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The mesh debate: Transvaginal anterior anchored mesh should not be abandoned

Einstein once said, ‘In the middle of difficulty, lies opportunity’. However, in this current climate when the use of synthetic transvaginal mesh in pelvic organ prolapse (POP) surgery is associated with increasing negative publicity, there is limited opportunity for progress in this field. In fact the authors consider what happened over the last few years a retrograde development. The blanket decision to suspend all mesh use in pelvic floor reconstructive surgery in Scotland in 2014, including synthetic suburethral slings which have a proven success record reaching back about 20 years, is an obvious example. The recent removal from the market of transobturator meshes including the PerigeeTM (American Medical Systems (AMS), Minnetonka, MN, USA) and Anterior ProliftTM (Ethicon, Somerville, NJ, USA) is another example of a retrograde development. While these were largely commercial decisions, it is inevitable that clinicians are now forced to revert back to procedures that have been shown to be less effective. In our opinion the discussion surrounding the use of transvaginal mesh has been dominated by emotion rather than science. Surgical management of POP is a challenging condition for pelvic reconstructive surgeons, with approximately onethird of prolapse procedures performed for recurrence.1 Among the different forms of POP, cystocele can be a particularly difficult condition to manage with a recurrence rate after traditional repair between 40 and 63%2–5 and up to 90% in some women.6 For this reason clinicians dealing with POP have been in a constant search for surgical techniques to improve outcomes. Mesh has been used in pelvic floor repair dating back to 1955, when Moore et al.7 first used tantalum mesh for anterior compartment prolapse repair. However, transvaginal mesh implants did not become popular until after the worldwide success of midurethral slings introduced in the early 1990s, triggering the development of anterior vaginal meshes anchored via the transobturator route (Anterior ProliftTM Ethicon, Somerville, NJ, USA and PerigeeTM AMS, Minetonka, MN, USA) in 2003–2004. Anterior anchored mesh kits were intended to provide better load resistance than native tissues in a minimally invasive approach, aiming to improve anatomical success rates. The introduction of these kits was followed by rapid and widespread adoption of polypropylene mesh in spite of limited data on safety and efficacy. In the USA, the use of vaginal mesh for prolapse repair increased from 8.1% in 2005 to 22.8% in 2010.8 Over the last decade, a growing body of data in this field has improved our understanding of mesh efficacy and safety. Accumulated evidence now suggests that synthetic mesh augmentation is superior to traditional repair for anterior compartment prolapse.9,10 In a recent systemic review11 including 13 randomised controlled trials (RCTs) and seven cohort studies, the use of synthetic nonabsorbable anterior compartment mesh was shown to result in superior anatomical success and relief of subjective prolapse symptoms, as well as lower reoperation rates for prolapse compared to native tissue repair. However, transvaginal mesh was not found to improve success in posterior and apical prolapse repair. The marked rise in vaginal mesh procedures has seen a dramatic increase in meshrelated complications. Some of these are Conflict of interest: Neither author has conflicts of interest.