Much has been said recently about complications associated with mesh used in pelvic prolapse repair, which can range from minor (mesh exposure to the vaginal wall) or severe (erosion into the viscera).
Researchers from Santiago, Chile sought to identify which patients undergoing mesh repair would be most likely to experience erosion or shrinkage. In their review, patients with the broad diagnosis of "dyslipidemia" were at higher risk of erosion and shrinkage, while surprisingly, postmenopausal patients had a lower risk.
At least two important caveats about these data must be noted. First, it is counterintuitive that postmenopausal women are less likely to have erosions, given current thinking that reducing estrogen thins the vaginal wall, raising the likelihood of erosion. It is not known whether the postmenopausal patients were receiving estrogen therapy, which could account for their lower erosion rate.
Second, study patients underwent prolapse repair from 2008-'09 using "PROLIFT-like" polypropylene mesh. In the U.S., such products are now used less commonly in favor of more lightweight mesh, including PROLIFT+M, which includes an absorbable monocryl component designed to improve comfort and minimize contracture.
In a second study, researchers from San Diego examined the difference in erosion rates among women who had a hysterectomy at the time of their mesh placement and those who did not undergo hysterectomy. Results showed a sixfold increased risk of erosion when total vaginal hysterectomy was performed at the time of robotic or standard laparoscopic sacrocolopexy. This finding validates that of previous studies showing that removing the uterus during prolapse repair compromises the vaginal wall, resulting in an increased erosion rate.
Interestingly, among those who had mesh erosion, just over half underwent additional surgery, while 26% opted for expectant management and the remainder were treated with vaginal estrogen. In the past, pelvic floor surgeons believed that all cases of mesh erosion required surgical repair. These data show that may not always be the case.
Our ability to predict mesh exposure and erosion is critical in minimizing these risks in patients undergoing prolapse repair. These two studies, while not providing definitive answers, move us in the right direction and provide building blocks for additional research..
Dr. Serels is head of the section of urogynecology at Norwalk Hospital, Norwalk, CT. He discloses that he is a lecturer/consultant for Boston Scientific.