Stephen T Jeffery. University of Cape Town, South Africa

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1 Stephen T Jeffery University of Cape Town, South Africa

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4 I still think there s a role for mesh in Prolapse surgery

5 Examples of my most recent mesh cases Case 1 62 yr old Sacrocolpopexy for vault prolapse 1 yr ago Rectal mesh erosion resulting in colostomy Presents with large vault prolapse point c =+ 10 Management = Anterior Single Incision Mesh

6 Examples of my most recent mesh cases Case 2 85 yr old Previous Vaginal Hyst and Repair. Presents with large vault prolapse mostly cystocele and vault Minimal posterior Management = Anterior Single Incision Mesh and Posterior Repair

7 Examples of my most recent mesh cases Case 3 62 yr old Operation 1: TAH and Marshall-Marchetti-Krantz Operation 2: Laparoscopic BSO Operation 3: Laparotomy for bowel obstruction Presents with large cystocele and vault prolapse Management = Anterior Single Incision Mesh

8 Plan for this talk 1 Look at the alternatives 2 Evidence for mesh use 3 Indications for vaginal mesh 4 How to do a safe mesh procedure 5 Managing complications

9 What are the alternatives? Mesh procedures should be viewed in context

10 Pelvic Organ Prolapse: Options? Vaginal Native Tissue Mesh Surgery Abdominal (Sacrocolpopexy) Open Laparoscopic Robotic

11 Native tissue surgery

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13 High Uterosacral Ligament Suspension VERSUS Sacrospinous Fixation

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16 ULS SSF Serious adverse events 16.5% 16.7% Neurologic pain 6.9% 12.5% Persistent Pain % Ureteric injury 3.2% 0% 0.5% ureteric injuries detected post op

17 Problems with Sacrocolpopexy

18 Laparoscopic sacrocolpopexy: The Learning Curve Lap SCP TAH Vag hyst Ovarian Cystectomy

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23 Bowel Injury Mortality Rate 3.6% Most litigations resulting in unfavourable outcome for the clinician were cases of delayed recognition of the injury Chapron C, Fauconnier A, Goffinet F et al. Laparoscopic surgery is not inherently dangerous for patients presenting with benign gynaecologic pathology. Results of a meta-analysis. Hum Reprod 2002; 17:

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28 So where does mesh really fit in?

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30 Re-operation for complications 1.9% 4.8% 7.2%

31 How do you define "most cases"?

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33 N=212 Main risk factor was advanced prolapse (Grade 4)

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36 Selecting a procedure is basically a balancing act

37 Selecting a procedure is basically a balancing act Sacrocolpopexy Bowel injury Ileus Osteomyelitis Bladder injury Longer anaesthesia

38 Selecting a procedure is basically a balancing act Vaginal native tissue/ mesh surgery Erosion Higher failure rate Vaginal pain Sexual dysfunction

39 Selecting a procedure is basically a balancing act Sacrocolpopexy Bowel injury Ileus Osteomyelitis Bladder injury Longer anaesthesia Vaginal native tissue/ mesh surgery Erosion Higher failure rate Vaginal pain Sexual dysfunction

40 How do I choose? Vaginal approach no mesh Primary surgery Primary recto/?enterocele < Grade 3 cystocele Procidentia I do sacrospinous fixation or Uterosacral ligament suspension

41 How do I choose? Vaginal approach with mesh Grade 3 and 4 cystocele (choose one with apical support) Vault in a patient who isn t suitable for sacrocolpopexy Recurrent cystocele

42 How do I choose? Sacrocolpopexy Shortened vagina Sexual function important All vault prolapse if possible (Young) healthy women

43 How to do it safely Rules for safe mesh placement 1 Only for high volume surgeons 2 Robust indications 3 Get proper consent 4 Make sure sacrocolpopexy or native tissue is not a better idea 5 Avoid posterior mesh 6 Choose an appropriate kit

44 High volume surgeons get better results

45 How to choose a mesh Single incision device Apical support Small size mesh? Lightweight mesh Full post-placement adjustability Avoid the trocar systems

46 New indications for mesh? Large hiatus GH+PB>10? Avulsion injury

47 Create the right expectation

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49 An important formula Expectation Disappointment = Reality

50 An unhappy patient Expectation Disappointment = Reality

51 An happy patient Expectation Disappointment = Reality

52 Dictum: Underpromise and overdeliver

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