Stephen T Jeffery University of Cape Town, South Africa
I still think there s a role for mesh in Prolapse surgery
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
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
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
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
What are the alternatives? Mesh procedures should be viewed in context
Pelvic Organ Prolapse: Options? Vaginal Native Tissue Mesh Surgery Abdominal (Sacrocolpopexy) Open Laparoscopic Robotic
Native tissue surgery
High Uterosacral Ligament Suspension VERSUS Sacrospinous Fixation
ULS SSF Serious adverse events 16.5% 16.7% Neurologic pain 6.9% 12.5% Persistent Pain 0.5 4.3% Ureteric injury 3.2% 0% 0.5% ureteric injuries detected post op
Problems with Sacrocolpopexy
Laparoscopic sacrocolpopexy: The Learning Curve Lap SCP TAH Vag hyst Ovarian Cystectomy
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: 1334 1342.
So where does mesh really fit in?
Re-operation for complications 1.9% 4.8% 7.2%
How do you define "most cases"?
N=212 Main risk factor was advanced prolapse (Grade 4)
Selecting a procedure is basically a balancing act
Selecting a procedure is basically a balancing act Sacrocolpopexy Bowel injury Ileus Osteomyelitis Bladder injury Longer anaesthesia
Selecting a procedure is basically a balancing act Vaginal native tissue/ mesh surgery Erosion Higher failure rate Vaginal pain Sexual dysfunction
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
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
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
How do I choose? Sacrocolpopexy Shortened vagina Sexual function important All vault prolapse if possible (Young) healthy women
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
High volume surgeons get better results
How to choose a mesh Single incision device Apical support Small size mesh? Lightweight mesh Full post-placement adjustability Avoid the trocar systems
New indications for mesh? Large hiatus GH+PB>10? Avulsion injury
Create the right expectation
An important formula Expectation Disappointment = Reality
An unhappy patient Expectation Disappointment = Reality
An happy patient Expectation Disappointment = Reality
Dictum: Underpromise and overdeliver