Mesh Augmented Prolapse Repair

Mesh augmented repair is a surgical approach to treating pelvic organ prolapse that uses synthetic mesh to provide additional support to the pelvic organs. This method can offer durability and lower recurrence rates in certain cases of prolapse.

What is Mesh Augmented Repair?

Mesh augmented repair involves using a synthetic, lightweight polypropylene mesh to reinforce and support the pelvic organs. This approach aims to provide a stronger, more durable solution, particularly in cases where native tissue has already failed or is significantly weakened.

Why Consider Mesh Augmentation?

Dr. Stewart explains the rationale for using mesh:

“Sometimes we use mesh for prolapse repair because the tissue has already failed us once and we would like to use something more durable. Mesh works for this approach and it lasts forever. Failure rates are low because the mesh is durable.”

Types of Mesh Augmented Repairs

Given the 2019 FDA statement regarding transvaginal mesh for pelvic organ prolapse, the use of mesh in prolapse repair has become more limited. In Dr. Stewart’s practice, mesh is only used for one specific type of prolapse repair:

Sacrocolpopexy: This is an abdominal approach to treat apical prolapse (prolapse of the top of the vagina or uterus). It can be performed through:

• Open surgery
• Laparoscopic surgery
• Robotic-assisted laparoscopic surgery (Dr. Stewart’s preferred approach)

Sacrocolpopexy involves attaching a piece of mesh from the top of the vagina to a stable structure on the sacrum (tailbone area). This provides strong, durable support for the vaginal apex.

It’s crucial to note that as of 2019, the FDA has ordered manufacturers to stop selling mesh devices specifically for transvaginal repair of pelvic organ prolapse. This means that mesh is no longer used for direct vaginal repairs of cystoceles (bladder prolapse) or rectoceles (rectal prolapse).

Dr. Stewart trusts the science that led to the FDA’s decision and does not place mesh transvaginally. The decision to use mesh in a sacrocolpopexy is made carefully, considering each patient’s individual situation and after thorough discussion of the potential benefits and risks.

Benefits of Mesh Augmented Repair

1. Potentially lower recurrence rates of prolapse
2. Durable long-term support for pelvic organs
3. May be particularly beneficial in cases of recurrent prolapse

Potential Risks and Complications

While mesh offers durability, it also comes with specific risks. Dr. Stewart emphasizes:

“We use mesh because it’s durable. For that durability, though, we trade some risk. The biggest risk we worry about is that the mesh could work its way through the skin of the vagina. This is called exposure or erosion and happens 2-5% of the time.”

Other potential risks include:

• Pain or discomfort
• Infection
• Urinary problems
• Pain during intercourse
• Organ perforation (rare)

Minimizing Risks

Dr. Stewart recommends three primary ways to decrease the risk of mesh exposure:

1. “If you smoke, quit. If you don’t, then don’t start.”
2. “If you have or develop diabetes, maintain good control of your blood sugars.”
3. “Use topical vaginal estrogen to keep the skin of the vagina thick, stretchy, and flexible.”

FDA Considerations on Mesh Use

The FDA has provided important information regarding the use of surgical mesh for pelvic organ prolapse:

• As of 2019, mesh for transvaginal repair of POP is no longer sold in the United States.
• Mesh is currently only indicated for abdominal surgeries (open, conventional laparoscopic, or robotic-assisted laparoscopic sacrocolpopexy).
• The safety and effectiveness of abdominal placement of surgical mesh for apical POP repair are well established.
• Compared to traditional vaginal surgery without mesh, abdominal apical prolapse repair with mesh (sacral colpopexy) results in less recurrent prolapse.
• Abdominal POP surgery using mesh (sacral colpopexy) appears to result in lower rates of mesh complications compared to transvaginal POP surgery with mesh.

The Surgical Procedure

Mesh augmented repair is typically performed under general anesthesia. The specific approach (abdominal, laparoscopic, or robotic) will be determined based on your individual case. The procedure generally involves:

1. Making five small (8mm) incisions in the abdomen to access the pelvic area
2. Placing and securing the mesh to provide support to the prolapsed organs
3. Closing the incisions

Recovery and Aftercare

Recovery from mesh augmented repair is similar to other prolapse surgeries:

• Hospital stay is usually 0-1 day
• Full recovery takes about 6-8 weeks
• Pelvic rest (no intercourse or tampon use) is recommended for 6-8 weeks

Dr. Stewart advises a common-sense approach to post-operative activity: “If it hurts, don’t do it.”

Is Mesh Augmented Repair Right for You?

Mesh augmented repair might be a good option if:

• You have recurrent prolapse after previous native tissue repair
• You have significant weakening of pelvic floor tissues
• You understand and accept the potential risks associated with mesh use

Making an Informed Decision

The decision to use mesh in prolapse repair should be made after thorough discussion with your urogynecologist. They will help you understand the potential benefits and risks based on your individual situation, ensuring you can make an informed decision about your treatment.