Synthetic mesh is commonly used in surgery for female stress incontinence and pelvic organ prolapse. According to Canadian Institute of Health Information data for the year 2010, there were more than 25,000 procedures done for stress urinary incontinence and 93% of these were mid urethral tapes using synthetic mesh. During the same year, there were almost 5000 procedures done for pelvic organ prolapse and 29% of these used mesh.
Tension free vaginal tapes (mid urethral tapes) revolutionized the management of stress incontinence with their introduction in 1998. The use of synthetic mesh to support the urethra allowed a minimally invasive approach to surgery that could be performed under local anesthetic without hospital admission. Long term data suggests success rates between 77-90% with more than 10 year follow up after surgery and complications were rare. 1 Mid urethral tapes continue to be the gold standard for management of uncomplicated stress incontinence in women.
Surgery for pelvic organ prolapse is associated with high rates or recurrence. Synthetic mesh may be used abdominally (culposacropexy) or transvaginally to increase long term success in patients at higher risk of recurrent prolapse. In one study comparing standard anterior colphorrhaphy to mesh repair in 389 women, composite success rates were 34% for colphorrhaphy alone versus 60.8% for mesh repair.2
In 2011, the US Federal Drug Administration (FDA) issued a safety communication which indicated that serious complications associated with surgical mesh for transvaginal repair of pelvic organ prolapse are not rare. The total complication rate was considered 0.67% (1503/225,000 over 3 years 2008-2010) for pelvic organ prolapse repairs. The safety communication was not strictly pertaining to mesh for stress incontinence. Complication rates for mid urethral slings according to the FDA during the same period were 0.021%.
There are many types of synthetic mesh available commercially for vaginal surgery and also other clinical conditions such as abdominal hernia repair. Meshes used vaginally are generally wide pore polypropylene, however, there may be relevant differences. Meshes have been tested independently and found to have different tensile strength and permanent elongation after cyclic loading.3 These variables may impact on the long term effectiveness of surgery and also complication rates. Thus, when one considers which specific mesh is being used, it is important to consider clinical study results of the individual mesh and not group results of all meshes and assume equivalence.
Finally, it has been shown that surgeon experience significantly affects complication rates of pelvic organ prolapse repair using mesh. Vaginal mesh exposure rates varied between 2.9% and 15.6% in one series comparing experienced surgeons to clinical fellows in training.
Thus, the use of vaginal mesh for stress incontinence and pelvic organ prolapse continues to play a significant role in the successful management of these conditions. Risks associated with the use of mesh can be minimized by ensuring that surgeons are experienced, specific meshes are well tested before coming to market, and that mesh is used when the benefit outweighs the risk.
Lesley K. Carr MD, FRCSC, is a urologist at Sunnybrook Health Sciences Centre and an associate professor at the University of Toronto's Department of Surgery
Citations:
1. Eleven years prospective follow-up of the tension-free vaginal tape procedure for treatment of stress urinary incontinence. Nilsson CG, Palva K, et al. Int Urogynecol J DOI 10.1007/s00192-008-0666-z.
2. Anterior Colporrhaphy versus Transvaginal Mesh for Pelvic-Organ Prolapse. Altman D, Vayrynen T, et al. NEJM 2011; 364:19.
3. Tensile properties of five commonly used mid-urethral slings relative to the TVT. Moalli PA, Papas N, et al. Int Urogynecol J DOI 10.1007/s00192-007-0499-1.
4. Trocar-guided Mesh Compared with Conventional Vaginal Repair in Recurrent Prolapse. Withagen MI, Milai AL, et al. Obstet Gynecol 2011; 117:242-250.
