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Synthetic meshes in genital prolapse

 

Arruda, R. M;
Girão, M. J. B. C.;
Sartori, M. G. F
.
Department of Ginecology
UNIFESP-EPM

 

Genital prolapse is a common condition affecting nearly half of multiparous women1. In the United States, genital prolapse leads to more than 300,000 surgeries costing over 1 billion dollars/year2, 3.
Treatment is essentially surgical and aims at restoring anatomy and relieving symptoms, as well as retaining or restoring vesical, intestinal and sexual function4, 5.
Some studies have reported high recurrence rates with conventional surgery, especially in cases of anterior (24% - 32% within one year)6,7 and posterior (18% - 24% within one year)6,7 defects. Thus, the primary goal of using surgical mesh in prolapse repair is to reduce recurrence after conventional surgery8. However, it is important to point out that the efficacy of vaginal mesh surgery is still controversial, as the indication, method of insertion, and safety of these materials remain to be established4.
Meshes may be synthetic or biological. The major advantages of synthetic meshes include their lower cost, high availability, and lack of risk of disease transmission9.
Synthetic meshes are nontoxic and may be mono or multifilament, micro or macroporous. Depending on the material, they can be absorbable (e.g., polygalactin, polyglycolic acid), nonabsorbable (e.g, polypropylene) or mixed9. Several studies have demonstrated that the clinical outcomes observed using absorbable synthetic meshes were comparable to those of conventional surgery10,11.
Pore size is of paramount importance, as it has a direct influence on mesh flexibility, the migration of leukocytes and fibroblasts, angiogenesis and material biointegration11, 12, 13. Thus, pores larger than 75 µm, featured by monofilament meshes, allow the migration of leukocytes and fibroblasts reducing the risk of infection and increased fibrosis11, 12. On the other hand, multifilament meshes have pores smaller than 10 µm which allow the passage of bacteria, but do not admit leukocytes 11, 12. Synthetic meshes made of polypropylene are currently the most indicated for use in gynecology as they monofilament and macroporous, and offer good elasticity in all directions11, 14.
Meshes may be offered in precut form including needles for mesh insertion. In cases of anterior defect, insertion is done by the transobturatory route. For the repair of apical or posterior defects, the mesh is inserted into the ischiorectal fossa. The variety of techniques used is one of the factors that limit comparing the results reported in the literature.

 

Anterior defects
 

Anatomical success rates with the use of polypropylene meshes for the repair of the vaginal anterior wall range from 89.1% to 100% over follow up periods of 18 to 36 months 15,16,17.
The most widely used mesh fixation systems for anterior defect mesh repair include mesh placement without fixation, mesh fixation to the most lateral prevesical fascia, mesh fixation to the tendineous arch, or  transobturator fixation.
Some authors perform concomitant colporrhaphy, while others believe it is not necessary when meshes are used14,17,18.  In cases of stress urinary incontinence repair, it is preferable to have a separate incision made for the insertion of the sling following prolapse repair18.

 

Apical defects

 

Apical defects are caused by the weakening of uterosacral and cardinal ligaments. These structures have been defined as type I vaginal support by DeLancey19.  Clinical manifestations include uterine prolapse, enterocele or vaginal vault prolapse.
Sacrocolpofixation, either abdominal or laparoscopic, is the standard surgical procedure used for vaginal vault prolapse20. Infracoccigeal sacropexy is a less invasive alternative and, contrarily to sacrospinousl colpofixation, maintains the vaginal axis in its normal position and does not depend on vaginal length21.
When meshes are used, a needle is inserted through the perirectal space toward the sacrospinous ligament where the mesh is fixed. The aim of this technique is to create an artificial uterosacral ligament by adequately implanting a tension-free mesh to reinforce the rectovaginal fascia (“tension-free” principle)21. The mean distance of trocart along its course to the pudendal vessels and rectum is 2.8cm (2.1 - 3.4 cm) and 0.5 cm (0,2 - 0,9 cm)22.
Literature data are scarce and few are the prospective and randomized studies. However, according to some authors, polypropylene meshes provide anatomical success rates ranging from 91% to 97.2% over  follow ups of 3 to 43 months22, 23.

 

Posterior defects

 

In cases of posterior defects, meshes are used to replace the rectovaginal fascia for rectocele repair 21.
Just as in cases of anterior defects, there is no standard technique for the repair of posterior defects. Meshes may be either unfixed or fixed to the fascia or to the sacrospinous ligament 21, 24, 25. Anyway, the mesh should be extended to the perineal body for level III defects repair 19, 21. Those who prefer not to perform concomitant colporrhaphy claim that this kind of surgery increases the incidence of complications such as abcesses and dyspareunia25.
Reported anatomical success rates obtained with polypropylene meshes range from 92% to 100%, during 23 to 45 months of follow up25,26.

 

Complicatons

 

Erosion is one of the major complications associated with mesh application. Overall erosion incidence with polypropylene meshes ranges from  9% to 13%, but may reach 25% with Marlex®, also made of polypropylene but more rigid than the meshes currently available8,12,27. In a prospective study of 230 patients, DeTayrac et al28 suggested that the use of a polypropylene mesh coated with collagen, polyethyleneglycol and glycerol  may decrease the incidence of erosion and dyspareunia.
Most frequently, erosions occur three to six months after surgery, but may be seen one year after the procedure22,28. They are commonly found in the midline suture region22,25,28, and may be symptomatic or asymptomatic, detected only at physical examination .
Erosion symptoms depend on the organ affected. In the vagina, reported symptoms include discharge, dyspareunia and bleeding. In the urethra and bladder, erosions may cause miccional urgency, dysuria, difficult urination, urine retention, pain, hematuria and repeat urinary infections.  When present in the rectum, erosion can cause strong colics, tenesmus and blood in stool29. Recommended actions to decrease the risk of erosion include the use of topic estrogen postoperation, treatment of vaginal infections, intra- and postoperative use of antibiotics, tension-free placement of the mesh the deepest possible, use of few and small incisions25, 29. Concomitant hysterectomy increases the relative risk of erosion, probably due to vascularization involvement28. Thus, some authors recommend preserving the uterus, even in cases of severe prolapse29. The incidence of infections seems to relate to factors such as mesh type (most frequently with multifilament meshes), surgeon’s experience, mesh surface area and  patient-related factors such as diabetes22. Severe cases may develop into fistulae, abcesses and sepsis22,29.
The occurrence of dyspareunia after polypropylene mesh vaginal insertion is said to range from 7.7% to 52.4%14,25. DeTayrac et al.28 reported that 87.5% of the patients presented this symptom before surgery. In addition, 20% of the patients with no preoperative sexual activity, started having it with no dyspareunia after surgery28.
Polypropylene meshes commonly undergo a retraction of 20% to 30% in all diameters. When the mesh is cut too short, such a retraction may cause pain of variable intensity, and, in some cases, it is necessary to remove the mesh, which is not always easy29. Mesh removal 20 months after insertion has been reported25. Other complications include hematoma, rectal/urethal/vesical lesion, fecal incontinence, urine retention, pudendal neuralgia, miccional urgency, urge incontinence, perineal pain and recurrence12,22,28,29.
The use of meshes for genital prolapse repair is still controversial. There is, however, some consensus. The use of meshes in cases of recurrence or in patients with very fragile fascial support may be cited as examples. Mesh insertion as the first surgical option still requires scientific support. The best material, capable of reducing the risk of erosion or infection remains to be established.

       
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