Vaginal mesh for incontinence and/or prolapse: caution required!

From anatomy to patient experience in pelvic floor surgery: Mindlines, evidence, responsibility, and transvaginal mesh

Beginning in the late 1990s, surgeons around the world widely adopted the transvaginal placement of permanent synthetic mesh for the treatment of several common pelvic floor disorders in women. By 2012 it had become the subject of extensive litigation, including one of the biggest mass-tort cases in U.S. history, with litigants reporting debilitating and unexpected complications. Based on qualitative research that includes interviews with surgeons, observations of medical conferences, and analysis of archival materials, we argue the adoption of transvaginal mesh cannot be fully explained without recognizing the role of mindlines, or collective moral-epistemological ways of knowing and acting responsibly. The adoption of mesh was anchored in a mindline focused on repairing anatomy. The harms that resulted from transvaginal mesh necessitated a shift to a focus on patient experience. We analyze the role of evidence-based medicine (EBM) in the re-organization of these surgeons' mindlines, showing that mindlines are not reducible to evidence as defined by EBM and that evidence thus defined facilitated the adoption of transvaginal mesh.

Bioerosion of Synthetic Sling Explants

This study was performed to investigate the changes over time in polypropylene (PP) mesh explants from women with stress urinary incontinence originally treated with a midurethral PP sling. Following Institutional Review Board (IRB) approval, 10 PP explants removed for pain or obstructive symptoms between January and June 2016 were analyzed through various techniques to determine the degradation of the material in vivo. Exclusion criteria were exposed or infected mesh sling or sling in place for less than six months. One pristine control was studied for comparison. The explant samples were analyzed with scanning electron microscopy to visualize the surface defects as well as infrared spectroscopy and energy dispersive X-ray spectroscopy to determine if the degradation was oxidative in nature. The results show qualitative and quantitative bioerosion over the surface of the explant samples and an increase in the content of oxygen pointing toward oxidative degradation occurring in vivo.

Iatrogenic Pelvic Pain: Surgical and Mesh Complications

Female stress urinary incontinence and pelvic organ prolapse are prevalent conditions in adult women. Among treatment alternatives, more traditional methods of surgical intervention have been supplanted by synthetic polypropylene mesh kits. However, novel complications with mesh-related exposure, pelvic pain alone or with dyspareunia, and increased incidence of revision surgeries, resulted in 2 FDA warnings on transvaginal mesh use for prolapse repair. This review examines the anatomy of the vagina and urethra, the etiology of pain related to mesh use, and the relevant surgical techniques for management of this complication along with their outcomes.

Management of complications of mesh surgery

PURPOSE OF REVIEW

Transvaginal placements of synthetic mid-urethral slings and vaginal meshes have largely superseded traditional tissue repairs in the current era because of presumed efficacy and ease of implant with device 'kits'. The use of synthetic material has generated novel complications including mesh extrusion, pelvic and vaginal pain and mesh contraction. In this review, our aim is to discuss the management, surgical techniques and outcomes associated with mesh removal.

RECENT FINDINGS

Recent publications have seen an increase in presentation of these mesh-related complications, and reports from multiple tertiary centers have suggested that not all patients benefit from surgical intervention.

SUMMARY

Although the true incidence of mesh complications is unknown, recent publications can serve to guide physicians and inform patients of the surgical outcomes from mesh-related complications. In addition, the literature highlights the growing need for a registry to account for a more accurate reporting of these events and to counsel patients on the risk and benefits before proceeding with mesh surgeries.

[Stress incontinence in elderly women]

Stress incontinence is one of the major challenges in geriatric medicine. This is becoming more apparent in routine urology practice with the demographic changes in the population. A thorough diagnosis for a correct treatment of stress incontinence is as important in elderly women as it is in younger patients. This includes assessing the risk factors of incontinence and obesity, parturition, pelvic surgery and changes in hormone levels are risk factors usually found in elderly women. These are the main reasons why this patient group is most frequently affected. Treatment options do not differ significantly from these of younger women. Lifestyle modification, weight loss and supervised pelvic floor training are the mainstays of conservative therapy and surgical treatment should only be considered after these options have been exhausted. In these cases minimally invasive surgical techniques offer clear advantages especially for elderly often multimorbid women.

[Prolapse surgery. With abdominal or vaginal meshes?]

In prolapse surgery several surgical techniques are available. The different open, laparoscopic and vaginal approaches are distinguished by distinct success and relapse rates and operation-specific complications. A safe and optimal therapeutic pelvic floor surgery should be based on the three support levels according to DeLancy and be individually adjusted for every patient. The vaginal approach may be used for all kinds of female genital prolapse and is a comparatively less invasive technique with a short time of convalescence. Apart from stress incontinence there is no need for synthetic meshes in primary approaches and excellent results with low complication and relapse rates can be achieved. An uncritical application of synthetic material is to be avoided in vaginal repair at all times. Abdominal surgical techniques, both open and laparoscopic, present their strengths in the therapeutic approach to level 1 defects or stress incontinence. They provide excellent functional and anatomical corrections and low relapse rates. Abdominally inserted meshes have lower complication rates than vaginal ones.

Tensile properties of commonly used prolapse meshes

INTRODUCTION AND HYPOTHESIS

To improve our understanding of the differences in commonly used synthetic prolapse meshes, we compared four newer generation meshes to Gynecare PS using a tensile testing protocol. We hypothesize that the newer meshes have inferior biomechanical properties.

METHODS

Meshes were loaded to failure (n = 5 per group) generating load-elongation curves from which the stiffness, the load at failure, and the relative elongation were determined. Additional mesh samples (n = 3) underwent a cyclic loading protocol to measure permanent elongation in response to subfailure loading.

RESULTS

With the exception of Popmesh, which displayed uniform stiffness, other meshes were characterized by a bilinear behavior. Newer meshes were 70-90% less stiff than Gynecare (p < 0.05) and more readily deformed in response to uniaxial and cyclical loading (p < 0.001).

CONCLUSION

Relative to Gynecare, the newer generation of prolapse meshes were significantly less stiff, with irreversible deformation at significantly lower loads.