What mesh was for
Synthetic mesh was introduced to reinforce weakened vaginal tissue and reduce recurrence after anterior repair.
What research found
A 2024 Cochrane review compared permanent transvaginal mesh with native tissue repair for vaginal prolapse. Mesh was linked to less awareness of prolapse and fewer repeat prolapse operations. Prolapse was also found less often on examination, although the certainty of that finding was very low.
Counting repeat surgery for prolapse, stress incontinence and mesh exposure together, mesh was linked to more operations overall. It was also linked to more bladder injury and more new stress incontinence. Mesh exposure was recorded in 11.8% of women who had mesh repairs, and 6.1% needed surgery for it. The authors concluded that this balance limits the role of permanent transvaginal mesh in a first operation.
Why its use changed
Reports of erosion, pain and repeat surgery led regulators to act. In July 2018 the UK paused the use of vaginally inserted mesh for prolapse and stress incontinence, and in April 2019 the US FDA ordered manufacturers to stop selling mesh for transvaginal prolapse repair. Mesh placed through the abdomen for apical prolapse remains in use.
NICE guidance from 2017 says that transvaginal mesh repair of anterior or posterior vaginal wall prolapse has serious but well-recognized safety concerns, and that evidence of long-term benefit is inadequate. It advises that the procedure should only be used in the context of research.
Native-tissue repair
Anterior colporrhaphy folds and stitches the patient's own tissue. Lower implant risk; recurrence depends on tissue quality.
Native tissue repair places no implant, so there is no mesh to be exposed. The Cochrane review above found prolapse on examination more often after native tissue repair than after permanent mesh, so it is fair to ask your surgeon what recurrence rate they see.
Ligament-based repair
Techniques that re-anchor the supporting ligaments aim to correct the cause of descent rather than only reinforce the wall. Pelvic ligament suspension at Podo restores support by re-anchoring the patient's own lax pelvic ligaments, without synthetic mesh.
Pelvic ligament suspension is not limited to cystocele. It is used for stress urinary incontinence, cystocele, rectocele and uterine prolapse.
If you already have a sling or mesh
Patients who have a sling or mesh from another clinic can be treated; if the existing mesh is well positioned, it is left in place and pelvic ligament suspension is performed. A sling or mesh that is poorly positioned can be removed at the clinic.
NICE advises that a woman offered a mesh operation for prolapse should be told what type of mesh is used and whether it is permanent, and should receive written details of the implant.
Questions to ask
Is mesh used, and if so where. What is your recurrence rate. How do you follow patients up. What happens if it recurs.
More questions worth asking
What type of mesh would be used, and is it permanent? Will I receive written details of any implant? If there is a problem, can the mesh be removed, and by whom?
Questions
Is vaginal mesh still used to repair a cystocele?
It depends on the country. In April 2019 the US FDA ordered manufacturers to stop selling mesh for transvaginal prolapse repair. In England, NICE advises that transvaginal mesh for anterior or posterior vaginal wall prolapse should only be used in research.
What does pelvic ligament suspension use for support?
Pelvic ligament suspension uses the patient's own ligaments and sutures, without synthetic mesh. It is used for stress urinary incontinence, cystocele, rectocele and uterine prolapse.
I already have a mesh. Can Podo treat me?
Patients who have a sling or mesh from another clinic can be treated; if the existing mesh is well positioned, it is left in place and pelvic ligament suspension is performed. A sling or mesh that is poorly positioned can be removed at the clinic. A consultation is needed to decide which applies to you.
Sources
- US FDA: FDA's activities, urogynecologic surgical mesh
- NICE guideline NG123: urinary incontinence and pelvic organ prolapse in women
- Cochrane review (2024): Transvaginal mesh or grafts or native tissue repair for vaginal prolapse
- NICE HealthTech guidance HTG456: Transvaginal mesh repair of anterior or posterior vaginal wall prolapse
Read about this at Podo
About the reviewer
Dr. Mo Hyung-jin, MD, PhD, board-certified OB-GYN specialist, is the medical director of Podo Women's Clinic. He developed the pelvic ligament suspension technique used at the clinic for stress urinary incontinence and pelvic organ prolapse. Profile