Pearls and Pitfalls of Mesh Surgery

Abstract

AbstractsObjectives This article attempts to offer balanced insight into the use of transvaginal mesh for pelvic organ prolapse especially in the light of the negative publicity in recent times. The role of transvaginal mesh has been in the limelight for a number of reasons and it is important to address this issue in an objective, fair, and balanced manner. The conventional approach to prolapse surgery has undergone a paradigm shift and the principles of mesh replacement surgery sharply contrast with many traditionally held beliefs. This has created a new set of challenges that has revealed a sharp division of opinion among specialists and sub-specialists alike. Conclusion The article is an attempt to explain how mesh surgery can be safely and efficiently performed in carefully selected cases and is based on the combined wisdom of some of the leading surgeons in the sub-specialty today.Keywords Reconstructive pelvic floor surgery Á Use of mesh Á Pearls and pitfalls Although the problem of urinary incontinence and pelvic organ prolapse has been recognized since antiquity, the first mention in the modern era of medicine was only in the midnineteenth century when Marion Sims first sought to establish the relationship of urology and gynecology. The life expectancy for women has almost doubled through the 20th century. With a significant increase in the post-menopausal female population, there is a growing demand for improved quality of life and management of pelvic floor dysfunction [1]. The surgery for pelvic organ prolapse has evolved over the past 200 years and continues to be influenced by dynamically changing concepts, involving not only newer approaches to the difficult problem of recurrent pelvic organ prolapse, but also a renewed understanding of pelvic floor anatomy.It is important that one's approach toward surgery for pelvic organ prolapse (POP) be dictated by patient symptoms. Indeed, operating on ''asymptomatic'' patients is best avoided because the only thing she will get post-operatively is ''symptoms'' [2,3]. Assessment of prolapse needs to done mindful of the day-to-day situations that aggravate it; for example, examining a woman after a bout of exercise. The dorsal or the lithotomy position may not reveal an enterocele, whereas a squatting or a semi-crouching position might be useful [4]. One should never hesitate to perform per rectal or bidigital examination which is not only useful in distinguishing between enteroceles and rectoceles, but also effectively evaluates damage to the perineal body. Investigation modalities like ultrasound, MRI, and defecation proctography are underutilized albeit extremely useful adjuncts in the pre-operative planning, especially for recurrent genital prolapse and often reveal