Introduction:
Transvaginal mesh is a web-like implant material placed through the vagina in females. It is commonly used in the treatment of pelvic organ prolapse (POP) and stress urinary incontinence (SUI). This helps to strengthen the pelvic muscles and support the organs of the pelvic region. In 2019, the Food and Drug Administration (FDA) banned the use of transvaginal mesh, citing that the complications outweigh the benefits of its usage.
What Are the Various Types of Mesh Used in Surgery?
The treatment objective of pelvic organ prolapse is to reinforce the weakened muscles of the pelvic region. This can be achieved either by the use of native tissue that is biologically available or synthetic materials. Biologically obtained materials are known as “grafts,” while synthetic materials are called “mesh.”
Various Grafts Used:
1. Autograft:
It refers to a piece of tissue obtained from a different site of the same individual. For example, commonly grafted muscles are the abdominal and gluteal muscles.
The major disadvantage of using an autograft is the comorbidity of the donor site, like infection or nerve damage.
2. Allograft:
Allograft is a tissue obtained from cadavers after thorough sterilization. This eliminates the risk of comorbidities.
3. Xenograft:
It is a graft obtained from a donor of a different species. It is commonly obtained from the submucosa or pericardium of swine or cows.
These biological grafts have a higher risk of infection and disease transmission, and there is always an anatomical mismatch leading to failure of surgery.
Synthetic Materials:
1. Synthetic Absorbable Mesh:
These are materials made of polyglactin or polyglycolic acid. They are absorbed by the enzymatic action of the body, and new fibers regenerate in the mesh region. The formation of new connective tissue helps strengthen the weakened pelvic muscles and ligaments.
2. Synthetic Non-Absorbable Mesh:
These are made of synthetic materials like plastic, polypropylene, or polyester. The most commonly used among them is polypropylene. Amid classified such synthetic non-absorbable mesh into four types based on pore size.
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Type 1: This has a pore size greater than 75 µm. This allows the entry of fibroblasts and blood vessels into the pores and helps in better integration of the mesh to surrounding structures. This is the choice of material to treat pelvic organ prolapse.
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Type 2: This has a pore size of less than 10 µm. Macrophages and collagen fibers cannot enter within this mesh. This increases the risk of infection, and there is a failure of integration.
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Type 3: This has a pore size greater than 75 µm and is braided. This also increases the probability of infection.
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Type 4: The pore size is less than 1 µm. Hence, it is rigid and cannot be used to place transvaginally.
What Is the Use of Transvaginal Mesh?
Transvaginal mesh is used to treat pelvic organ prolapse and stress urinary incontinence. Factors that cause pelvic organ prolapse and stress urinary incontinence include:
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Pregnancy.
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Childbirth (including multiple births).
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History of hysterectomy.
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Long-term history of constipation.
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Obese individuals.
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Heavy lifting or improper gym workouts.
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Aging.
These factors can cause one or more organs of the pelvic region, like the uterus, bladder, bowel, or top of the vagina, to drop down from its anatomical site and engorge into the vagina. This causes pain and discomfort. In addition, stress urinary incontinence can cause urine to leak when the patient coughs, sneezes, or laughs. A transvaginal mesh relieves this and reinforces the muscles and ligaments.
How Is a Transvaginal Mesh Placed?
The aim of placing a transvaginal mesh is to prevent the bulging of pelvic organs into the vagina. Transvaginal mesh is implanted surgically through the vagina to repair the pelvic region and support the muscles. This provides a cob-like cushioning effect for the weak pelvic muscles.
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This is achieved by placing different incisions in the anterior or posterior vaginal wall depending on the patient’s defects.
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This is followed by the repositioning of the pelvic organs, implantation of the mesh, and sutural.
A transvaginal mesh can be used in any of the following ways depending on the patient's condition.
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Sutured as an inlay in the defective region.
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Surround the vagina like a network.
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Inserted into pelvic spaces.
How Does the Body React After Implantation?
Factors that influence the integration of mesh are:
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The density of mesh.
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Pore size.
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Stiffness of mesh.
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Response of the body.
Transvaginal mesh placement initiates a cascade of reactions in the body that includes inflammation, foreign body reaction, granulation tissue formation, or rejection. This can be minimized using a mesh with large pores since it reduces the surface area and allows for better penetration with the surrounding structures. Inflammatory reactions can also be reduced by coating the mesh with collagen.
What Are the Complications of Using Transvaginal Implants?
The major advantage of using a transvaginal mesh is the reduced risk of infection because it is biologically inert. But the complications of the surgery are higher when compared to the benefits. Hence, transvaginal mesh comes under class 3 medical device (it presents the risk of illness or injury).
Common complications include:
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Bleeding.
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Pain in the pelvic region.
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Swelling.
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Injury to surrounding structures.
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Formation of hematoma.
Complications pertaining to the use of transvaginal mesh are
1. Mesh Erosion:
It is the most common postoperative complication. This can be due to infection or sutural damage leading to erosion of the surrounding tissues and extrusion of the implant. Erosion in the urinary bladder can also cause fistulas. Secondary complications due to mesh erosion are
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Vaginal discharge and bleeding.
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Scarring.
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Burning sensation.
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Pain during sexual intercourse.
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Urinary retention.
2. Pelvic Pain:
This occurs due to postoperative inflammation. Inflammation causes increased formation of collagen, leading to reduced mesh flexibility and pain.
3. Perforation:
Transvaginal mesh can perforate the lining of surrounding organs like the rectum or bladder. This is treated by removal of the mesh followed by reconstruction of the perforated walls of the organs.
How Are the Complications Treated?
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Non-steroidal anti-inflammatory drugs or steroids treat mild pain and inflammation.
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Major complications are treated by revision surgery. It is a surgery performed to remove the transvaginal mesh and treat the secondary complications.
What Are the Alternatives to Transvaginal Mesh?
There are several alternatives to the use of transvaginal mesh.
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Improving pelvic floor function by physiotherapy.
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Use of pessary. Pessary is a device made of plastic or silicone and is self-inserted into the vagina to support the pelvic organs and muscles.
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Lifestyle modifications like weight loss and avoiding heavy lifting.
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Bladder training to treat stress incontinence.
Conclusion:
The use of transvaginal mesh has been banned because of the various complications. Therefore, extensive research should be done in this field to replace the transvaginal mesh with a material with minimal or no complications. It is advisable to consult a doctor in case of pain in the pelvic region for effective alternative treatment planning.
