Meshes : pro and con
The use of meshes has been debated for the last 15 years
What is a mesh
Pelvic floor descent can be considered as a mechanical problem caused by insufficiently solid support tissues or by a tear of the support tissue from its attachment to the bone. Hence it increases with age (wrinkles also are caused by a decrease in collagen quality) and after delivery.
a tear of the attachment to the bone is logically treated by reattachment : ie a site specific repair
a decrease in quality of the support tissue should be treated by reinforcement with a foreign substance ie a mesh
Which mesh ?
Many types of meshes exist. We should realize that this variety is mainly caused by commercial arguments and much less by scientific arguments.
It has become clear that the polypropylene meshes are the way to go, provided the pore size is large, and that light weight is better.
Organic meshes today should not be used unless experimentally.
Results are often slightly better with a mesh while recurrences are much less.
In addition a site specific repair cannot correct insufficient strength of the support tissues
drawback of meshes
The main concern is a mesh erosion : this occurs in 5 to 7% and can be very difficult to correct.
Other intra-abdominal complications as bowel obstructions can occur
When later another is intervention is needed the presence of a mesh will make this intervention much more difficult.
What to do and who should do it ?
In younger women with good quality of collagen a site specific repair is preferable
When the quality of collagen is less a mesh is preferable.
The main problem however is the skill of the surgeon : meshes apparently seem easy surgery and are performed by many.
Meshes require however a very skilled surgeon in order to minimize complications.
Obviously surgeons not skilled to do laparoscopic interventions, will not offer site specific repair and will overuse vaginal meshes.
Recent concern on the use of meshes and FDA recommendations
In the October 2012 newsletter of the Australian endoscopy society recent concerns on the use of meshes are discussed together with the FDA recommendations concerning training.
The key issue however is not addressed : the main problem are the surgeons not the meshes. FDA recommends obtaining knowledge and training in vaginal and vaginal mesh surgery.
- what is missing is that unless the surgeon is equally skilled in laparoscopic surgery and promontofixation, it is unlikely that a fair balance of vaginal versus laparoscopic surgery will be offered to the patient. In addition
- what is missing is that evidence of knowledge and training is limited to presence at meetings. The skills itself are never assessed. This is another nice example that videoregistration should be mandatory.