To Mesh or Not To Mesh Part 1: Mesh and Prolapse
There is a common misperception since the fallout from the 2011 FDA warnings regarding polypropylene mesh products – that all mesh is very risky and can cause serious harm to a large percentage of patients. This change in public thinking and rampant reminder of mesh issues via legal advertisements and mailings has certainly changed the way that we, as Urogynecologists, counsel and treat patients.
In the mid-2000s, the medical device industry started developing mesh net systems that would, in theory, make our repairs of prolapse stronger. The FDA now requires the industry to prove that these devices are effective which has led to safer and softer meshes that minimize risk.
Why Do We Use Mesh?
There are two uses for mesh in pelvic floor surgery: prolapse and stress incontinence.
Prolapse is due to the relaxation and failure of the support system of the pelvic floor, which leads to a ‘bulge’ in the vagina (or sometimes outside). This can cause distress and discomfort and, sometimes, even bladder dysfunction.
What Are The Options?
There are many ways to alleviate the discomfort of prolapse, both surgical and non-surgical. Non-surgical options include placement of a pessary, which is a silicone device that acts as a barrier for the prolapse. There are different shapes and sizes that can be customized for each patient. For women who choose to use a pessary, this is a safe, alternative option to surgery.
There are two different kinds of prolapse surgery: native tissue repair and mesh augmented repair.
Native tissue simply means that we use your own muscles, connective tissue, and ligaments of the pelvic floor to repair the prolapse. There are several different ways to do native tissue repair, all of which have durable success rates. Some patients, however, may have a higher risk of recurrence of the prolapse, which leads to repairs involving biologic or synthetic mesh materials. The benefit of these repairs is relatively mild pain issues and, because the whole surgery is done vaginally, no abdominal incision.
Transvaginal mesh repairs, using the newer and lighter mesh products, have become much safer than the ones primarily used at the time of the FDA warnings. They generally utilize less mesh area, which leads to fewer issues with chronic pain or erosion of the mesh into the vaginal tissues. Research supports use of mesh for bladder support as well as support at the top of the vagina only; it may increase durability of the repair, leading to less recurrence of bulge. Transvaginal mesh procedures also are done vaginally rather than abdominally.
Mesh can be used abdominally as well to attach the vaginal walls to a very strong ligament near the bottom of the spine. This surgery requires either a large or several small abdominal incisions and may increase recovery time.
So, which is the best option? Compiling all of the data, that answer isn’t yet clear because there are many factors that go into a decision such as surgical approach. Discuss this in detail with your doctor and make the choice you think is right for you after all the options are presented.
Read more about mesh in To Mesh or Not to Mesh Part 2: Stress Incontinence and click here for an overview of transvaginal mesh.