Mesh Use in Pelvic Organ Prolapse
The use of meshes to repair pelvic organ prolapse has generated significant interest in the past few years among members of the medical community, the media, the general public, and of course the legal community. Ads from attorneys regarding mesh litigation are all over the internet and on television. Very few patients I see nowadays have not heard of surgical meshes. Most of those patients are appropriately concerned. Unfortunately, the subject is complex and requires a great deal more discussion than simply resorting to the statement “mesh is bad”. Yes, sometimes, without question, mesh is bad. Its use can sometimes lead to significant complications and distress on the part of the person in whom it was implanted. However, like many things in medicine and in life, it is neither purely bad nor a purely good. Like many things in medicine, it may result in excellent long term relief of symptoms or it may cause an array of unwanted and even disabling side effects. In other words, it is a double-edged sword.
Understanding a brief history of mesh may be helpful in understanding what circumstances may make its use acceptable and even desirable as well as what circumstances make it less appropriate or even ill-advised.
Historically, the use of mesh for surgical repairs began to augment hernia repairs, particularly those with a high likelihood of failure or recurrence. Much was learned about the biology of different types of mesh after it began being used for repair. Many areas of the body are potentially appropriate for non-biologic patches, including large arteries such as the aorta, or areas undergoing significant daily stresses, such as the abdominal wall. The use of permanent materials for repairs arises from the desire to make the repair last longer than a biologic material might allow. Since there has always been a relatively high failure rate for pelvic organ prolapse repairs, new approaches were sought to improve long-term success. Because pelvic organ prolapse occurs through a natural hernia in the pelvic floor support muscles, the idea of replacing the torn and damaged connective tissue or augmenting it through the use of a permanent graft material developed. Many types of synthetic meshes have been developed and tried for repair of pelvic floor defects. The only type in current use is the Type 1 (Amid classification) macroporous monofilament polypropylene mesh. The large pore size (macroporous) is designed to allow ingrowth of tissue and ability of cells in the immune system to pass through the holes in the mesh in order to reduce chronic infection risk and create a better bonding of tissue with graft. This material should be soft, lightweight, flexible, and able to bond well with tissue, lending support without weakening the tissue. When used to create an anti-incontinence sling, multiple worldwide studies have demonstrated long-term efficacy with a low rate of complications when used properly. If we review all of the studies published regarding this particular use of mesh, there is good evidence that it can be used safely with mostly good outcomes and low rates of serious complications. Despite the data, there is no doubt that as a synthetic implant it can lead to complications requiring further surgery and even sometimes permanent problems. It is one reason to consider other options prior to having a surgical treatment for stress incontinence (discussed in another blog).
Use of mesh in a transabdominal surgery to correct prolapse is also well-studied, and those studies demonstrate that it is very effective with low rates of mesh-related complications. Failure rates are reduced compared with biologic grafts and longterm success is high. Placing a specialized mesh implant through a small abdominal incision and then attaching it to the abdominal side of the vagina, without making incisions in the vagina, allows the graft to take hold with a greatly reduced risk of mesh eroding through into the vagina.
The recent FDA warning regarding the use of mesh in treating pelvic organ prolapse specifically identifies an increased risk with transvaginal placement of the mesh. In other words, when a mesh graft is placed via incisions made in the vaginal walls, and then closing the vaginal incisions over the mesh, there is an increased risk of mesh-related complications (approximately 18 per cent) with a failure rate that is nearly identical to the failure rate of repairs done transvaginally without mesh. What this means is that meshes placed through the vagina increase complication risks without significantly reducing failure risks.
To summarize the information, it is helpful to think of surgical mesh grafts for pelvic organ prolapse in this way: 1. The mesh sling used for urinary incontinence is well studied, has a low complication rate (5%) and low failure rate, allows for quick recovery in most cases, and has a low likelihood of causing difficulties urinating after placement. It is a reasonable option for many women seeking a surgical treatment for stress incontinence, but it is a synthetic material placed through the vagina.
2. Specialized mesh placed through the abdomen (via large or small incisions) to treat pelvic organ prolapse has a low failure rate, low complication rate (3%), and high success rate. It is currently the “gold standard” for pelvic organ prolapse repair, but it is still a synthetic material.
3. Mesh placed transvaginally to treat pelvic organ prolapse has not been shown to have a significantly lower longterm failure rate than transvaginal repairs performed without mesh, but the rate of mesh related complications appears to be relatively high (18%) when used in this way.
Other resources for information include The Cochrane Library (see link below)
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