Slings and meshes in the therapy of prolapse and urinary incontinence
Authors: Fekete Zoltán 
Published: September 2019

Pelvic organ prolapse (POP) is an important health issue for women, with up to 20% of women undergoing one or more operations to correct prolapse over their lifetime [1]. The reported rate or stress urinary incontinence (SUI) coexisting with POP is as high as 63–80% [2]. The classical anterior colporrhaphy has a high relapse rate for anterior compartment descent (26–58%), and anti-SUI effectiveness of this non-prosthesis method is only negligible (42%–62%) [3,4], so according to the current guidelines anterior colporrhaphy is not indicated in case of SUI . It is also known that the postoperative complication rate for very effective prosthesis operations is high. Permanent implants have been associated with higher rates for de novo stress incontinence (relative risk 1.39), bladder perforation (relative risk 3.92) and postoperative dyspareunia [5]. Synthetic transvaginal mesh has been employed in the treatment of POP with increasing popularity and is usually highly effective in controlling the principal symptoms of prolapse. Based on the US Food and Drug Administration (FDA) warnings of 2008 and 2011, specialists should arrive at a more precise balance between the low success rate for non-mesh techniques and the higher number of postoperative complications of prosthesis methods [6]. Therefore, in a retrospective study, we aimed to evaluate and compare anti-POP efficacy, anti-stress incontinence (anti-SUI) efficacy, and the early (six weeks) and late (36 months) postoperative complication rates for anterior vaginoplasty and the most commonly used transvaginal mesh (TVM) operations. In our series, we found that the TVM operations were significantly better in the reconstruction of POP (91.3% vs. 66.3%; p<0.001) and SUI (90% vs. 55%, p<0.001) after three years of follow-up. Hence, in our study, de novo urge incontinence (DNUS) was significantly more frequently observed (11.86% vs. 0%). Extrusion of the implanted mesh was found in 8.3% of cases involving a prosthesis. In our cases, the implanted mesh was fixed to the peri-urethral tissue with two anchoring stitches, as we had hypothesised; this is superior to the original TVM for anti-incontinence. Previous studies have reported that mesh operations provide unfavourable SUI cure rates. Therefore, the anchoring used as additional anti-incontinence surgical strategies is increasingly being scrutinized to achieve better postoperative continence without any significant side-effects for patients with both POP and SUI. A randomized prospective study was designed to evaluate the anti-SUI effectiveness of that anchoring technique. Mesh contraction and bunching may cause nerve entrapment as well as excessive tension on the fixed mesh arms, which both lead to pain. It is documented that mesh folding and contraction are among the reasons for chronic pelvic pain, dyspareunia and mesh extrusion. A new concept involving an anchorless implant was developed to reduce the side-effects of prosthesis operations. The assumption was that an anchorless neo-pubocervical fascia would accurately mimic the physiological support system, therefore providing adequate support. A new type of mesh was designed with a flexible frame. In our multi-centre study, seventeen patients (84.2%) had Stage 0 prolapse and three patients (15.8%) had Pelvic Organ Prolapse Quantification system (POP–Q) (International Continence Society (ICS)) Stage 1 prolapse after two years of follow-up. No cases of mesh erosion or chronic pelvic pain were documented at follow-up. There has been a drop in the rates for intra-operative bladder perforations and vesicovaginal fistulas (VVF) after the introduction of infra-pubic operative techniques, but the suitable reconstructive technique is still questionable. We reintroduced an “oldy but goody” operative technique of Lehoczky’s island flap implantation for prosthesis-induced VVF. In our short series, all the operated cases were free of fistulas after three months of follow-up. Although the rate for concomitant SUI in patients with POP is as high as 63–80% [2], the effective treatment for coexisting SUI and POP is still debated. The anti-SUI efficacy of the prosthetic placement is barely 72–83% [34-36]. Therefore, the research group developed a modification to the transobturator four-arm TVM to increase its anti-incontinence effect. The proposed modification to the original surgical procedure includes the suture of the anterior part of the mesh to the mid-urethra to prevent the mesh sliding. We think that the appropriate elevation of the mid-urethra would thus occur with the anterior arms and that would achieve a more effective anti-incontinence. We designed a single-centre, prospective, double-blind (participant, investigator/surgeon, outcome assessor), randomized, controlled trial to evaluate the anti-SUI success rate for the modified TVM.