Transvaginal mesh: Further study of risks, benefits needed

Dr. Serels' recent article ("Surgical correction of vaginal vault prolapse," Urology Times Clinical Edition, June 2009, pages s12-s18) was a nice review of vaginal vault prolapse repairs. I did notice that colpocleisis was left out, which has a high success and satisfaction rate (95%) in properly selected patients with advanced pelvic organ prolapse (Int Urogynecol J Pelvic Floor Dysfunct 2008; 19:1603-9). Obviously, this procedure is only appropriate in older women not seeking to maintain coital function.

As the article did emphasize synthetic mesh techniques, I would also like to point out that clinical practice guidelines were recently published after a systematic review of graft use in transvaginal prolapse repair. The Society of Gynecologic Surgeons' review group concluded that there was not enough data to guide any recommendations regarding the use of non-absorbable synthetic graft in the posterior vaginal compartment or in multiple compartments. There was a weak recommendation suggesting that non-absorbable synthetic graft may improve outcomes in the anterior compartment, but with "significant trade-offs" (Obstet Gynecol 2008; 112:1123-30 and 1131-42).

At this point, I don't think it is clear at all whether transvaginal mesh offers superior anatomic or symptomatic outcomes compared to traditional apical suspension repairs. Due to complications specific to transvaginal mesh placement, well-designed comparative effectiveness trials are needed to better clarify the risk-benefit ratio of these procedures.