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Genital Prolapse Surgery: What Options Do We Have in the Age of Mesh Issues?

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Genital Prolapse Surgery: What Options Do We Have in the Age of Mesh Issues? Journal of Clinical Medicine Review Genital Prolapse Surgery: What Options Do We Have in the Age of Mesh Issues? Guenter K. Noé 1,2 1 Department of Obstetrics and Gynecology, University of Witten-Herdecke, 41540 Dormagen, Germany; [email protected] or [email protected] or [email protected] 2 Rheinlandclinics Dormagen, 41540 Dormagen, Germany Abstract: Here, we describe the current laparoscopic procedures for prolapse surgery and report data based on the application of these procedures. We also evaluate current approaches in vaginal prolapse surgery. Debates concerning the use of meshes have seriously affected vaginal surgery and threaten to influence reconstructive laparoscopic surgery as well. We describe the option of using autologous tissue in combination with the laparoscopic approach. Study data and problematic issues concerning the existing techniques are highlighted, and future options addressed. Keywords: pelvic floor repair; laparoscopic repair; vaginal repair; mesh use; native tissue 1. Introduction Vaginal prolapse is and remains a problem for a large number of women around the world. After a prolonged period of slow development, prolapse surgery progressed significantly towards the end of the 1990s. For a long time, native tissue repair dominated the surgical procedure. These techniques are advantageous as they do not require any foreign material to be implanted. A number of techniques were introduced, but were not investigated in multicenter studies. The influence of alloplastic material in the lower Citation: Noé, G.K. Genital Prolapse pelvis, its side effects, and complications were clearly underestimated. In the last two Surgery: What Options Do We Have decades, mesh materials have been used to an increasing extent in pelvic floor surgery, and in the Age of Mesh Issues? J. Clin. have almost triggered a crisis. In the last few years, we have learned more about material Med. 2021, 10, 267. https://doi.org/ characteristics and behavior in tissue. As patients with weakened connective tissue cannot 10.3390/jcm10020267 permanently be reconstructed, meshes are very helpful. Surgeons’ lack of experience, too little training, too little knowledge about the material properties, and incorrect indication Received: 23 December 2020 were certainly very decisive for the mesh problem. Accepted: 11 January 2021 After the withdrawal of numerous mesh products from the market and negative Published: 13 January 2021 media campaigns in many countries, the use of synthetic fabrics declined significantly [1]. This had a major impact on vaginal reconstructive surgery. Traditional methods such as Publisher’s Note: MDPI stays neu- colporraphy, the Manchester-Fothergill procedure, and sacrospinous fixation re-emerged tral with regard to jurisdictional clai- as important approaches. Various mesh products were developed for the latter procedure, ms in published maps and institutio- and were marketed along with clever fixation techniques. Once mesh surgery began its nal affiliations. triumphant advance at the end of the 1990s, we were confronted with the problem of meager study data on traditional procedures that meet the current requirements. In some countries, the use of meshes in sacropexy is viewed critically by government Copyright: © 2021 by the author. Li- agencies. The technique is still recognized as the “gold standard” in prolapse surgery [2–4], censee MDPI, Basel, Switzerland. but the extensive use of deep mesh placement is associated with greater mesh exposure This article is an open access article and shrinkage [5]. Degradation of the material is followed by its spread within the body. distributed under the terms and con- Current study data indicate that these materials cause local effects on muscle, as well as ditions of the Creative Commons At- fatigue syndrome [6,7]. The mesh problem in vaginal surgery has encouraged the use tribution (CC BY) license (https:// of native tissue and laparoscopic procedures. In the last decade, lateral suspension [8] creativecommons.org/licenses/by/ and pectopexy [9] were introduced as alternatives to sacrocolpopexy for laparoscopic 4.0/). J. Clin. Med. 2021, 10, 267. https://doi.org/10.3390/jcm10020267 https://www.mdpi.com/journal/jcm J. Clin. Med. 2021, 10, 267 2 of 10 pelvic floor repair. Apart from laparoscopy, traditional vaginal procedures based on mesh materials or sewing applicators were developed further. 2. Vaginal Pelvic Floor Surgery Vaginal surgery is more ambiguous than laparoscopic surgery. Regulations and practices concerning the use of meshes differ from one country to the other. All of the J. Clin.existing Med. 2021 methods, 10, x FOR PEER of REVIEW vaginal mesh application are used in Germany. The indications2 forof 10 their use have become more stringent, but meshes are not subject to any official restrictions, although governed by a variety of regulations. The use of meshes is entirely prohibited in some countries. In others,floor repair. their useApart is from permitted laparoscopy, in clinical traditional studies vaginal or procedures at selected based centers. on mesh Inma- terials or sewing applicators were developed further. yet other countries, it is common practice to use self-tailored meshes. Although a number2. Vaginal of single-center Pelvic Floor Surgery studies revealed the superiority of mesh surgery, the so-called PROSPECT (PROlapseVaginal surgery Surgery: is more Pragmaticambiguous than Evaluation laparoscopic and surgery. randomised Regulations Con- and trolled Trials) trial showedpractices no concerning benefits the [10 use]. Theof meshes above-mentioned differ from one country study to data the other. have All been of the interpreted diversely.existing An objective methods of presentation vaginal mesh application is almost are impossible used in Germany. at the The present indications time. for their use have become more stringent, but meshes are not subject to any official re- However, research effortsstrictions, are although still being governed focused by a variety on enhancing of regulations. the The safety use of ofmeshes meshes is entirely in vaginal surgery. Oneprohibited of the many in some debated countries. issues In others, is whethertheir use is thepermitted quantity in clinical of mesh studies or or theat se- combination of differentlected alloplastic centers. In tissuesyet other (suchcountries, as it the is common combined practice use to of use incontinence self-tailored meshes. tapes Although a number of single-center studies revealed the superiority of mesh surgery, and prolapse meshes)the is aso-called crucial PROSPECT determinant (PROlapse of success Surgery: [Pragmatic11,12]. The Evaluation second and debated randomised issue Con- is geographical centralizationtrolled Trials) of trial pelvic showed floor no surgerybenefits. [10] in. orderThe above-mentioned to achieve better study data outcomes. have been Many studies suggestinterpreted strong evidence diversely. of An a objective close connection presentation betweenis almost impossible surgical at expertise the present and time. complication rates [13However,]. A large research number efforts of are publications still being focused in the on last enhancing decade the have safety addressed of meshes in vaginal surgery. One of the many debated issues is whether the quantity of mesh or the this issue in nearly everycombination field of of surgery. different alloplastic The vast tissues majority (such ofas investigationsthe combined use identifiedof incontinence a clear link between successtapes and rates, prolapse complications, meshes) is a crucial the dete numberrminant of success performed [11,12]. The interventions, second debated and the surgeon’s expertise.issue is geographical centralization of pelvic floor surgery in order to achieve better out- The use of meshescomes. is Many nearly studies impossible suggest strong or veryevidence limited of a close in connection some countries. between surgical Tradi- ex- pertise and complication rates [13]. A large number of publications in the last decade have tional methods are experiencingaddressed this aissue renaissance in nearly every in thesefield of regions.surgery. The For vast several majority decades, of investigations the sacrospinous ligamentidentified was used a clear for link apical between fixation. success rates, Vaginal complications, mesh surgery the number developed of performed in in- the 1990s and currentterventions, alternative andmethods the surgeon’s are expertise. also based on fixation to this ligament. A The use of meshes is nearly impossible or very limited in some countries. Traditional Cocrane analysis in 2013methods examined are experiencing randomized a renaissance trials in thatthese comparedregions. For several vaginal decades, (especially the sacro- sacrospinous fixation)spinous and sacrocolpopexy ligament was used for (SC). apical The fixati reviewon. Vaginal disclosed mesh surgery the superiority developed inof the SC, but also highlighted1990s the and significantly current alternative longer methods operating are also times based andon fixation the longer to this learningligament. A curve for SC [14]. MeshCocrane surgery analysis has in replaced 2013 examined sacrospinous randomized fixationtrials that tocompared a significant vaginal (especially extent. sacrospinous fixation) and sacrocolpopexy (SC). The review disclosed the superiority of The technology of meshSC, but fixation also highlighted has been the revived. significantly It islonger either operating performed times and using the
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