Patterns emerge in mesh use for pelvic repair

Key Points

Palm Springs, CA-Synthetic mesh has become the material of choice among many surgeons for repairing vaginal prolapse, but little is known about how surgeons use it and whether physician demographics have any bearing on usage. In a study designed to uncover patterns of synthetic mesh use, researchers from Mount Auburn Hospital, Cambridge, MA, found that those doctors who are most likely to use mesh are male surgeons, those in private practice, and those who did not undergo fellowship training.

"Many of us are concerned about long-term outcomes and complications of these procedures. I thought it would be interesting, in the midst of all of the discussion, to find out exactly what pelvic surgeons are doing in terms of using synthetic mesh in their surgeries."

Almost all (99.5%) of the 259 respondents reported using synthetic mesh, including 93% of those physicians who perform sacrocolpopexy and 93% of those who perform suburethral slings. When engaged in vaginal reconstructive surgery, 151 (56%) of respondents said they use synthetic mesh on at least some occasions.

"I was impressed by how many surgeons use mesh, and by the relative comfort demonstrated with mesh for suburethral sling," Dr. Pulliam noted.

Preference patterns

Survey data showed that more male respondents (74.3%) than females (55%) use synthetic mesh in vaginal reconstructive surgery (p=.002). Mesh use was also more common among those in private practice compared with those in academic settings (80.4% to 57.3%, p<.001) and in those who did not have fellowship training compared with those who did (82.1% to 54.8%, p<.001). A logistic regression model showed that fellowship-trained surgeons were 2.5 times more likely to use mesh than were those who were not fellowship-trained (95% confidence interval, p=.008).

"I suspect many fellowship-trained respondents are more comfortable doing abdominal sacrocolpopexies, a procedure that suspends the vaginal apex," Dr. Pulliam said. "Many of the total vaginal mesh procedures can be used for apical suspensions and performed by a vaginal approach. These procedures could be useful to a surgeon who doesn't do sacrocolpopexies, but who is looking for a procedure to suspend the vaginal apex."

As for the differences between the sexes of the surgeons responding, Dr. Pulliam was less certain about the reason, although she noted that other studies also have found differences in the practice styles of male and female physicians.

Among surgeons who use mesh for anterior or posterior colporrhaphy, the most common indication was "native tissue is inadequate for repair," followed by "failed prior posterior or anterior colporrhaphy."

Those who do not use mesh expressed concern over complications of mesh erosion, which, in some cases, can be treated easily with an estrogen cream and, in others, could require extensive surgical repair. Most respondents (96.9%) reported having cared for a patient with mesh erosion, most commonly vaginal.

Other concerns among those who do not use mesh were the relative lack of safety and efficacy data and sexual function after mesh placement.