Posted August 2024

Dr Carey recently presented on alternatives to pelvic mesh for prolapse at the recent AGES Pelvic Floor Symposium in Sydney. The following abstract is an over view of his presentation

Prolapse, What Is New in the Post Mesh Era – Marcus Carey
Changing practices in prolapse surgery continues to be driven by the ongoing pelvic mesh controversy.
Increasing reporting and awareness of mesh-related complications in pelvic floor surgery has resulted in
official warnings and restrictions by regulatory bodies, widely publicised litigation and class actions, and an
increasing reluctance by patients, surgeons and hospitals to accept using mesh in pelvic floor surgery, even for
sacrocolpopexy (SCP). In some countries, recent regulatory changes have resulted in mesh for SCP being
unavailable or tightly restricted. Regulatory authorities in the United Kingdom, New Zealand and Australia
have either paused or restricted the use of mesh for POP. In Australia, due mainly to the regulatory changes,
no medical device company has made an “on-label” mesh available for SCP.
SCP using polypropylene mesh is widely acknowledged as the ‘gold-standard’ procedure for apical
compartment pelvic organ prolapse (POP) with reported objective success rates of 68-100%. The use of SCP to
treat pelvic organ prolapse has increased in recent years coinciding with a dramatic decline in trans-vaginal
mesh since the Food and Drug Administration (FDA) warnings. However, there are significant risks of serious
mesh-related complications including mesh exposure/erosion, chronic pain, sepsis, sexual dysfunction, nerve
entrapment, sinus tract formation, and fistulae. Mesh-related complications often require revision surgery.
The Colpopexy and Urinary Reduction Efforts (CARE) trial reported mesh-related complications in 10.5% of
participants.
Taking into consideration the ongoing pelvic mesh controversy, restricted pelvic mesh in some countries and
recognising the limited success with transvaginal apex suspension surgeries there is an increasing role for
effective mesh-free alternatives for SCP such as autologous fascia lata and rectus sheath. Non-autologous
biologic grafts, including cadaveric fascia lata, porcine intestinal submucosa, and bovine pericardium have
inferior long-term outcomes compared to mesh most likely due to graft resorption and host versus graft
reactions.
The ICI 2021 advises that hysterectomy should not be performed with mesh SCP because of the high risk of
mesh exposure (estimated to be 10%).
There has been renewed interested in the Manchester (hysteropexy) procedure. A recent RCT of 393
participants reported a composite success of 77.0% in the sacrospinous hysteropexy group and 87.3% in the
Manchester group (JAMA Aug. 2023).
Vaginal pessaries should be made available to patients as alternative to prolapse surgery. The American
College of Obstetricians and Gynaecologists recommends that a vaginal pessary should be offered before
surgical intervention in all women with symptomatic prolapse. Advantages of pessaries include ease of
outpatient insertion by a range of healthcare providers, low cost, reversibility, and suitability for the elderly
and women with medical co-morbidity. With an ageing population, the prevalence of pelvic organ prolapse is
expected to increase and vaginal pessaries will play an increasingly important role in management. However,
compared to the surgery, vaginal pessaries remain under researched.