Patient selection influences pelvic mesh surgery success
While the use of a mesh for pelvic organ prolapse repair resulted in an elevated risk of repeat surgery compared with native tissue repair, the mesh itself did not influence the need for repeat procedure, according to a US-based study.
“Our results show that the mesh itself and surgeon experience do not appear to be the problem, rather we may not be choosing wisely who receives a mesh implant,” said study lead investigator Assistant Professor Christopher Elliott from the Stanford School of Medicine, Stanford, and Santa Clara Valley Medical Center, San Jose, California, US.
“[U]se in specific patients with careful patient selection may be warranted,” said Elliott and co-authors.
Using data from the Office of Statewide Health Planning and Development, researchers identified 110,329 women (mean age 58.2 years, 64.3 percent Caucasian) who underwent pelvic organ prolapse repair in California between 2005 and 2011. Of these, 16.2 percent of the procedures required the use of a mesh. Patients were followed up for a mean 3.5 years with 85 percent of repeat procedures carried out within 3.3 years of the initial procedure.
Women who underwent prolapse repair with a mesh were more likely to require repeat surgery (surgery due to mesh-related complications or subsequent surgery for recurrent pelvic organ prolapse) than those who underwent native tissue repair (5.4 percent vs 4.3 percent; p<0.001). [J Urol 2018;200:389-396]
When type of procedure was taken into consideration, patients who used a mesh had an approximately 0.7 percent lower rate of repeat procedures for recurrent pelvic organ prolapse repair but about a 1.5 percent higher rate when the repeat procedure was for a mesh-related complication.
Use of the mesh was not associated with an increased need for repeat surgery (odds ratio [OR], 1.05, 95 percent confidence interval [CI], 0.96–1.13; p=0.27).
Repeat surgery rates were higher at facilities that were more likely to use mesh compared with those that were least likely to use mesh (OR, 1.55, 95 percent CI, 1.33–1.80; p<0.001).
The use of mesh for anterior or apical repairs or concomitant incontinence procedure was associated with a higher risk for repeat surgery (OR, 1.18, 95 percent CI, 1.10–1.26; p<0.001; OR, 1.09, 95 percent CI, 1.02–1.16; p=0.01; and OR, 1.09, 95 percent CI, 1.02–1.15; p=0.006, respectively), compared with mesh use for posterior repair which resulted in a reduced risk (OR, 0.88, 95 percent CI, 0.83–0.94; p<0.001).
“It is quite reassuring that in the right hands, mesh surgery for pelvic organ prolapse can lead to a positive benefit-to-risk ratio,” commented Professor Alexander Gomelsky from Louisiana State University Health-Shreveport in Shreveport, Louisiana, US, in an accompanying editorial.
“[W]hen used judiciously and in the optimal patient, outcomes after mesh surgery may be optimized and complications may be minimized. However, the right patient for these operations currently remains largely in our hindsight,” he said.
“Further research is … warranted to better understand which patients specifically are at higher risk for failure of native tissue repair and who might benefit the most from mesh augmentation,” said the authors.
“We hope our results can be used as a benchmark of first generation mesh outcomes to compare to future generations of vaginal prolapse mesh and further the discussion of vaginal mesh use for prolapse in light of recent negative reports,” concluded Elliott.