MIPS Lecture @ UNUFU Meeting | 24-26 September 2015
Mesh or not Mesh for POP Surgery
Author: Dr Aslam Mansoor
Pelvi-perineology unit. University Hospital of Clermont-Ferrand. France
The first decade of this century has seen the rapid development of mesh reinforcement surgery for pelvic organ prolapse. The advent of TVT in late nineties and the good vaginal tolerance of polypropylene encouraged surgeons to put large meshes to treat POP vaginally. The description of TOT was followed by the description of trans–obturator arms fixation of meshes.Tension-free Vaginal Mesh (T.V.M) and the world-wide distribution of kits with the aim of simplifying surgical techniques, thus making it accessible to every surgeon.
This popularization of synthetic meshes in POP surgery was accompanied by a rapid rise in reports of mesh related complications, with vaginal wall erosion up to 25%, chronic pain, 5.5% and sexual problems up to 17% (1). Theses complications are often difficult to treat requiring further reconstructive surgeries. In July 2011, the FDA made a Safety Communication and Update on Serious complications associated with transvaginal placement of surgical mesh for POP. This led to a wave of class action litigation law suits raised against device manufacturers by patients who have suffered mesh complications. Several major manufacturers have withdrawn their products from the market.
The FDA alert pointed out
- lower rates of mesh complications when mesh is placed abdominally compared to transvaginally.
- no evidence that transvaginal apical or posterior repair with mesh provides any added benefit compared to traditional surgery without mesh
- transvaginal anterior repair with mesh augmentation may provide an anatomic benefit compared to traditional POP repair without mesh, this anatomic benefit may not result in better symptomatic results.
- the emergence of two major complications of mesh transvaginal surgery, vaginal erosion and mesh contraction ( shrinkage)
Mesh enthusiasm among surgeons as well as a high industrial lobbying led to a situation where a large number of mesh has been put for POP transvaginally and may explain the high rate of complications. One can also question about the quality of training of the surgeons who have been doing these mesh surgeries. Should mesh surgeries be reserved to surgeons specially trained in POP surgery?