2 of Gynecologic Surgeons Systematic Review Group (SGS- SRG) issued two publications, “Clinical practice guidelines on vaginal graft use” [3] and “Graft use in transvaginal pelvic organ prolapse repair, a systematic review” by Sung et al. [4]. The objective of the former was to establish guidelines regarding the employment of synthetic grafts or native tissue repair in POP repair [3]. Weak evidence was found for the superiority of native tissue repair in anterior vaginal wall repair, when compared with biologic graft (4 trials). Weak evidence was also found for the superiority of native tissue repair in anterior vaginal wall repair, when compared with absorbable synthetic graft (2 trials) [3]. Moreover, weak evidence was found for nonabsorbable synthetic mesh improving anatomic outcomes of anterior vaginal wall repair, albeit with signiﬁcant tradeoﬀs in regard to the risk of adverse events (2 trials). Regarding the superiority of native tissue repair for posterior prolapse versus absorbable synthetic graft or biologic graft, evidence was also weak (3 trials). Finally, no comparative studies were found that addressed the use of biologic grafts in multiple compartment repair compared with native tissue repair; the use of absorbable synthetic graft in multiple compartment vaginal wall repair compared with native tissue repair, or the use of nonabsorbable synthetic graft in multiple compartment repair compared with native tissue repair [3]. In conclusion, the authors noted that while the data supporting a lower rate of prolapse recurrence in graft use is limited, physicians should nevertheless consider and communicate to patients the seemingly improved durability of the procedure in the face of potential adverse events [4]. Due to the insuﬃcient evidence, from a medical-legal point of view, the best course of action regarding the use of vaginal mesh in POP is a matter of debate. Some advocate that distinct informed consent be obtained for the use of vaginal mesh [5]. However, in a letter to the editor, Ann Weber states, “obtaining informed consent from patients for vaginal mesh placement during prolapse surgery cannot be achieved in light of the current dearth of data regarding risks and beneﬁts [6],” and suggests that such procedures be regarded as “experimental.” Despite the paucity of peer-reviewed studies on the use of vaginal mesh in pelvic ﬂoor prolapse repair, professional interest seems on the rise in recent years. A search of the PubMed database for the keywords “vaginal mesh” yields 118 articles published in 2009, 98 in 2010, and 53 as of July 2011, in all languages. These include randomized trials, basic science (e.g., ultrasound, histology, and animal models), case reports, retrospective series, guidelines, professional surveys, and reviews. The purpose of the current study was to evaluate the common practice of Israeli urogynecologists, and to evaluate trends in the practice of pelvic organ prolapse repair during the last two years. 2. Materials and Methods An electronic survey was mailed to all fellowship-trained urogynecologists aﬃliated with an academic institute in Obstetrics and Gynecology International Israel, in 2009 and again in 2011. The survey consisted of 7 Likert-scale score items and 3 open questions. Possible responses to the 7-point Likert-score questions ranged from “none of the time” to “all of the time.” Subjects included general mesh use; mesh use in light of comorbidity (diabetes, menopause, and stress urinary incontinence); and considerations of other factors (sexual activity, fertility). See The appendix for the full questionnaire. The open questions inquired about preferred type of surgery in three clinical sce- narios. Participants were instructed not to consider ﬁnancial factors in their decision making. Surveys were mailed back anonymously. 3. Statistical Analysis SPSS for Windows version 18 (SPSS, Inc., Chicago, IL) was used for data management and statistical analysis. The chi- square test was used for comparison between dependent groups of categorical variables. All tests were considered signiﬁcant at the .05 level. All tests were 2 sided. 4. Results The response rate of those who answered both in 2009 and 2011 was 68% (15/22). An increase in the number of urogynecologists who reported “frequently” or “almost always” using vaginal mesh for the repair of primary POP increased from 47 to 67%. Similarly, for recurrent POP, the number who would use vaginal mesh increased from 80 to 93%. For women older than 70 years, 60% of urogynecologists in 2009 compared with 33% in 2011 stated that they will rarely or never use meshes for POP repair. Regarding a case of a 55-year-old sexually active woman with uterine prolapse stage III, there was no change in the practice of the surveyed urogynecologists, with none of the participants choosing to perform abdominal or laparoscopic surgery, instead participants recommended vaginal hysterec- tomy and apical suspension with or without graft insertion. Regarding an 80-year-old healthy women with procidentia, only 13% chose to perform colpocleisis in 2009 compared with 47% in 2011 (P < 0.001). Finally, regarding the case of a 35-year-old patient with stage III uterine prolapse who desired to preserve fertility, 2 (13%) recommended Manchester surgery with the insertion of vaginal mesh in 2009 while 7 (47%) recommended the use of mesh in 2011, with only one of them recommending Manchester surgery (P < 0.001). 5. Discussion This survey shows an increasing trend in the use of vaginal mesh for pelvic organ prolapse (POP) repair by Israeli pelvic ﬂoor surgeons over the last two years. This was apparent for