Is transvaginal mesh procedure a potential measure for pelvic organ prolapse repair when performed by expert surgeons?

Abstract

The aim of this study was to verify the safety and efficacy of transvaginal mesh by analyzing the 2-year follow-up data of patients performed by a surgeon with a high volume of procedures. Methods: A total of 617 patients with pelvic organ prolapse underwent transvaginal mesh by a single surgeon. Complications and anatomical status of each patient were examined up to 24 months after surgery. Risk factors for the recurrence were also analyzed.Results: Regarding complications, we experienced 10 patients (3.8%) of bladder injuries in anterior transvaginal mesh and eight (3.4%) in anterior and posterior transvaginal mesh. Massive blood loss was observed in four patients, but there was no case of blood transfusion. Mesh exposures were seen in seven patients (1.2%). A total of 100 patients (16.2%) had prolapse recurrence, defined as the Pelvic Organ Prolapse Quantification System stage ≥II. As to recurrences on the operated compartments, we observed five patients (2.0%) for anterior transvaginal mesh, three (6.5%) for posterior transvaginal mesh, five (7.4%) for combined transvaginal mesh, and 31 (14.2%) in anterior and posterior transvaginal mesh. Regarding Point C before operation in the anterior and posterior transvaginal mesh, the recurrence rates were more than 23% in patients with a Point C of 4 or more. Binominal regression analyses showed that higher body mass index, younger age, and higher stage of uterine prolapse were significant risk factors. Conclusions: The transvaginal mesh surgery is safe when conducted by experts. However, the recurrence rate may exceed 20% for high-stage uterine prolapse even when conducted by experts.

Are anterior mesh arms necessary in Japanese‐style transvaginal mesh surgery for cystocele?

“…14 There was also a report by a surgeon almost identical to the present study, which showed an anatomical recurrence rate of 2% at 2 years postoperatively. 6 In this study, we used the transobturator two-arm mesh, which produced therapeutic effects equivalent to those previously reported with the transobturator four-arm mesh. Therefore, the anterior mesh arms may be omitted in Japanese-style TVM surgery.…”

“…Takeyama et al reported that in young patients with advanced cystocele and uterine prolapse who underwent TVM surgery with a transobturator four-arm mesh similar to the Prolift type, the rate of recurrence was significantly higher than in older patients. 6 Padoa et al reported that in 52.2% of patients who underwent robot-assisted sacrocolpopexy for advanced cystocele, prolapse recurred. 30 TVM-A2 may be suitable for such cases, but the results may be the same even with a different technique.…”

“…4 In Japan, Prolift-type TVM surgery with self-cut polypropylene mesh was introduced in 2005, has been uniquely developed 5 and is a safe and efficient procedure still performed to treat POP, with few mesh-related complications. 6,7 In Japanese-style TVM surgery, which is Prolifttype TVM surgery modified by Japanese surgeons, self-cut mesh is placed between the entire vaginal wall and the muscle layer of the urinary bladder with special needles necessary for the mesh arms to penetrate the firm tissue around the ischial spine (e.g., the site of adhesion of the sacrospinous ligament [SSL] to the ischial spine), the arcus tendinous fascia pelvis (in anterior TVM), and SSL (in posterior TVM). Unlike the procedures performed in Western countries, Japanese-style TVM surgery includes elaborate anchoring and extension of the mesh without wrinkles.…”

“…The four important anchoring points are firm tissue around both sides of the ischial spine, the center of the distal vaginal wall, and the uterine cervix. 5,6 The anterior mesh arms are designed to help the mesh expand only laterally; therefore, the anchoring of anterior mesh arms through the obturator foramen did not seem necessary. Broad paravesical dissection performed to insert the anterior mesh arms increases the risk for bladder injury, ureteral injury, blood loss, and voiding disorders.…”

“…However, TVM surgery with polypropylene mesh was discontinued in the United States by the US Food and Drug Administration because of a high number of mesh‐related complications and is no longer performed in most Western countries 4 . In Japan, Prolift‐type TVM surgery with self‐cut polypropylene mesh was introduced in 2005, has been uniquely developed 5 and is a safe and efficient procedure still performed to treat POP, with few mesh‐related complications 6,7 …”