Should surgeons continue to implant mesh sheets behind the vagina?

Can surgical reconstruction of vaginal and ligamentous laxity cure overactive bladder symptoms in women with pelvic organ prolapse?

“…The anatomical recurrence (failure) rates in the anterior/ apical and the posterior/apical study [23,24] of 22.4% and 23.4%, respectively, can be responsible for failure of symptom cure but also for the observed recurrence of symptoms. Petros et al [33] recently argued that mesh surgery can produce 'tethered vagina syndrome', which can also be associated with urgency symptoms; however, the specific symptom in patients with this syndrome 'immediate urine loss when standing up' was not addressed in that study. This failure of 'Elevate' surgery, coinciding with a return of or lowered cure rate for OAB symptoms, provides further evidence that OAB and POP are related and is entirely consistent with the predictions and explanation of the 'integral theory'.…”

Re: The mess of mesh

“…Few who write about the MUS or mesh sheets for prolapse have ever read the original papers on which this technology is based: the differential role of ligaments (structure) and vagina (function), why tapes (which provoke collagen formation) are required to reinforce damaged ligaments (collagen leaches out of the ligaments after the menopause), why the vagina needs to be preserved during surgery (it transmits the muscle forces which close the urethra on effort and open it for micturition [Figure ] and why vaginal scarring from mesh sheets can contract to cause severe pelvic pain can be explained by ‘like the intestine, the vagina has an autonomic nerve innervation and crushing or stretching may cause severe pain’ . How the massive urine loss sometimes seen after mesh implantation can be explained by scarring which ‘tethers’ the muscle forces (arrows, Figure ) so the urethra is forcibly pulled open by the stronger posterior vectors; why treatment is by skin graft, not MUS, which will make it worse – all addressed in a 2018 editorial which also described how ligament only repair (no vaginal excision) can achieve 90% cure rates for pelvic organ prolapse (POP) – high symptom cure with low tape erosion rates . Some questions raised by Dr Chien are addressed anatomically below.…”

“…Dr Chien correctly requests ‘more robust evidence’. Studying the functional anatomy, how implanted tapes create neoligaments, ligament‐only surgery for prolapse, and pathogenesis of de novo symptoms may assist that quest.…”