The most common and proven mesh for vaginal surgery is type I polypropylene. It is inert, soft, and has a wide weave to allow tissue ingrowth and acceptance into body tissues. All others are inferior. Many comprehensive reviews of mesh are available and have been published, including my review article in Urology in 2005.
We know that mesh reinforced repairs significantly reduce recurrence rates for bladder lift surgery, but is it safe, should it be used, what complications can occur and how can they be minimized?
Surgeon experience and patient selection are of paramount importance. A doctor who has done 10 mesh cases a year is likely not going to be as proficient as one who does 100 a year, nor as comfortable taking care of complications when they arise. This is common sense. Is the patient’s health and body appropriate for mesh placement: this answer is often easily answered with good clinical judgment based on a history and physical, but there are issues than can exist that may weigh in on a decision, such as: overall health, diabetes, prior radiation or surgeries, immune disorders, etc.
Nothwithstanding mesh properties that either enable it to be incorporated into tissue or not, surgical technique alone can lead to complications. Bladder injury, bleeding, bowel perforation and wrong suture selection are uncommon but significant surgical issues that occur even in the best of hands. That is just how statistics fall out. 99 consecutive cases may go smoothly, but the 100th will have a complication. That is the nature of surgery and human error. That is the whole reason for informed patient consent. Complications can happen to anybody and they must be addressed promptly. Patients should not be embarrassed to question the doctor or bring to light an issue, and doctors should not think themselves perfect. Honesty is the best policy, and the sooner a complication is realized, the sooner it can be addressed.
The most common place vaginally-placed mesh can cause a complication is exposure in the vagina. The incision line may not heal well or promptly, and mesh will be seen or felt during sex. It can give the sense of pulling or tightness, or cause infection, discharge, blood or pain. An exam will readily make the diagnosis. Mesh exposure is not a new phenomenon, and it is well described. Rated can vary between 6 to 38 percent. The amount of mesh placed, how it is placed, the quality of vaginal tissue, type of suture used, dissection technique, patient activity during recovery, infection of the mesh and bleeding are all factors related to mesh exposure. Often, local excision, time and estrogen cream will fix this.
A fistula is a very rare complication of any surgery, including mesh surgery anywhere in the body, and the vagina is no different. It is so rare that it is often not clear if it’s related to the presence of mesh or an undetected injury at the time of surgery.
Pain with sex: Dyspareunia. This can occur with bladder drop and is itself an indication for surgery, but dyspareunia is a well-known complication of vaginal surgery even without mesh. Overtightening the vagina will lead to pain with penetration. Pain from mesh can occur if it folds or doesn’t lay flat, is too tight or conforms the wrong way around the vagina. Many studies exist on pain or resolution of pain after vaginal surgery with slings (TVT) or bladder lifts. The overall consensus in the literature is that mesh slings improve sexual function and not worsen it. Restoring vaginal anatomy with or without mesh reduces pain with sex, yet there are studies that show a low but significant number of women who have dyspareunia after mesh repair. Some cases are mixed with other vaginal surgeries, and so the true incidence is unknown. A detailed sexual history pre-operatively is important in determining the likelihood of this being a factor.
Mesh materials and patients' bodies change over time. Most biological meshes do not last and lead to recurrence. Synthetic meshes can shrink over time after being scared in. Menopause, weight gain or loss can affect the quality of mesh repair as well.
The FDA released an alert in October 2008 to physicians and patients about potential mesh complications for transvaginal surgery. Most reconstructive surgeons were well aware of these issues and so this was nothing new necessarily; however, it highlights the need for public awareness. Although excellent long-term data for TVT exists (10 to 13 yrs), we have at best five-year data for mesh and bladder repair. Refinement in technique, surgeon experience, product selection and patient appropriateness are all equal factors in successful management of pelvic organ prolapse.