As many people would be aware there is currently significant media coverage regarding vaginal prolapse, in particular the use of mesh for vaginal repair. It can be very difficult to navigate through the discussion and separate fact from fiction, and to remove emotion and hysteria from the argument. Unfortunately there is also a lack of understanding about what constitutes a mesh, and what surgeries may or may not be ok. So in an attempt to make it all a little clearer I thought I would give you my perspective.
Prolapse vs incontinence
Firstly, prolapse surgery is different to surgery for stress incontinence. Prolapse surgery aims to correct the protrusion into the vagina whereas incontinence surgery aims to stop bladder leakage in situations such as coughing, sneezing, jumping and running.
The most extensively researched treatment for stress incontinence is a minimally invasive procedure called a “mid-urethral sling”. Tens of thousands of women have had this procedure dating back nearly 20 years. It involves generally 3 small incisions, and a small tape (which is made of the same material as a mesh) is introduced to provide support under the bladder neck. Cure rates are very high and complication rates very low. The Cochrane Database (which is a collection of high quality independent reviews based on quality medical research) supports the use of mid urethral slings and in particular says that their safety profile is good. So basically this procedure should not be grouped with the use of mesh for prolapse.
I have personally performed many hundreds of these surgeries and continue to believe that as long as patient selection is appropriate that this is a safe and effective procedure.
“Native tissue” repair vs mesh repair
There has long been debate regarding what is the best way to treat prolapse as there are different surgical techniques available. Well before the arrival of mesh on the scene surgeons have argued how best to correct prolapse and how to try to prevent recurrence. Roughly 1 in 10 women in this country end up having a prolapse surgery in their lifetime - and unfortunately a further 1 in 10 will require a second operation.
I perform a particular type of repair called “site-specific surgery”. The concept behind this is that due to various risk factors (including childbirth, ageing, and later menopause) the supportive layers of tissue in the vagina become torn away from their normal attachments leading to prolapse. The surgery identifies this tissue and aims to reattach the tissue to its original place, therefore restoring normal vaginal anatomy. Permanent sutures are placed quite deep and underneath the vaginal skin, with the evidence in my own patients supporting better longer term cures using this technique compared with more traditional surgery. Preliminary data from over 500 cases done at OGB is currently being analysed and will be compared with traditional techniques and with mesh. My feeling from looking at this so far is that the failure rates will be much lower than those with mesh. Complication rates are also extremely low.
The issue regarding mesh repair is that it was originally introduced with not enough evidence to say that it is any better than no mesh. There was also no specific training required and no regulation of mesh use. Complication rates are higher and even re-operation rates for prolapse are higher in women who have had mesh surgery.
This is not to say that there is never a place for mesh surgery. I have performed about 100 vaginal mesh procedures but only after attending training specific to this operation, and with careful follow up. However, the current medico-legal climate makes it very difficult to argue that there is a place for vaginal mesh at the moment until more trials are carried out.
Abdominally placed mesh
For many years gynaecologists have been using mesh placed from above the vagina (rather than through the vagina) to correct prolapse of the top of the vagina. Again, the use of mesh in this type of surgery is not included in the current controversy.
This operation (sacral colpopexy) has a very high success rate but requires significant expertise to perform. I am able to perform this using a laparoscopic (keyhole) technique which allows patients to head home the day after the surgery. So if your prolapse is suitable for a repair using this technique the use of mesh is not part of the current media hype.
Dr Michael Bardsley
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