Transvaginal mesh repair of pelvic organ prolapse

What is transvaginal mesh?

This refers to transvaginal implantation of surgical mesh to repair areas of tissue damage /weakness which cause pelvic organ prolapse (POP). The  premise for transvaginal mesh repair comes from the excellent surgical outcomes where mesh has been used to treat abdonimal wall hernia (since 1950s),  abdominal repair of  POP (since 1970s), and urinary stress incontinence (since late 1990's). The aim of transvaginal mesh is therefore to increase the longevity of pelvic organ prolapse repairs.

How does transvaginal mesh work?

Through small incision in the vaginal wall, surgical mesh is carefully implanted into spaces /compartments in the pelvis using specially designed instruments.  The mesh is held in place by sutures or tissue fixation devices to pre-determined points in the pelvic floor muscles and ligaments. In time, cells grow into the pores of the mesh to create a sling or hammock support system thus restoring normal anatomy.

How is transvaginal mesh different from traditional non-mesh repairs?

In traditional non-mesh repairs, the torn or damaged connective tissue is brought back together by absorbable suture materials. The strength of non-mesh repair relies entirely on the quality of the individual's own scar tissue formation.  The variable success of traditional non-mesh repairs, compared with the consistently excellent outcomes of surgical mesh repairs in inguinal and incisional herniae, and the continuing refinement of mesh for transvaginal works, have encouraged surgeons and researchers to look for ways to improve the long-term results of pelvic floor repair in recent years.

What types of surgical mesh are available for treatment of pelvic organ prolapse?

There are many different types of surgical mesh. However, they can be broadly divided into 4 groups: (1) non-absorbable synthetic (e.g. polypropylene), (2) absorbable synthetic (e.g. polyglycolic acid), (3) biologic (e.g. acellular collagen derived from bovine or porcine sources), (4) composite (e.g. a combination of absorbale and non-absorable).

Where in the pevis have transvaginal mesh been used?

Transvaginal mesh has been implanted into (1) the anterior vaginal wall to repair the anatomical defects which cause cystocoele (bladder hernia), (2) into the posterior vaginal wall to repair the anatomical defects which cause rectocoele (rectal hernia),  (3) into the top of the vagina  to re-inforce the anatomical defects which cause uterine prolapse or enterocoele (small bowel).

Are the benefits of transvaginal mesh repairs proven?

To date,  there is no conclusive evidence that using transvaginally implanted surgical mesh improves clinical outcomes compared to tradtional non-mesh repairs. There is also a lack of good-quality research and long-term data to confirm or refute the medium to long-term benefits of transvaginal mesh. However, our CARE data,  and the published evidence  available to date, point to the following findings:

  • transvaginal mesh augmentation to the anterior vaginal wall does seem to result in superior anatomical outcomes. However, this does not necessarily mean superior symptomatic or functional (sexual or bladder) outcomes  
  • transvaginal mesh augmentation to apical or posterior vaginal walls does not appear to produce any added benefit compared to traditional non-mesh repair
  • abdominal or laparoscopic mesh repair offers superior anatomical outcomes than traditional non-mesh and mesh repairs to the vaginal apex or uterus
What are the risks of transvaginal mesh repair?

No repair surgical procedure is risk-free and this is true of transvaginal mesh repair. Experience to date indicates that major complications are uncommon. General risks of pelvic organ prolapse surgery may include injury to bladder, bowel, blood vessels and nerves of the pelvis, tender scars, painful intercourse. Additional risks associated with transvaginal mesh include mesh erosion, extrusion, inflammation, infection. Mesh complications may impair patient's quality of life and may require additional, at times multiple surgeries.  Complete removal may rarely be unsuccessful and may not result in complete resolution of pain.

Recommendations regarding transvaginal mesh repair surgery?

As every individual patient has different types of pelvic floor defects, different tissue quality, different health status, different expectations, you should consult with a gynaecologist who has extensive experience in a whole range of non-surgical and surgical treatments for pelvic organ prolapse.

Before considering surgery:

  • beware of all POP treatment options - conservative (wait-see, pelvic floor exercise, topical hormones, vaginal pessary) and surgical options
  • beware of the risks and benefits, success and failure rates of traditional vs. transvaginal vs. abdominal vs laparoscopic non-mesh and mesh repairs
  • ask the surgeon to explain the reasons behind the recommended treatment  
  • beware of the additional risks associated with the use of surgical mesh
  • ask the surgeon for information pamphlet about the specific product / material to be used
  • ask the surgeon about his/her experience regarding the recommended surgery, the chosen surgical mesh, risk prevention and management

After surgery:

  • notify the surgeon of any complications or abnormal symptoms (persistent vaginal discharge/bleeding, pelvic pain, bladder or bowel disturbance, painful sex)
  • continue with annual check-ups
  • talk to the doctor about any questions or concerns

With 20 years experience in traditional non-mesh, over 1200 transvaginal and laparoscopic non-mesh and mesh procedures, and successful treatment of many tertiary referral cases, you are welcome to consult Associate Professor Alan Lam for his advice regarding pelvic organ prolapse surgery, particularly in relation to transvaginal mesh surgery.