How mesh became a four letter word

Evaluation of Benefits and Harms of Surgical Treatments for Post-radical Prostatectomy Urinary Incontinence: A Systematic Review and Meta-analysis

CONTEXT

No meta-analysis has comprehensively addressed both benefits and harms, or the certainty of evidence of the implantable continence devices used in men to treat postprostatectomy urinary incontinence (PPI).

OBJECTIVE

To evaluate the benefits and harms of surgical treatments for patients suffering from PPI and assess the certainty of evidence. The primary benefit was cure (one or fewer pad per day), and the primary harm was reoperations defined by surgical procedures following implantation.

EVIDENCE ACQUISITION

We perform a search of Medline, PubMed, Embase, Cochrane Library, and gray literature. We included observational studies addressing PPI surgical interventions if they involved cohorts of ≥50 participants. The Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach provided the framework for certainty of evidence assessment informed by value and preference judgments provided by patients, and an advocacy group member (Canadian Cancer Society).

EVIDENCE SYNTHESIS

Of 85 observational studies involving 13 100 patients, three addressed bulking agents, 35 male synthetic slings, ten adjustable continence therapies (ACTs), and 37 artificial urinary sphincters (AUSs). Cure was 26.1% (95% confidence interval [CI]: 10.6-51.4, I2 = 92.8%, very-low-quality evidence) for bulking agents, 58.6% (95% CI: 51.3-65.5, I2 = 89.1%, low-quality evidence) for slings, 63.2% (95% CI: 57.6-68.5, I2 = 22.5%, very-low-quality evidence) for ACT, and 74.0% (95% CI:61.2-83.7, I2 = 92.1%, very-low-quality evidence) for AUS. Estimated rates of reoperation were 5.8% (95% CI: 1.9-11.6, I2 = 94.1%, moderate-quality evidence) for slings, 23.8% (95% CI: 5.9-61.0, I2 = 95.5%, low-quality evidence) for ACT, and 22.2% (95% CI: 15.2-31.3, I2 = 92.3%, high-quality evidence) for AUS.

CONCLUSIONS

Available evidence regarding the benefits of surgical interventions for PPI remains mainly uncertain while suggesting important harms. These results should guide consent procedures for PPI surgery in the context of shared decision-making, with disclosure of the uncertainty of evidence.

PATIENT SUMMARY

Despite being used worldwide, available evidence regarding the benefits of surgeries to treat postprostatectomy urinary incontinence remains mainly uncertain while suggesting important harms. This highlights the need for a more rigorous evaluation process for commercially available surgical devices.

A modified Delphi process to establish research priorities in hernia surgery

BACKGROUND

Abdominal wall hernia repair is one of the most commonly performed surgical procedures worldwide, yet despite this, there remains a lack of high-quality evidence to support best management. The aim of the study was to use a modified Delphi process to determine future research priorities in this field.

METHODS

Stakeholders were invited by email, using British Hernia Society membership details or Twitter, to submit individual research questions via an online survey. In addition, questions obtained from a patient focus group (PFG) were collated to form Phase I. Two rounds of prioritization by stakeholders (phases II and III) were then completed to determine a final list of research questions. All questions were analyzed on an anonymized basis.

RESULTS

A total of 266 questions, 19 from the PFG, were submitted by 113 stakeholders in Phase I. Of these, 64 questions were taken forward for prioritization in Phase II, which was completed by 107 stakeholders. Following Phase II analysis, 97 stakeholders prioritized 36 questions in Phase III. This resulted in a final list of 14 research questions, 3 of which were from the PFG. Stakeholders included patients and healthcare professionals (consultant surgeons, trainee surgeons and other multidisciplinary members) from over 27 countries during the 3 phases.

CONCLUSION

The study has identified 14 key research priorities pertaining to abdominal wall hernia surgery. Uniquely, these priorities have been determined from participation by both healthcare professionals and patients. These priorities should now be addressed by well-designed, high-quality international collaborative research.

Laparoscopic removal of a synthetic retropubic mid-urethral sling (tension-free vaginal tape): step-by-step technique

INTRODUCTION AND HYPOTHESIS

The synthetic mid-urethral sling (MUS) has been the pre-eminent surgical treatment option for stress urinary incontinence (SUI) in women in recent times. However, increasing numbers of patients are now requesting mesh removal, secondary to persisting symptoms attributed to their sling. We present a video demonstrating a combined vaginal and laparoscopic approach to this procedure; along with supporting information outlining essential pre-operative assessment, counselling, and governance considerations.

METHODS

A 60-year-old woman presented with a 4-year history of pelvic pain. She ascribed this to her retropubic MUS (a tension-free vaginal tape). Following extensive work-up, the mesh was removed using the technique described.

RESULTS

On review, 3 months post-operatively, the patient reported improvement in the vaginal discomfort she had experienced prior to the procedure-albeit with concomitant deterioration in her SUI.

CONCLUSIONS

An open or laparoscopic approach can be employed to dissect out the retropubic arms of an MUS. The latter provides a superior view of the retropubic space and confers potential advantages regarding recovery and cosmesis. The surgical technique detailed is safe and effective, especially when augmented by thorough preparation and patient counselling.

Establishing the Queensland Pelvic Mesh Service: Preliminary experience

BACKGROUND

Transvaginal mesh (TVM) has been used for treatment of pelvic organ prolapse (POP) and stress urinary incontinence (SUI). Mesh-related complications are reported in 3% of women receiving mid-urethral sling surgery for SUI and in up to 20% of women who receive TVM for POP. The Australian Senate Enquiry report in March 2018 recommended that each Australian state establish specialist multidisciplinary units for management of TVM complications.

AIMS

The aims of this study are to report on the setting up of the Queensland Pelvic Mesh Service (QPMS) and summarise its first 24 months to provide a potential framework for the establishment of similar service models within Australia and internationally.

MATERIALS AND METHODS

The planning and implementation of QPMS was a complex two-stage co-design process involving clinicians and consumers representing women with TVM complications. Consumer input in planning was important for the optimal establishment of QPMS to meet women's holistic needs.

RESULTS

From April 2019 to April 2021, 484 women had been treated by the medical team; 257 women had undergone cystoscopy and examination under anaesthesia; 91 patients had undergone mesh revision surgery - 65 complete excision and 25 partial excision and one sling division; and 180 women had been discharged from QPMS.

CONCLUSIONS

Providing a comprehensive multidisciplinary service for managing TVM complications requires careful planning with consumer involvement before initiation. Addition of these patients to an existing service may not succeed. Emphasis on surgery may be misplaced for many. QPMS patients, as in sufferers with chronic pain conditions, benefit from psychological support and allied healthcare.

Variation in availability and use of surgical care for female urinary incontinence: a mixed-methods study

Background

Urinary incontinence affects between 25% and 45% of women. The availability and quality of services is variable and inequitable, but our understanding of the drivers is incomplete.

Objectives

The objectives of the study were to model patient, specialist clinician, primary and secondary care, and geographical factors associated with referral and surgery for urinary incontinence, and to explore women’s experiences of urinary incontinence and expectations of treatments.

Design

This was a mixed-methods study.

Setting

The setting was NHS England.

Participants

Data were collected from all women with a urinary incontinence diagnosis in primary care data, and all women undergoing mid-urethral mesh tape surgery for stress urinary incontinence were included. Interviews were also carried out with 28 women from four urogynaecology clinics who were deciding whether or not to have surgery, and surveys were completed by 245 members of the Royal College of Obstetricians and Gynaecologists with a specialist interest in urinary incontinence.

Data sources

The sources were patient-level data from Hospital Episode Statistics, the Clinical Practice Research Datalink and the Office for National Statistics mortality data linked to Hospital Episode Statistics. Interviews were conducted with women. An online vignette survey was conducted with members of the Royal College of Obstetricians and Gynaecologists.

Main outcome measures

The main outcome measures were the rates of referral from primary to secondary care and surgery after referral, the rates of stress urinary incontinence surgery by geographical area, the risk of mid-urethral mesh tape removal and reoperation after mid-urethral mesh tape insertion.

Results

Almost half (45.8%) of women with a new urinary incontinence diagnosis in primary care were referred to a urinary incontinence specialist: 59.5% of these referrals were within 30 days of diagnosis. In total, 14.2% of women referred to a specialist underwent a urinary incontinence procedure (94.5% of women underwent a stress urinary incontinence procedure and 5.5% underwent an urgency urinary incontinence procedure) during a follow-up period of up to 10 years. Not all women were equally likely to be referred or receive surgery. Both referral and surgery were less likely for older women, those who were obese and those from minority ethnic backgrounds. The stress urinary incontinence surgery rate was 40 procedures per 100,000 women per year, with substantial geographical variation. Among women undergoing mid-urethral mesh tape insertion for stress urinary incontinence, the 9-year mesh tape removal rate was 3.3%. Women’s decision-making about urinary incontinence surgery centred on perceptions of their urinary incontinence severity and the seriousness/risk of surgery. Women judged urinary incontinence severity in relation to their daily lives and other women’s experiences, rather than frequency or quantity of leakage, as is often recorded and used by clinicians. Five groups of UK gynaecologists could be distinguished who differed mainly in their average inclination to recommend surgery to hypothetical urinary incontinence patients. The gynaecologists’ recommendations were also influenced by urinary incontinence subtype and the patient’s history of previous surgery.

Limitations

The primary and secondary care data lacked information on the severity of urinary incontinence.

Conclusions

There was substantial variation in rates of referrals, surgery, and mesh tape removals, both geographically and between women of different ages and women from different ethnic backgrounds. The variation persisted after adjustment for factors that were likely to affect women’s preferences. Growing safety concerns over mid-urethral mesh tape surgery for stress urinary incontinence during the period from which the data are drawn are likely to have introduced more uncertainty to women’s and clinicians’ treatment decision-making.

Future work

Future work should capture outcomes relevant to women, including ongoing urinary incontinence and pain that is reported by women themselves, both before and after mesh and non-mesh procedures, as well as following conservative treatments. Future research should examine long-term patient-reported outcomes of treatment, including for women who do not seek further health care or surgery, and the extent to which urinary incontinence severity explains observed variation in referrals and surgery.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 9, No. 7. See the NIHR Journals Library website for further project information.

Five thousand years of minimal access surgery: 1990-present: organisational issues and the rise of the robots

The last 30 years have seen a revolution in the provision of minimal access surgery for many conditions, and technological advances are increasing exponentially. Many instruments are superseded by improved versions before the NHS and publicly funded health services can offer widespread coverage. Although we tend to think of minimal access surgery as a modern concept, Parts I and II of this series have shown that there is a 5000-year history to this specialty and our predecessors laid down many principles which still apply today. During the 19th and early 20th centuries, minimal access surgery was driven forward by visionary individuals, often in the face of opposition from colleagues and the medical establishment. However, in the last 30 years, innovation has been driven more in partnerships between healthcare, scientific, financial, educational and charitable organisations. There are far too many individuals involved to detail every contribution here, but this third part of the series will concentrate on some of the important themes in the development of minimal access surgery to its current status.

Long-term mesh complications and reoperation after laparoscopic mesh sacrohysteropexy: a cross-sectional study

INTRODUCTION AND HYPOTHESIS

The paucity of long-term safety and efficacy data to support laparoscopic mesh sacrohysteropexy is noteworthy given concerns about the use of polypropylene mesh in pelvic floor surgery. This study is aimed at determining the incidence of mesh-associated complications and reoperation following this procedure.

METHODS

This was a cross-sectional postal questionnaire study of women who underwent laparoscopic mesh sacrohysteropexy between 2010 and 2018. Potential participants were identified from surgical databases of five surgeons at two tertiary urogynaecology centres in the UK. The primary outcome was patient-reported mesh complication requiring removal of hysteropexy mesh. Secondary outcomes included other mesh-associated complications, reoperation rates and Patient Global Impression of Improvement (PGI-I) in prolapse symptoms. Descriptive statistics and Kaplan-Meier survival analyses were used.

RESULTS

Of 1,766 eligible participants, 1,121 women responded (response proportion 63.5%), at a median follow-up of 46 months. The incidence of mesh complications requiring removal of hysteropexy mesh was 0.4% (4 out of 1,121). The rate of chronic pain service use was 1.8%, and newly diagnosed systemic autoimmune disorders was 5.8%. The rate of reoperation for apical prolapse was 3.7%, and for any form of pelvic organ prolapse it was 13.6%. For PGI-I, 81.4% of patients were "much better" or "very much better".

CONCLUSIONS

Laparoscopic mesh sacrohysteropexy has a low incidence of reoperation for mesh complications and apical prolapse, and a high rate of patient-reported improvement in prolapse symptoms. With appropriate clinical governance measures, the procedure offers an alternative to vaginal hysterectomy with apical suspension. However, long-term comparative studies are still required.

Minimally invasive organ-preserving approaches in the management of mesh erosion after laparoscopic ventral mesh rectopexy

AIM

This is a systematic approach for minimally invasive methods in the management of mesh erosion after laparoscopic ventral mesh rectopexy.

METHODS

All patients managed with organ-preserving techniques for mesh erosion were identified from a prospective database and clinical records were reviewed. Each patient was contacted via telephone and a structured questionnaire was applied. A Likert score was used to assess patient symptoms and overall satisfaction with management. One or more of the following techniques were used: (i) transanal or transvaginal trimming/excision of exposed mesh and sutures, with or without using transanal endoscopic micro surgery or transanal minimally invasive surgery; (ii) laparoscopic pelvic assessment and detachment of mesh from the sacral promontory.

RESULTS

Eleven patients were managed for mesh erosion with organ-preserving techniques. All were women with a median age of 60 years [interquartile range (IQR) 53.5-68.5]. Vaginal, rectal, perineal erosion and recto-vaginal fistulation occurred in five, four, one and one patient respectively. Vaginal erosions presented at a median of 51 months (IQR 36-56) after index laparoscopic ventral mesh rectopexy compared to 17.5 months (IQR 14.5-27.25) for the rectal erosions. Median follow-up time was 24 months (IQR 19-49). Four of the meshes (36%) were removed completely whereas seven (63%) were partially removed. Vaginal erosions required a median of two procedures to achieve resolution as opposed to five for rectal. Out of 11 patients, eight were satisfied with the outcome of their management, whereas two were not and one remained ambivalent.

CONCLUSION

An organ-sparing minimally invasive approach is feasible in managing mesh erosions but requires multiple procedures and months to complete.

Making a decision about surgery for female urinary incontinence: a qualitative study of women's views

Introduction and hypothesis

This qualitative interview study explores aspects women with urinary incontinence(UI) reflect upon when considering whether or not to have surgery. Conducted prior to the recent mesh pause in the UK, the article provides insights for current and future approaches to shared decision-making.

Methods

Qualitative in-depth interviews of 28 patients referred to secondary care for stress and mixed UI who were considering UI surgery. Participants were recruited from four urogynaecology clinics in the Midlands and South England, UK. Interviews were conducted in clinics, in patient homes, and by telephone. Data analysis was based on the constant comparative method.

Results

Participants’ accounts comprised three key concerns: their experience of symptoms, the extent to which these impacted a variety of social roles and demands, and overcoming embarrassment. Accounts drew on individual circumstances, values, and concerns rather than objective or measurable criteria. In combination, these dimensions constituted a personal assessment of the severity of their UI and hence framed the extent to which women prioritized addressing their condition.

Conclusions

Acknowledging women’s personal accounts of UI shifts the concept of ‘severity’ beyond a medical definition to include what is important to patients themselves. Decision-making around elective surgery must endeavour to link medical information with women’s own experiences and personal criteria, which often change in priority over time. We propose that this research provides insight into how the controversy around the use of mesh in the UK emerged. This study also suggests ways in which facilitating shared decision-making should be conducted in future.

'What research was carried out on this vaginal mesh?' Health-related concerns in women following mesh-augmented prolapse surgery: a thematic analysis

OBJECTIVE

To understand health-related issues in women following mesh-augmented prolapse surgery.

DESIGN

Inductive thematic analysis of free-text comments from participants in a cross-sectional study of laparoscopic mesh sacrohysteropexy.

SETTING

Tertiary urogynaecology centres, United Kingdom.

POPULATION

Women who underwent laparoscopic mesh sacrohysteropexy by surgeons based at two tertiary urogynaecology centres between 2010 and 2018.

METHODS

A total of 1766 potential participants were contacted by post and invited to complete paper, online or telephone questionnaires containing a free-text comments section. Of 1121 participants (response proportion 63.5%), 752 (67.1%) provided such comments. These were analysed with a six-stage inductive thematic analysis, using NVivo 11® software.

MAIN OUTCOME MEASURES

Themes developed from free-text comments.

RESULTS

Following familiarisation, 29 codes and 189 sub-codes were identified. These defined six themes: pelvic floor symptoms, health status, treatment success, mesh, pain and care received. The majority of comments centred on the first of these six themes. There were concerns about mesh use and a desire for more information. A range of pain symptoms were mentioned, often associated with pelvic floor symptoms, prolapse surgery or mesh.

CONCLUSIONS

Despite the mesh controversy, pelvic floor symptoms and their impact on quality of life remain the principle concern of women following mesh-augmented prolapse surgery. There is a need for quality, accessible and evidence-based information sources for those women with concerns, and for those considering such surgery in the future, particularly regarding mesh safety and postoperative recovery. The relationships between pain, prolapse, mesh and pelvic floor surgery require further study.

TWEETABLE ABSTRACT

Following mesh-augmented prolapse surgery, pelvic floor symptoms remain women's main focus; pain deserves further research.

Transvaginal mesh, gender and the ethics of clinical innovation

On 10 October 2018, Australian Health Minister Greg Hunt issued a national apology to the Australian women who experienced 'horrific outcomes' following surgery using transvaginal mesh-acknowledging the 'historic agony and pain that has come from mesh implantation'. This apology followed many decades of 'innovative' use of transvaginal mesh for the treatment of pelvic organ prolapse. We use the case of transvaginal mesh to explore how clinical innovation may not only harm patients, but also entrench vulnerability and exacerbate existing inequities-in this case, those relating to gender.

Geographical variation in rates of surgical treatment for female stress urinary incontinence in England: a national cohort study

OBJECTIVE

To examine geographic variation in use of surgery for female stress urinary incontinence (SUI), mainly midurethral mesh tape insertions, in the English National Health Service (NHS).

DESIGN

National cohort study.

SETTING

NHS hospitals.

PARTICIPANTS

27 997 women aged 20 years or older who had a first SUI surgery in an English NHS Hospital between April 2013 and March 2016 and a diagnosis of SUI at the same time as the procedure.

METHODS

Multilevel Poisson regression was used to adjust for geographic differences in age, ethnicity, prevalence of long-term illness and socioeconomic deprivation.

PRIMARY OUTCOME MEASURE

Rate of surgery for SUI per 100 000 women/year at two geographic levels: Clinical Commissioning Group (CCG; n=209) and Sustainability and Transformation Partnership (STP; n=44).

RESULTS

The rate of surgery for SUI was 40 procedures per 100 000 women/year. Risk-adjusted rates ranged from 20 to 106 procedures per 100 000 women/year across CCGs and 24 to 69 procedures per 100 000 women/year across the STP areas. These regional differences were only partially explained by demographic characteristics as adjustment reduced variance of surgery rates by 16% among the CCGs and 35% among the STPs.

CONCLUSIONS

Substantial geographic variation exists in the use of surgery for female SUI in the English NHS, suggesting that women in some areas are more likely to be treated compared with women with the same condition in other areas. The variation reflects differences in how national guidelines are being interpreted in the context of the ongoing debate about the safety of SUI surgery.

In support of mesh for hernia repair

Strong case