The Controversy About Vaginally Implanted Mesh
By Marja Sprock, M.D.

Turn on your TV and you will hear ads to contact a lawyer if you have had an implant of vaginal mesh. Open the newspaper and you will read the latest FDA warning about vaginally implanted mesh. This might make you wonder why we even use those meshes. As with every story, there are two sides. As a urogynecologist and skilled vaginal surgeon, I use vaginally implanted meshes and will continue to do so when they give the best alternative for a patient's treatment. 

So why would a surgeon with all this threatening material coming out still insert vaginal meshes. The answer can be short, because there is an indication and advantage to using them in some patients.

A fact that gets often overlooked is that a mesh does not get inserted in a normally supported vagina with strong healthy tissue.

Meshes are, and if used correctly should only be used in severely prolapsed (descended from the normally supported position) vaginas. If the support is broken and the tissue is very weak, it has been proven by combining several studies, that the longevity of the repair is better with a mesh on the front wall of the vagina. Some of the problems cited in the July 13th   2011, FDA warning are excellent to be aware of, however are not only a problem with the vaginally placed mesh repairs, but also with non-mesh repairs.

The FDA reports complications with mesh repair as vaginal extrusion of mesh, erosion, sexual dysfunction, urinary tract injury, pain and other complications. It is essential to recognize that many of these complications are known to occur with and without mesh repair. And maybe even more importantly, mostly surgeries turn out to be “the best thing I ever did and wished I had done it years ago” event. A severely prolapsed vagina can cause debilitating problems, varying from being up the whole night to urinate, lower back pain, continuous pressure, and difficulty having a bowel movement or urinate, inability to have intercourse, recurrent urinary tract infections, and inability to exercise due to discomfort to keep on adding.

Any surgery, be it on your vagina, your nose, shoulder or knee, has risks. Mesh repair may improve long-term anatomic results of surgery as compared to non-mesh repairs for some prolapse, but the debate is out how good does a repair need to be for a patient to feel better. A lot of studies nowadays are focused on does the patient feel better and often the repair does not make the A+ mark. Meshes were introduced into vaginal surgery because of the high failure rate of conventional repairs, lowering the bar may make non-mesh repairs appear to be just as good, but what about long-term?

In all honesty I see a fair amount of patients in consultation who have undergone a repair without mesh, where such an extreme amount of tissue was removed that they will never be able to complain about sex with intercourse, since they have barely a vagina left. On a monthly basis I see more women with difficulty after a vaginal repair without mesh for an initial appointment than with. Obviously some women have been faced with significant problems after either repair, so choose your surgeon wisely. Surgeons require rigorous training of pelvic anatomy, mesh implantation techniques and recognizing which patient would and would not benefit from surgical repair and use of a mesh. Experienced high volume surgeons have persistently better outcomes in a wide array of specialties and surgeries.

Treatments for vaginal prolapse are numerous and vary from exercises to pessaries (intra-vaginal support devices) to surgery. Surgeries can be through the vagina or abdomen. The abdominal surgeries are mostly performed with a laparoscope or a robot. Treatment choice depends on the severity of the prolapse, the severity of bother and the age and mobility, as well as health and desire for sexual activity of the patient.

Example of one square inch of an open weave mesh pattern that is currently being used in some vaginal prolapse repairs

Meshes have improved significantly over the years. If your vaginal prolapse was repaired with a vaginally placed mesh and you are happy with your repair and have resumed all regular activities, you are in the majority.

For the people who have a bothersome prolapse and are considering repair, do your homework. a urogynecologist, especially one who has done advance fellowship training, has chosen this subject as one of their areas of expertise. I often get a laugh when I state “I fix vaginas for a living”; however it is an art that should be taken seriously.

Read the FDA safety communication and ask questions.  I have included a link to the FDA communication (click here) and a report that I and many other skilled surgeons have signed that lists our comments on the FDA report.  Click here for our reply. 

We use the AMS Elevate Prolapse Repair system. Click here for a brochure from AMS that talks about the prolapse problem and the Elevate solution.

My goal is an A+ repair and it depends on the patient and her tissue quality how I will attempt to achieve it. Sometimes we have to settle for a B and the patient is very pleased.

The future will tell us if A+ were wiser than B’s, let’s try to prevent the E’s and F’s though.

Marja Sprock, MD is a fellowship trained urogynecologist under David Richardson, MD at Henry Ford Hospital in Detroit. Her practice, Central Florida UroGynecology, is in Rockledge, FL.

Please call for an appointment at 321-806-3929, send us a note or visit us online at www.CFUroGyn.com.