Obstetrics and Gynecology International to have insuﬃcient uterosacral or cardinal ligament strength at the time of vaginal hysterectomy [47]. Since Randall and Nichols’ 1971 publication, the pro- cedure has changed little [48, 49]. The most notable modiﬁcations have been related to instrumentation: the introduction of the Miya Hook [50], the Shutt needle driver [51], and the Laurus needle driver, presently known as the Capio (Boston Scientiﬁc, Natick, MA) [52]. Other reported surgical approaches to correct vault and advanced uterine prolapse include the iliococcygeus ﬁxation (ﬁrst described by Inmon) [53], endopelvic fascia ﬁxation [54, 55], coccygeous muscle ﬁxation [56], high uterosacral ligament suspension [57, 58], and levator myorrhaphy [59]. Thus, upon exiting the twentieth century, it had been the eﬀort and ingenuity of a multitude of accomplished surgeons, attempting to prevent and correct vaginal vault prolapse, which led to many of the surgical techniques presently used to correct advanced apical prolapse. Notably, of the surgeries established in the nineteenth century, only the LeFort colpocleisis has endured. 7. Quantifying Prolapse In October 1995, the International Continence Society formally adopted the document that would introduce the Pelvic Organ Prolapse Quantiﬁcation (POP-Q) to the larger gynecology community. This document, three years in the making, and validated in six centers in Europe and the United States, would replace Baden-Walker and other descriptive measures as the means to objectively report ﬁndings of pelvic organ prolapse [60]. Subsequently, the POP-Q has become the standard means by which to report pelvic organ prolapse in the international literature and has been increasingly embraced by physicians in their clinical practices [61]. However, the POP-Q is not without its potential confounders [62, 63]. Thus, both clinicians and clinical investigators have turned to the various imaging modalities that allow for in situ evaluation of the female pelvic organs and their supporting structures. Imaging pelvic ﬂoor anatomy can be traced back to Berglas and Rubin’s method of levator myography in which they injected radio-opaque dye into the levator ani muscles, vagina, and endocervix, revealing by X-ray that the vagina did not rest at a steep incline, but rather lie almost horizontal, parallel to the levator plate [64]. Since that time, both magnetic resonance imaging (MRI) and sonography have advanced notably to better visualize the pelvic ﬂoor. Hedvig Hricak ﬁrst described female pelvic anatomy by MRI in 1983 [65]; however, he was most concerned with its ability to diﬀerentiate benign versus malignant conditions involving the pelvic organs [66]. Yang and colleagues, in 1991, would introduce dynamic MRI. This would allow MR images to be taken during valsalva [67]. Further, 2D and 3D MRI has been used in research studies to evaluate levator ani status in women with and without pelvic ﬂoor disorders [68, 69]. The most recent advances in MRI technology, such as HASTE (half-Fourier-acquisition single shot turbo spin echo technology), FISP (fast imaging with steady-state free precession), and TSE (turbo spin-echo), allow for 5 the fast acquisition of images simultaneously in all three compartments (anterior, central, and posterior), making MRI a valuable option to aid in the evaluation of pelvic ﬂoor disorders, including prolapse. Already, MRI is replacing ﬂuoroscopy as the means to perform defecography studies in some institutions, and it continues to be evaluated in research protocols investigating its potential role in the clinical evaluation of pelvic organ prolapse [70]. Although MRI is fascinating technology, it has its ﬂaws: exams are performed in the supine position, it does not allow for patient biofeedback during imaging, it may not be tolerated well by some patients, and it is costly. As an alternative, sonography which has been utilized to aid in evaluating the urogynecologic patient since the mid- 1980s has the advantage of lower cost, relative ease of use, minimal patient discomfort, shorter study durations, and wide availability [71, 72]. The advent of 3D/4D sonographic imaging has improved the clinical utility of pelvic ﬂoor sonography, and the transperineal/translabial approach has made it more patient friendly. Dietz and colleagues have reported 3D/4D sonography to be more accurate than physical exam in detecting levator muscle injuries and that sonographic injuries to the levator muscles are associated with pelvic organ prolapse, including apical prolapse [73, 74]. Sonography has also been used to image vaginal mesh implants, as it is able to readily detect mesh size and position (as opposed to MRI or CT) [75]. 8. Apical Prolapse Surgery in the 21st Century Two major shifts have occurred in the surgical management of apical prolapse in current practice: the introduction of vaginal mesh and that of advanced endoscopic surgery. Graft use in pelvic reconstructive surgery can be traced back to the early 1900s [76]. In 1955, Moore and colleagues reported the use of tantalum mesh in the repair of cystoceles [77]. The concept that pelvic organ prolapse is a type of hernia, comparable to other fascial defects, made attractive the idea of replacing weakened fascia of the pelvic ﬂoor with a more reliable biologic or synthetic material. Over the inter- vening years, a number of auto-, allo-, and xenografts have been used with this intent in pelvic ﬂoor repairs. However, the success general surgeons achieved using polypropylene mesh in the correction of incisional hernias signiﬁcantly inﬂuenced the use of this mesh by pelvic ﬂoor surgeons (type I monoﬁlament, macroporous polypropylene mesh becoming the standard) [78]. Additionally, the success of the tension-free transvaginal tape (TVT) mid-urethral sling with its facility of use, clinical eﬀectiveness, and marketability as an all-inclusive “kit” demonstrated the potential for mesh to improve surgical outcomes and opened a mar- ket in women’s health care medical device manufacturers could exploit. In 2001, Petros introduced the infracoccygeal sacropexy (Intravaginal Slingplasty Tunneler, Tyco, USA) as a novel means to transvaginally correct vault prolapse using polypropylene mesh [79]. Petros’ mesh was multiﬁlament and complications due to perirectal abscesses and ﬁstula formation led to its removal from the market. However, since that time, a steady stream of mesh “kits” have been