Weighing the benefits and harms of transvaginal mesh

Low- and moderate-quality evidence suggests no difference between artificial mesh and native tissue repair of vaginal prolapse.
Low- and moderate-quality evidence suggests no difference between artificial mesh and native tissue repair of vaginal prolapse.

A review of evidence highlighting the benefits and harms of using artificial mesh to repair vaginal prolapse has been published in the Cochrane Database of Systematic Reviews.

Led by Christopher Maher, MD, PhD, of the Royal Brisbane Women's Hospital in Queensland, Australia, a team of researchers conducted an analysis of 37 randomized controlled trials to determine the potential benefits and harms of using artificial mesh versus native tissue to repair vaginal prolapse; use of the mesh studied in these research papers has been disallowed since 2011.

“While transvaginal permanent mesh is associated with lower rates of awareness of prolapse, reoperation for prolapse, and prolapse on examination than native tissue repair, it is also associated with higher rates of reoperation for prolapse, stress urinary incontinence, or mesh exposure and higher rates of bladder injury at surgery and de novo stress urinary incontinence,” the researchers stated. “The risk-benefit profile means that transvaginal mesh has limited utility in primary surgery. While it is possible that in women with higher risk of recurrence the benefits may outweigh the risks, there is currently no evidence to support this position.”

The analysis, including low- to moderate-quality evidence gathered from 4,023 women, found that when permanent mesh was used, 10% to 15% of patients were aware of prolapse, compared with 19% of women who were aware of prolapse after undergoing native tissue repair. In addition, women who underwent permanent mesh repair had lower rates of repeat surgery, although 8% of these women did require repeat surgery for mesh exposure.

Additional low-quality evidence showed no difference in effectiveness of absorbable mesh when compared with native tissue repair, and no evidence existed to show a potential difference between biological graft and native tissue repair.

"This is a very significant review informing women about the surgical options available for the treatment of this debilitating condition," said Dr. Maher. "It summarizes the evidence of effectiveness of these approaches and their complications. It provides women with more information to make an informed choice about what treatment is best for them.”

According to the researchers, limited evidence suggests that absorbable mesh may reduce rates of recurrent prolapse on examination compared to native tissue repair. “But there was insufficient evidence on absorbable mesh for us to draw any conclusions for other outcomes,” they concluded. “There was also insufficient evidence for us to draw any conclusions regarding biological grafts compared to native tissue repair.”

In a corresponding editorial, Cindy Farquhar, MD, MPH, of the Department of Obstetrics and Gynecology at the University of Auckland in New Zealand, and Coordinating Editor of the Cochrane Gynecology and Fertility Group, commented, “This evidence underlines the need to balance the potential harms against the potential benefits of surgery. Future studies should report adverse events carefully and include reporting pain and quality of life.”

References

  1. New health evidence gives women informed choice in the prolapsed surgery debate [news release]. London, England: Cochrane Library. Posted: February 9, 2016. Accessed February 17, 2016.
  2. Maher C, Feiner B, Christmann-Schmid C, et al. Transvaginal mesh or grafts compared with native tissue repair for vaginal prolapsed. Cochrane Database Syst Rev. 2016;(2). doi: 10.1002/14651858.CD012079.
  3. Farquhar C. No implementation without evaluation: the case of mesh in vaginal prolapsed surgery. Cochrane Database Syst Rev. 2016;(2). doi: 10.1002/14651858.ED000108 
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