would like to point out that the failure rates the authors refer to do not only relate to apical recurrences, as most failures after mesh repair systems seem to occur in the untreated compartment. van Raalte et al demonstrated apical recurrence after a specific mesh kit procedure in only 3.1% of patients. Many asymptomatic anatomical failures refer to “point Aa failures.” This term warrants an explanation. Anterior mesh kits do not address urethro-/trigonoceles when present. In these patients point Aa is the most dependent part of the vaginal wall and will therefore determine the value of point Ba. This will lead to anatomical failures (POP-Q, stage >1) despite the fact that these vaginas may demonstrate perfect midvaginal and apical support.

To conclude, we want to stress that midcompartment involvement of anterior prolapse warrants a total approach with fixation of the apex or cervix to the sacrospinous ligament using a posterior mesh or sacrospinous-ligament fixation and certainly not an anterior mesh repair only.