Current situation of transvaginal mesh repair for pelvic organ prolapse

Safety and Efficacy of Vaginal Implants in Pelvic Organ Prolapse Surgery: A Meta-analysis of 161 536 Patients

CONTEXT

Among the many surgical treatments for pelvic organ prolapse (POP), better results can be achieved with the use of vaginal implants. However, owing to perceived complications, vaginal implant surgeries have been restricted or banned in many countries.

OBJECTIVE

To assess the real value of vaginal implants in POP surgery and compare the safety and efficacy of operations with and without implants.

EVIDENCE ACQUISITION

A systematic search was performed in three medical databases. Randomised controlled trials and observational studies comparing the safety and efficacy of vaginal POP surgery with implants versus native tissue were included. Safety outcomes were defined as different types of complications (functional and non-functional) and reoperations for complications. Efficacy outcomes were parameters of anatomical success and the rate of reoperations due to recurrence. A multivariate meta-analysis framework was used to estimate pooled odds ratios (ORs) with confidence intervals (CIs) with simultaneous control for study correlations and estimation of multiple correlated outcomes.

EVIDENCE SYNTHESIS

We included 50 comparative studies in the analysis. Rates of reoperation for complications (OR 2.15, 95% CI 1.20-3.87), vaginal erosion (OR 14.05, 95% CI 9.07-21.77), vaginal bleeding (OR 1.67, 95% CI 1.25-2.23), and de novo stress urinary incontinence (OR 1.44, 95% CI 1.18-1.75) were significantly higher in the implant group. Rates of anatomical success (OR 3.22, 95% CI 2.06-5.0) and reoperation for recurrence (OR 0.55, 95% CI 0.36-0.85) were superior in the implant group.

CONCLUSIONS

POP surgeries with vaginal implants are more effective than surgeries without implants, with acceptable complication rates. Therefore, the complete prohibition of implants for POP surgeries should be reconsidered.

PATIENT SUMMARY

We compared vaginal surgery with and without implants for repair of pelvic organ prolapse. Despite higher complication rates, vaginal implants provide better long-term results overall than surgery without implants.

Knowledge mapping and visualization analysis of pelvic organ prolapse repair with mesh from 2001 to 2021

Aims: In recent decades, extensive attention has been paid to the application of mesh to repair pelvic floor defects. However, a large body of related literature has not been system summarized. The purpose of this study is to summarize and visualize the literature on pelvic organ prolapse (POP) repair with mesh using bibliometrics. Methods: Medical literature regarding POP repair with mesh were searched and obtained in the Web of Science™ Core (WoSCC) database from 2001 to 2021. Microsoft Excel 2020, CiteSpace and VOSviewer were used to conduct the bibliometric and knowledge-map analysis. Results: In the past 20 years, a total of 2,550 articles and reviews have been published in 35 journals, and the published and cited results show a growing trend. Cosson M and International Urogynecology Journal were the authors and journals with the highest output, respectively. The United States, France and the United Kingdom are among the top three countries/organizations in relevant publications in worldwide. 584 key words in the literature are divided into 8 clusters, which are mainly related to prolapse type, risk factors, surgical methods, imaging, quality of life and bioengineering. Using clinical research and tissue engineering technology to reduce mesh complications is the current hot spot in this field. Conclusion: Reasonable application of mesh and avoiding mesh complications are still the most concerned topics in POP research. Although clinical research, surgical improvement, biological mesh and bioengineering technology have shown promising results, it is still urgent to carry out clinical transformation application research.

What a mesh! An Australian experience using national female continence surgery trends over 20 years

PURPOSE

To review the evolution of female continence surgical practice in Australia over the last 20 years and observe whether vaginal mesh controversies impacted these trends.

MATERIALS AND METHODS

From January 2000 to December 2019, medicare benefit schedule codes for female continence procedures were identified and extracted for: mesh sling, fascial sling, bulking agent, female urethral prosthesis, colposuspension, and removal of sling. Population-adjusted incidences per 100,000 persons were calculated using publicly available demographic data. Three discrete phases were defined over the study time frame for analysis: 2000-2006; 2006-2017, and 2017-2019. Interrupted time-series analyses were conducted to assess for impact on incidence at 2006 and 2017.

RESULTS

There were 119,832 continence procedures performed in Australia from 2000 to 2019, with the mid-urethral sling (MUS) the most common (72%). The majority of mesh (n = 63,668, 73%) and fascial sling (n = 1864, 70%) procedures were in women aged < 65 years. Rates of mesh-related procedures steeply declined after 2017 (initial change: -21 cases per 100,000; subsequent rate change: -12 per 100,000, p < 0.001). Non-mesh related/bulking agents increased from + 0.34 during 2006-2017 to + 2.1 per 100,000 after 2017 (p < 0.001). No significant change in mesh extraction was observed over 2006-2017 (+ 0.06 per 100,000, p = 0.192). There was a significant increase in mesh extraction procedures after 2017 (0.83 per 100,000, p < 0.001).

CONCLUSION

Worldwide, controversy surrounding vaginal mesh had a significant impact on Australian continence surgery trends. The most standout trends were observed after the 2017 Australian class-action lawsuit and Senate Inquiry.

Sacrospinous ligament suspension with transobturator mesh versus sacral colpopexy for genital prolapse

OBJECTIVE

To compare the safety and efficacy of abdominal sacral colpopexy and sacrospinous ligament suspension with the use of vaginal mesh for apical prolapse.

METHOD

This retrospective study was conducted from 2005 to 2012 and included 89 women with apical prolapse who underwent surgery. Assessments included pre- and postoperative Pelvic Organ Prolapse Quantification (POP-Q) stage. Rates of objective cure and immediate/late complications were compared.

RESULTS

In total, 41 of the 89 women underwent sacrospinous ligament suspension, and 48 of the women underwent abdominal sacral colpopexy. A total of 40.4% of the women had vault prolapse (p=0.9361). Most of them had no complications (93.2%) (p=0.9418). Approximately 30% of the women had late complications; local pain was the main symptom and was found only in women who underwent the abdominal procedure (25.6%) (p=0.001). Only the women who were submitted to the vaginal procedure had mesh exposure (18.4%). The objective success rate and the rate of anterior vaginal prolapse (p=0.2970) were similar for both techniques.

CONCLUSION

Sacrospinous ligament suspension was as effective and had a similar objective success rate as abdominal sacral colpopexy for the treatment of apical prolapse. Sacrospinous ligament suspension performed with the use of vaginal mesh in the anterior compartment was effective in preventing anterior vaginal prolapse after surgery.