Transvaginal mesh or grafts compared with native tissue repair for vaginal prolapse

Abstract

While transvaginal permanent mesh is associated with lower rates of awareness of prolapse, reoperation for prolapse, and prolapse on examination than native tissue repair, it is also associated with higher rates of reoperation for prolapse, stress urinary incontinence, or mesh exposure and higher rates of bladder injury at surgery and de novo stress urinary incontinence. The risk-benefit profile means that transvaginal mesh has limited utility in primary surgery. While it is possible that in women with higher risk of recurrence the benefits may outweigh the risks, there is currently no evidence to support this position.Limited evidence suggests that absorbable mesh may reduce rates of recurrent prolapse on examination compared to native tissue repair, but there was insufficient evidence on absorbable mesh for us to draw any conclusions for other outcomes. There was also insufficient evidence for us to draw any conclusions regarding biological grafts compared to native tissue repair.In 2011, many transvaginal permanent meshes were voluntarily withdrawn from the market, and the newer, lightweight transvaginal permanent meshes still available have not been evaluated within a RCT. In the meantime, these newer transvaginal meshes should be utilised under the discretion of the ethics committee.

Quality of Life, Sexuality, Anatomical Results and Side-effects of Implantation of an Alloplastic Mesh for Cystocele Correction at Follow-up after 36 Months

“…Well-known risks for all methods used for pelvic floor reconstruction include chronic pain, dyspareunia and recurrent prolapse [1,14,25]. These factors can significantly reduce the quality of life of affected patients even after surgery.…”

“…As the recurrence rate after conventional anterior colporrhaphy with autologous tissue is high [1,13], the aim is to improve the long-term stability of the pelvic floor through implantation of an alloplastic mesh. A Cochrane analysis of the data on alloplastic meshes in prolapse surgery showed significantly better results in terms of anatomical outcome [14]. But, particularly with 1st generation implants, a number of new adverse events occurred following the implantation of alloplastic meshes and included vaginal erosion, pain and dyspareunia [15].…”

Adverse events after first, single, mesh and non-mesh surgical procedures for stress urinary incontinence and pelvic organ prolapse in Scotland, 1997–2016: a population-based cohort study

“…(29) Currently available trials on surgical management of prolapse are generally small, of moderate quality at best, and provide information on short term outcomes only. (12,33) The available trial evidence suggests that vaginal mesh surgery for prolapse of the anterior compartment is more effective (in terms of objective repair of the compartment operated on) over the short term than similar non-mesh surgery, but is associated with a higher risk of subsequent development of prolapse of other compartments and/or incontinence. Contrary to the available trials, we find no evidence that mesh surgery for anterior or posterior compartment prolapse provided in routine clinical practice is more effective than non-mesh surgery over the longer term.…”

“…(10) Despite a number of randomised controlled trials investigating the use of mesh in female incontinence and prolapse surgery, there is a lack of evidence on outcomes in routine practice, particularly long term outcomes. (7,11,12) Transvaginal mesh surgery, particularly for prolapse, is currently controversial. Patient advocacy groups have raised concerns about poor long term outcomes.…”

Canadian Urological Association position statement on the use of transvaginal mesh

“…Although fewer women have symptomatic prolapse after transvaginal mesh repair compared to traditional repairs, the magnitude of this difference is small. 11 In addition, women have an over two-fold higher risk of additional surgery, primarily from the unique risk of mesh removal or revision. The treatment of these complications is often technically challenging and may not fully correct the associated symptoms.…”