About one of every nine women in the United States will have surgery for a vaginal support defect (pelvic organ prolapse). Our armamentarium of surgical options for helping these patients now includes improved mesh designs and new synthetic mesh kits for transvaginal repair.
The development of synthetic mesh is important, as we have learned over the years that some women have visceral connective tissues (the connective tissues that support the vagina, bladder, and rectum) that are not strong enough to maintain a conventional surgical repair. We have learned, moreover, that surgical repairs utilizing the patient's native tissue too often do not last: Failure rates of 20%–50% have been reported.
Although it's still unclear what constitutes the “perfect mesh,” we have found that the use of a permanent, loosely woven polypropylene mesh can improve our operative results and significantly decrease the failure rates of our reparative vaginal surgery in women with vaginal support defects.
The failure of previous conventional reparative surgery for vaginal support defects is a clear indication for mesh. I operate on many patients who have recurrences of prolapse, and most of the time I use a permanent polypropylene mesh. For almost 4 years, I have been using the transvaginal Prolift systems for anterior, posterior, and total pelvic floor repair; other gynecologic surgeons favor different mesh kits that are currently available.
In October 2008, the Food and Drug Administration issued a Public Health Notification saying that it had received over 1,000 reports from surgical mesh manufacturers of complications associated with mesh devices that are used to repair pelvic organ prolapse and stress urinary incontinence. The warning lists the most frequent complications, such as erosion through vaginal epithelium, infection, pain, and urinary problems. However, the warning does not report which meshes were used—some meshes have been taken off the market—or provide a denominator of the number of total mesh placements.
The warning serves as a reminder of what gynecologic surgeons have advocated thus far: the need for significant experience in reparative vaginal surgery before using mesh implants. It is only in the last 10–15 years that gynecologic surgeons have acquired a detailed understanding of vaginal support anatomy, and of what happens to that anatomy to cause vaginal support defects.
To use mesh kits, the physician must both understand this anatomy and the variability in patients' connective tissues, and have experience in dissection techniques and the safe development of the proper dissection planes between the bladder and vagina, between the rectum and vagina, at the vaginal apex, and in the paravaginal and pararectal areas.
We must be able to dissect without causing undue bleeding or injury, and we must know how to minimize the exposure or erosion of mesh, which is usually through the vaginal wall. (Erosion of the mesh into the bladder or rectum is very rare.) Fortunately, we have access in the postgraduate arena to human cadaver courses that can give us valuable experience.
I have had very few complications in using mesh kits for pelvic floor repair, but I always tell patients that they have a 5% risk of infection, rejection of the mesh, or erosion or exposure of the mesh, as well as a 5%–10% chance of developing dyspareunia. I inform them, of course, that implantation of the mesh is permanent. And I always ask the patient to work with me in diagnosing or resolving any problem, complication, or unexpected outcome if it occurs.
Preparing for the Procedure
I use permanent polypropylene mesh for patients who have a recurring, symptomatic vaginal support defect. Even after the vagina is estrogenized, the vaginal wall in these patients is smooth and lacks the transverse ripples that are indicative, theoretically, of healthy connective tissue that could itself be used for repair.
The Prolift system that I use comprises precut nonabsorbable mesh implants (different precut implants for anterior, posterior, and total repairs) and a set of instruments (anatomical guides and retrieval devices with cannulas) to facilitate mesh placement.
The patient is placed in the dorsal lithotomy position, with her thighs at about 80 degrees to horizontal. She is not overly abducted, and her sacrum is well padded. I recommend using boot-type stirrups. A Foley catheter is inserted.
At 1 hour before anesthesia is administered, I give the patient a dose of prophylactic antibiotic. So far, I have not seen infection from mesh in any of the hundreds of Prolift procedures I've performed.
Anterior Prolapse Repair
The use of anatomical landmarks is critical to the mastery of dissection techniques.