Complications of vaginal mesh: our experience

In the January issue of this journal, an interesting study on “Management of complications arising from transvaginal mesh kit procedures” [1] and a “Review of synthetic meshrelated complications in pelvic floor reconstructive surgery” [2] reopened this much debated problem. First, we straightaway want our readers to know our conflicting interests and also our major concern for objectivity, though B.J. is a patent holder on ProliftTM and both authors have a large implication in studies of the French TVM group and in the many training sessions on this surgical procedure and its complications. Unlike nearly all previous editorials, we would like here not only to describe potential hazards but also encourage the reader to analyse them objectively. In our opinion, complications of vaginal meshes are often overestimated, sometimes overemphasised, often poorly described and managed. Complications can be overestimated because it is always easier to publish a complication in an important urologic or gynaecologic journal than to follow hundreds of patients in a long prospective survey. It is only through this latter approach that we can really assess the complications rate. The second reason is linked to the fact that it is often unclear whether complications implicated with the use of mesh are actually due to the mesh or the surgical technique. Today, the six published randomised controlled trials (RCTs) do not show more complications in the arm with prosthetic meshes than in the arm without meshes, but discriminating power is insufficient. Whilst waiting for large national registers results, we added up the severe complications of three significant series: a Scottish one reporting 289 patients [3], a Scandinavian one with 148 patients [4] and the results of the French TVM group gathering 1,541 patients and not yet published. On these 2,078 patients, apart from partial excision of meshes after vaginal exposure (2.6%), there were 55 severe complications: haemorrhages >500 ml or important haematoma (1.2%), deep infection (0.9%), visceral erosion (0.1%) and removal of a mesh for pain or dyspareunia or other severe complication (0.9%). In the same way, if we put together all series published on ProliftTM, 1,882 interventions, the percentage of each of these severe complications is never over 2.5%, and the maximal reported rates are 12% for mesh exposition, 17% for prosthetic contraction and 9% for de novo dyspareunia. We will later come back on the sexual impact of these interventions. These complication rates must be known by the surgeons (and, of course, their patients!), but they do not seem unacceptably high. Complications may sometimes be overemphasised by surgeons who do not use meshes for vaginal repair but are referred the most severe complications which might bias their opinion. Sexual problems are most frequently put forward by the detractors of vaginal prosthetic meshes. That remains the main concern for surgeons, so some only propose vaginal implants to non-sexually active women. The first publications, we must admit, did not precisely analyse functional and sexual consequences of these Int Urogynecol J (2009) 20:893–896 DOI 10.1007/s00192-009-0926-6