To Mesh or Not to Mesh Part 2: Mesh and Stress Incontinence
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.
Stress incontinence is the unintentional loss of urine due to ‘stressors’ such as laughing, coughing, sneezing, or jumping on a trampoline (because your urethra doesn’t have proper support and ends up moving too much with activity). This movement does not allow for closure when you cough and sneeze, and therefore, a leak can occur.
What Are The Options for Incontinence?
Similar to prolapse, there are conservative and surgical options available. To avoid surgery, some women choose physical therapy to strengthen the pelvic floor. Others may prefer using an incontinence-specific pessary to help them when doing certain activities like exercise.
Surgically, there are quite a few options. The most common is a mid-urethral sling, which is considered our gold standard. It is a thin mesh tape that provides the support back to the area under the urethra. We do tend to use this procedure more often than other approaches because it has a 90% success rate and is a very quick day surgery that patients tend to recover from quickly.
Slings are overall quite safe with erosion rates of 1-2%. Other complications that can occur include difficulty emptying the bladder, which is most often temporary, and more rarely, damage to the bladder or blood vessels in the pelvis. Slings are outpatient procedures that are often very easy to recover from and have been shown to be more than 90% effective, even after 10 years or more.
Alternative options to slings may depend on the focus and expertise of your surgeon. Older procedures that do not utilize mesh are still viable and effective options. Burch Urethropexy suspends the urethra, attaching it to a strong ligament behind your pubic bone. This often requires a bikini line abdominal incision, but can also be done laparoscopically.
Rectus fascia slings are also used to correct stress incontinence. This procedure requires an abdominal incision to ‘harvest’ a piece of strong connective tissue from below the belly button and place that tissue in a similar manner to the mid-urethral sling. Both of these procedures have longer operative times and longer hospital stays, but outcomes can be comparable to a synthetic sling.
Lastly, there are materials that can be used to ‘bulk up’ the inside of the urethra near the opening to the bladder. This causes a small outlet from the bladder and therefore less leakage. The overall success of these procedures is less than those stated above.
So, which one is best for you? These are very individualized decisions that depend on your health, past surgeries, and preferences. Discussing all the options in detail with your physician will help guide you to your best choice.