What a mesh we're in!
Patients with pelvic organ prolapse present with varying symptom states. Treatment is guided by the patient’s degree of symptoms and functional defects. The recent controversy fueled by the trial lawyer escalation of FDA committee reports has left many confused as to appropriate treatment options for these patients.
Before providing my opinion on the use of mesh I want to stress that we offer non-surgical and surgical treatment for symptomatic pelvic organ prolapse with or without the use of mesh. The approach is individualized dependent upon the patient’s symptoms, anatomic defect, surgical history and the patient’s personal opinions.
With that said, I have used mesh for select patients for 15 years and have been very pleased with the results. In my opinion mesh augmented surgery has revolutionized the care of women with pelvic organ prolapse for the better. Of course, it certainly is not appropriate for every patient with pelvic organ prolapse. No procedure is for this matter. However for the many women suffering from debilitating symptoms as a result of prolapsing pelvic organs transvaginal mesh has been a lifeline. For every woman with a mesh complication there are 20 women who are extremely pleased and much better off than prior to surgery.
There is a huge discrepancy between what the FDA said and what trial lawyers would like you to believe. For the most part basically what the FDA said was that physicians placing mesh should be well trained, patients informed of the risks associated with mesh, and appropriate studies be performed on mesh products before coming to market. A huge part of the problem is that a few early mesh products were introduced into the market by a “fast track” FDA process rather than the longer and stricter FDA process.These resulted in the initial approval of poor mesh products.These have been removed from the market.In addition there were many surgeons with limited experience or training performing the procedures.Most of these have left the market as well with all of the controversy and legal exposure.
With the current mesh products and techniques, most of the complications listed with mesh augmented surgeries are not unique to mesh surgeries and can occur with procedures that are not augmented with mesh. The only complication listed that is unique to mesh augmented procedures is the risk of mesh erosion.There are some complications that are more common with mesh repairs such as chronic pelvic pain.
With proper placement of mesh, the erosion rate is less than 4%. The reoperation rate for recurrence of prolapse when mesh is not used for vaginal repairs is known to be 30-40%. More than 99% of mesh erosions are exposures in the vagina that can be treated in the office or with a same day surgical procedure.On the other hand, recurrence would require a complete redo of the surgery.
NOTE: In 2011, the FDA recommended that patients get more information about transvaginal mesh from their surgeon. Dr. Ashford has provided his answers to the FDA's recommended "questions to ask your surgeon about transvaginal mesh surgery". Click here to read.
Please don’t misunderstand. Severe complications have occurred when looking at the data worldwide. Mesh erosions into visceral organs like the bladder or rectum would be more complicated and difficult to correct. Thankfully these are extremely rare.
The bottom line is that every patient’s condition should be approached with an open minded and objective assessment of the problem and all the options available to correct the problem. Every option has potential risks and benefits. Providing patients open and objective information with all options will result in optimal care and patient satisfaction.
The first decade of the 21st century was a period of rapid evolution in the care of women with pelvic organ prolapse. Most of the issues that have occurred are a function of how rapidly this area of medicine has changed. Most gynecologists in practice at the start of this revolution had no history or training in the use of transvaginal mesh. Researchers and developers needed time to perfect better delivery systems. The mesh products utilized required closer inspection and thought. Changes such as larger pore sizes and lower mesh loads have dramatically impacted tissue ingrowth and decreased mesh exposures.
Without a doubt, placement of transvaginal mesh for pelvic organ prolapse should be used cautiously by experienced surgeons with extensive training in pelvic surgery. After more than 15 years experience with pelvic floor surgery and the use of mesh transvaginally, I’ve had the advantage of personally performing many surgeries. I’ve performed repairs with and without mesh, with sacrospinous ligament fixation, with site specific mesh repair, abdominal sacrocolpopexy, laparoscopic sacrocolpopexy and transvaginal mesh kit repairs. Every approach or procedure has a place and time. No two patients are the same and care must be individualized. No one surgical approach will fit all.
When needed, I am a believer in the use of transvaginal mesh. An unbiased view of the data supports using mesh in the appropriate patient. Moreover, I’ve seen it with my own eyes. The use of mesh provides good anatomic repair without narrowing or shortening of the vagina which is common with the old imbrication repairs that most gynecologists were taught.It provides an efficient, fast and complete repair for even the very elderly. It is durable and safe.It works.
Melvin Ashford, MD
Are you experiencing problems with transvaginal mesh?
Dr. Ashford accepts and welcomes patients who may be experiencing problems with mesh placed by other physicians. While mesh is great for the right patients, it is not right for all. Dr. Ashford has experience removing mesh when necessary.