Synthetic vaginal mesh has received a great deal of press of late, most of it negative. Is this justified? Is there a place for the use of synthetic mesh in the repair of pelvic organ prolapse? If you question most experts in the field I think the answer is, overwhelmingly, yes. I certainly think so. But it is not quite that simple. There are many related questions which much be asked and answered before one can reach a conclusion. The more important question from a patient’s perspective should be, “Is synthetic mesh right for me?”
I have always been a mesh minimalist. There are so many medical and surgical products introduced to the market, many of which have no benefit to the patient. I assess any new surgical product with a skeptical eye. Does the product add anything new, is it beneficial to patients, is it cost effective? These are all very important questions which should be answered affirmatively before I will consider incorporating a new product into my practice.
The issue with synthetic mesh goes much deeper and has many other variables. I do believe it provides a benefit to the right patient when placed by a qualified surgeon. The problem with mesh over the years has been multifactorial. You have had numerous companies jumping on the mesh bandwagon manufacturing “copy-cat” mesh kits and then trying to place them in the hands of every Dr. Tom, Dick or Harry with a pulse.
This is a major problem. Firstly, there are too many gynecologists who were never properly trained in basic “bread and butter” gynecologic surgery, never mind in the field of advanced pelvic reconstructive surgery. There are surgeons who, as their obstetric practices have died- off, have tried to reinvent themselves as pelvic reconstructive surgeons and are self-proclaimed experts in the field spending a great deal of money advertising themselves as such. Patients beware.
These procedures require specialized training and a real understanding of the pelvic anatomy. Not something many gynecologic residency programs offer. When synthetic mesh is placed in a patient by unqualified hands it can be very dangerous. It is under these circumstances that synthetic mesh began to find itself on the receiving end of bad press and the watchful eye of the FDA, and rightly so. However, when placed by a qualified surgeon in the right patient it provides a very nice option for patients suffering from symptomatic pelvic organ prolapse.
The key for me is to discuss the risks and benefits of each option with a patient and let them decide which option, given these risks and benefits, they feel is most appropriate for them. One of the greatest positives about using synthetic mesh in these repairs is…that it lasts forever; one of the biggest negatives…, it lasts forever. This long term durability is a strength and a weakness. This is why each individual patient must decide for themselves if the benefits outweigh the risks. If not, they may wish for their surgeon to use a biologic mesh whose material provides a “scaffolding” for their body to create new native support tissue. But if you were to return and biopsy the area, say 6 months later, there would be no evidence that the biologic mesh was ever there. Each scenario has its risks and benefits.
It is very important that a patient be counseled on her options and to let her decide which option is best for her with her physician’s assistance. Then, only a qualified pelvic surgeon should do the repair and place the mesh, whether biologic or synthetic or, perhaps, perform a repair with no mesh at all.
As I mentioned before, I have always been a mesh minimalist. When a patient decides that synthetic mesh would be best for her, I always prefer to use the least amount of synthetic material, placed in just the right place to achieve the desired support of the pelvic structures.
Every approach has it positives and negatives and any repair can eventually fail and the symptoms can return. But synthetic mesh does have something to offer patients who suffer from these conditions.
The American Urogynecologic Society, the leading non-profit organization dedicated to the treatment of pelvic floor disorders, recently published a very important position paper on the subject that is definitely worth a read, a link to which is provided here. Because of the environment that had developed with copy-cat companies and unqualified surgeons, this increased scrutiny was warranted, but not to the degree that a beneficial product should be completely removed from our surgical repertoire. Just remember: right product, right procedure, right patient, right surgeon. Do not settle for anything less.