THE USE OF MESH IN PELVIC ORGAN PROLAPSE SURGERY

THE USE OF MESH IN PELVIC ORGAN PROLAPSE SURGERY - TO USE OR NOT TO USE - THAT IS THE QUESTION.

Dr Christopher Chong
Obstetrician, Gynaecologist, Urogynaecologist
Chris Chong Women and Urogynae Centre, Gleneagles Hospital
Past International Board of Directors, IUGA
Urogynae Committee, AOFOG
Visiting Consultant, KK Women's and Children's Hospital
Chairman, O & G Committee, Medical Advisory Board, Mt. Alvernia Hospital
Singapore

The lifetime risk of pelvic organ prolapse has been assessed to be 11%, with a recurrence rate of 30% for moderate to severe prolapses. Anterior compartment and apical vaginal prolapses are the most difficult to treat. Pelvic organ prolapse is a problem of the aging population. Singapore is the fastest aging population in Asia. Life expectancy has gone up to 81 - 83 for women in Singapore. The incidence of pelvic organ prolapse, being associated more with the elderly, is thus expected to rise.

Surgical treatment for pelvic organ prolapse is aimed at restoring anatomy and preserving functions, including sexual function. This can be done via the abdominal ( open or laparoscopic ) or vaginal route. When pelvic organ prolapse is severe, the existing tissues of the patient are expected to be very weak. Re-using these weak tissues for support is likely to result in a high recurrence rate. It is with this in mind that meshes are developed to try to reduce recurrence rates without compromising on restoring anatomy or function.

There are many types of meshes developed, both synthetic and non-synthetic. Non-synthetic meshes such as fasia lata from autograft or allograft are difficult to come by and to harvest. Latest studies have ventured into injecting stem cells into meshes. Synthetic meshes have the problems of rejection, infection and erosion. The advancement is then to find the best synthetic mesh to use. These meshes are classified into different grades, grade 1 being those with the least infection, rejection and erosion rates.

It is also important that we reduce complication rates other than proper selection of the mesh. Gentamicin wash of the mesh and the operative site, and antibiotics during and after surgery have been used to reduce infection rates. The mesh should be laid loose. Vaginal skin should not be cut. The use of a vaginal pack for a day after surgery should be considered. Oestrogens before and after surgery, when the wound has healed, especially in severely atrophic vaginal epithelium has helped me to prevent erosions.

The question is whether meshes should be used. In Singapore, meshes are not used as a first line of treatment - they are reserved for severe prolapses and recurrent prolapses. Only Grade 1 meshes should be used. The success rate of the modified mesh Anterior Repair with prolene mesh, and more recently the Anterior Prolift procedure is about 94%, with low complication rates ( most commonly mesh erosion and voiding problems ).

Gone are the days when women should suffer pelvic organ prolapse in silence. We are working towards improving our success rates for severe prolapses, including using meshes for selected cases. Patients need to be educated, and doctors to be vigilant to prevent pelvic organ prolapse, failing which, it is very important to seek treatment early for better success rates.