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THE JOURNAL OF FEMALE
URINARY INCONTINENCE


Debate Forum
 
 
The Journal of Female Urinary Incontinence has opened this space so you can rid yourself of doubts and change ideas about controversial topics of female urinary incontinence.
In this edition we have we have Prof. Cássio Riccetto, Associate Professor from Universidade Estadual de Campinas - UNICAMPwho in a practical way broach:
 
"Is mesh repair necessary in all cases of vaginal anterior wall
prolapse repair?"
 
The high failure rate of pelvic floor fascial defect repair might be explained not only by the poor support provided by the pubocervical fascia and rectovaginal support, but also by the difficulty posed by anatomical reconstruction using classic techniques such as colporrhaphy, as described by Kelly, and myorrhaphy of anus elevators.
Following the successful application of synthetic materials in abdominal wall herniorraphy, several prostheses for the treatment of urogenital prolapse have recently appeared.  However, there are some potential problems in this simple approach: (a) vaginal elasticity, indispensable during sexual intercourse and labor, is not a common concern in abdominal herniorrhaphy; (b) the pressure applied by pelvic víscera on the vagina is often significantly lower that that is going to be supported by the abdominal mesh; and (c) the vaginal environment may frequently be colonized by the enteric flora, potentially pathogenic. Thus,  the high global efficacy rate of mesh use in herniorrhaphies is not likely to be observed in colporrhaphies.
On the other hand, there is no doubt that mesh application allows standardizing procedures and thus significantly contribute to the fast dissemination of knowledge on prolapse treatment. Moreover, it is a very helpful tool in borderline situations such as severe and recurrent prolapse, particularly in cases of pericervical ring defects (or vaginal vault prolapse), which represent real challenges to surgeons.
Thus, in face of all these questions and the lack of experimental models that can be easily reproduced, how should mesh use be approached?
Considering the knowledge available to date, it it our opinion that meshes should be judiciously used in cases of recurrent and severe prolapse in patients without high expectations of future sexual activity, and after careful guidance. Very often, the use of a mesh is decided during surgery, after the surgeon has dissected the structures and checked whether site-specific repair can be performed.
At the same time, both clinical and experimental studies with a prospective and randomized design should be conducted in order to provide, in a near future, evidence to support the surgeon’s decision and the patient’s welfare
.