Pelvic Organ Prolapse Repair Using Mesh

Pelvic organ prolapse and urinary incontinence are common conditions affecting many adult women today. Pelvic organ prolapse is the abnormal descent or herniation of the pelvic organs from their normal attachment sites or their normal position in the pelvis. Pelvic floor defects are created as a result of childbirth and are caused by the stretching and tearing of the endopelvic fascia and the levator muscles and perineal body. Prolapse may also result from pelvic tumors, sacral nerve disorders, and diabetic neuropathy. Other medical conditions that may result in prolapse are those associated with increases in intra-abdominal pressure such as obesity, chronic pulmonary disease, smoking and constipation. Impaired nerve transmission to the muscles of the pelvic floor may predispose them to decreased tone, leading to further sagging and stretching. Voiding difficulties and urinary frequency, urgency, or incontinence are common symptoms associated with pelvic organ prolapse. If present, these symptoms should be investigated because advanced prolapse may contribute to lower urinary tract dysfunction. It has been estimated that the lifetime risk of requiring at least one operation to correct incontinence or prolapse is approximately eleven percent. The assessment of quality of life is helpful in determining appropriate treatment.

In recent years, several new procedures utilizing graft material to replace or augment "poor" paravaginal connective tissue have been used for patients with significant pelvic organ prolapse. Any natural or synthetic substance that incorporates or integrates into a patient's tissues during the treatment is defined as a biomaterial. The ideal compound should be inert, sterile, noncarcinogenic, mechanically durable and should cause no inflammatory or immunological response. Potentially, grafts can allow an effective transvaginal approach for the patient who has "very poor tissue" that could otherwise be repaired only with a vaginal narrowing or obliterative procedure or by a combined abdominal/vaginal procedure.

Follow up studies of less than two years show mixed results using these new graft procedures. All allograft and xenograft materials resorb with time; therefore, the long-term strength of the repair is dependent on the ability of the host's connective tissues to maintain strength after being incorporated into or encapsulated around the graft. Studies of various synthetic meshes used for a number of surgical repairs including abdominal hernia repairs and paravaginal procedures seem to indicate that low density monofilamentous polypropylene meshes have an infection and erosion rate much lower than high density meshes with multiple filaments.

Chronic pain may develop in the area of the mesh. Severe, adverse effects, such as mesh erosion into the bladder, development of fistulas, "band" formation in the vagina and bladder, and rectal dysfunction seem to be rare. These post operative problems could be reduced by using techniques to avoid tension on the graft material, by the avoidance of devascularization of the paravaginal tissue during dissection and by making sure that the graft is placed flat in the space to avoid bunching up. Thus far, anatomical successes with traditional procedures are considerably less than those reported with mesh procedures. With the exception of mesh erosions, the adverse effects which have occurred with mesh procedures have also occurred with the more traditional procedures. However, patient satisfaction with traditional procedures has been good. At this time there is not enough evidence to determine the long-term benefit/risk ratio for transvaginal "mesh" procedures. It is very difficult to answer the question whether mesh procedures have a better benefit/risk ratio than traditional procedures since no one traditional procedure is universally considered "gold standard" and there is no agreement as to which "mesh procedure" is best. Available data indicates that mesh procedures may produce anatomical success rates higher than traditional procedures when performed by surgeons who are experienced in prolapse repair procedures. On the other hand, the incidence of serious adverse effects may be higher with mesh procedures. Patients should be made aware of the potential complications and adverse effects and given all the options.

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