The use of prostheses in pelvic reconstructive surgery: joy or toy?
ABSTRACT The high recurrence rate of pelvic organ prolapse (POP) of up to 30% after pelvic reconstructive surgery makes a more refined surgery imperative, as well as the need for either biological or synthetic prostheses as adjuvant treatment. Patients with recurrence risks may benefit from the adjuvant treatment: (1) to substitute for the lack of supportive tissue; (2) to reinforce inadequate tissue; (3) to induce new supportive tissue; and (4) to consolidate and complement the insufficient surgical techniques. However, some debatable issues in use of the prosthetics remain. The use of prosthetics enables the simultaneous repair of all vaginal defects of POP and concomitant anti-incontinence surgery to be faster, easier and more precise. Nevertheless, great care should be devoted to the actual and theoretical short- and long-term risks, many of which have not been fully elucidated. Despite the lack of various ideal characteristics, the type I monofilament, macroporous polypropylene, has been suggested to have the lowest incidence of infection and erosion among the nonabsorbable prostheses. There is good evidence to support the use of nonabsorbable synthetic mesh for abdominal sacrocolpopexy, while the use of prostheses for repairing isolated anterior and posterior compartment defects remains controversial. There have been no long-term studies with sufficient patient numbers to prove whether synthetic or biological prostheses are superior during vaginal surgery. Tension-free vaginal mesh techniques with procedural kits are being adopted increasingly, despite the paucity of data. Although short-term follow-up studies have shown tension-free vaginal mesh to be a safe and effective technique to correct POP, anatomic and functional results of long-term follow-up studies, however, have not yet confirmed the effectiveness and safety. Mesh erosion remains a concern, with variable rates according to different materials and approaches. Newly developed prostheses offer an alternative option to pelvic reconstructive surgery. However, some questions remain: (1) Should prostheses be considered for primary repairs, secondary repairs, or solely in patients with risk factors for recurrence? (2) Which prosthetic material is better: synthetic or biological ones; absorbable or nonabsorbable ones? (3) Do the benefits of prosthetics in pelvic reconstructive surgery outweigh the risks of complications? These questions are explored and reports in the literature reviewed.
- SourceAvailable from: iuga2012.com[Show abstract] [Hide abstract]
ABSTRACT: Pelvic floor disorders affect about half of the female population, creating one of the major problems of later life. With respect to pathogenesis, it was traditionally taught that endopelvic connective tissue attenuates after childbirth. In fact, healthy pubocervical fascia is like canvas - it does not stretch, but will tear at pre-determined weak points. However, adjacent connective tissue does eventually degenerate, because the mechanical forces that drive collagen homeostasis are not properly transmitted within torn suspensory hammocks. Colporrhaphy ignores the true sites of obstetric fascial avulsion and the secondary connective tissue weakness that accumulates over time. Plication repairs are therefore palliative, rather than curative. Given the astounding prevalence and high cost burden of pelvic organ prolapse, society can no longer afford to persist with suboptimal therapies. This chapter examines lessons from hernia surgery that should catalyze a dramatic improvement in prolapse repair outcomes. Hernia formation reflects both mechanical and metabolic events.12/2010: pages 19-39;
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ABSTRACT: Currently, most implants used for reinforcement in surgical treatment of pelvic floor disorders are knitted monofilament polypropylene (PP). While previously recognized as inert, PP is associated with high complication rates. Some recent literature suggests polyester prosthetics based on poly(ethylene terephthalate) (PET), which may be more inert in vivo. A sample of 100 implants explanted from patients due to complications was examined to evaluate the relative degradation characteristics of PP and PET prosthetics. Histological, microscopic (scanning electron microscopy, SEM) and chemical analysis (Fourier transform infrared (FTIR) spectroscopy and differential scanning calorimetry (DSC)) were conducted on these explants. Poly(ethylene terephtahlate) explants appeared to sustain less degradation in vivo than the PP explants observed in this cohort. This is the first study to evaluate synthetic implants used in a vaginal approach for pelvic floor reinforcement. The study provides evidence contrary to published literature characterizing PP as inert in such applications. Additionally, the study suggests the need for clinical trials comparatively investigating the performance of new types of monofilament prosthetics, such as those comprising PET.International Urogynecology Journal 03/2010; 21(3):261-70. · 2.17 Impact Factor
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ABSTRACT: AIMS: The use of surgical mesh for female pelvic floor reconstruction has increased in recent years. However, there is paucity of information about the biological responses of host stroma cells to different meshes. This study was aimed to establish an in vitro experimental model to study the micro-environment of extracellular matrix (ECM) with embedded mesh and the stroma cell behaviors to different synthetic meshes. METHODS: Matrigel multi-cellular co-culture system with embedded mesh was used to evaluate the interaction of stroma cells and synthetic mesh in a simulated ECM environment. Human umbilical vein endothelial cells (HUVEC) and NIH3T3 fibroblasts were inoculated in the system. The established multi-cellular Matrigel co-culture system was used to detect stroma cell recruitment and tube formation ability for different synthetic meshes. RESULTS: HUVEC and NIH3T3 cells were recruited into the mesh interstices and organized into tube-like structures in type I mesh material from Perigee, Marlex and Prolift 24 hr after cell inoculation. On the contrary, there was little recruitment of HUVEC and NIH3T3 cells into the type III mesh of intra-vaginal sling (IVS). CONCLUSIONS: The Matrigel multi-cellular co-culture system with embedded mesh offers a useful in vitro model to study the biological behaviors of stroma cells in response to different types of synthetic meshes. The system can help to select ideal mesh candidates before actual implantation into the human body. Neurourol. Urodynam. © 2013 Wiley Periodicals, Inc.Neurourology and Urodynamics 06/2013; · 2.67 Impact Factor
Taiwan J Obstet Gynecol • June 2008 • Vol 47 • No 2
■ REVIEW ARTICLE ■
The high recurrence rate (30%) after surgery for
pelvic organ prolapse (POP) makes a more refined
reconstructive surgery imperative . There are some
risk factors for POP recurrence, e.g. poor tissue quality
before and during surgery, impaired healing, chronic
diseases causing increased intra-abdominal pressure
(due to obstructive pulmonary disease, asthma or con-
stipation), high-grade cystocele, and age 60 years or
older [2,3]. Patients with risk factors may benefit from
adjuvant prosthetic materials during pelvic reconstruc-
tive surgery. Therefore, biological and synthetic prosthe-
ses have emerged as adjuvant prosthetic materials .
Through the evolution of pelvic reconstructive surgery,
prostheses have played important roles as reinforcement
THE USE OF PROSTHESES IN PELVIC
RECONSTRUCTIVE SURGERY: JOY OR TOY?
1Division of Urogynecology and Pelvic Floor Reconstruction, Department of Obstetrics and Gynecology, Chi Mei Foundation
Hospital, Tainan, and 2Department of Obstetrics and Gynecology, College of Medicine, Taipei Medical University, Taipei, Taiwan.
The high recurrence rate of pelvic organ prolapse (POP) of up to 30% after pelvic reconstructive surgery makes
a more refined surgery imperative, as well as the need for either biological or synthetic prostheses as adjuvant
treatment. Patients with recurrence risks may benefit from the adjuvant treatment: (1) to substitute for the lack of
supportive tissue; (2) to reinforce inadequate tissue; (3) to induce new supportive tissue; and (4) to consolidate
and complement the insufficient surgical techniques. However, some debatable issues in use of the prosthetics
remain. The use of prosthetics enables the simultaneous repair of all vaginal defects of POP and concomitant
anti-incontinence surgery to be faster, easier and more precise. Nevertheless, great care should be devoted to
the actual and theoretical short- and long-term risks, many of which have not been fully elucidated. Despite the
lack of various ideal characteristics, the type I monofilament, macroporous polypropylene, has been suggested
to have the lowest incidence of infection and erosion among the nonabsorbable prostheses. There is good evidence
to support the use of nonabsorbable synthetic mesh for abdominal sacrocolpopexy, while the use of prostheses
for repairing isolated anterior and posterior compartment defects remains controversial. There have been no
long-term studies with sufficient patient numbers to prove whether synthetic or biological prostheses are superior
during vaginal surgery. Tension-free vaginal mesh techniques with procedural kits are being adopted increas-
ingly, despite the paucity of data. Although short-term follow-up studies have shown tension-free vaginal mesh
to be a safe and effective technique to correct POP, anatomic and functional results of long-term follow-up
studies, however, have not yet confirmed the effectiveness and safety. Mesh erosion remains a concern, with
variable rates according to different materials and approaches. Newly developed prostheses offer an alternative
option to pelvic reconstructive surgery. However, some questions remain: (1) Should prostheses be considered
for primary repairs, secondary repairs, or solely in patients with risk factors for recurrence? (2) Which prosthetic
material is better: synthetic or biological ones; absorbable or nonabsorbable ones? (3) Do the benefits of pros-
thetics in pelvic reconstructive surgery outweigh the risks of complications? These questions are explored and
reports in the literature reviewed. [Taiwan J Obstet Gynecol 2008;47(2):151–156]
Key Words: pelvic organ prolapse, pelvic reconstructive surgery, prosthesis, tension-free vaginal mesh
*Correspondence to: Dr Ming-Ping Wu, Division of
Urogynecology and Pelvic Floor Reconstruction,
Department of Obstetrics and Gynecology, Chi
Mei Foundation Hospital, 901, Chung Hwa Road,
Yung Kang City, Tainan, Taiwan.
Accepted: January 4, 2008
adjuvant (Figure). Once a successful material is identi-
fied or developed, it may decrease operating time and
morbidity during vaginal surgeries. However, some de-
batable issues in the use of prostheses for pelvic floor
reconstructive surgery remain.
Prostheses can serve as a scaffold for tissue in growth
after pelvic reconstructive surgery with the purpose to:
(1) substitute for the lack of supportive tissue; (2) rein-
force inadequate tissue; (3) induce new supportive tissue
growth; and (4) consolidate and complement insuffi-
cient surgical techniques . With the use of prosthe-
ses, the surgeon can repair all vaginal defects faster,
easier and more accurately. In the anterior compart-
ment, a graft can be anchored bilaterally to the arcus
tendineus fasciae pelvis, re-creating a level II attachment.
In the apical and posterior compartment, it is located
apical and posterior to the level of the ischial spine,
re-creating a level I support . Prostheses can also be
potentially used to treat stress urinary incontinence con-
comitantly using different shaped materials . The ideal
pelvic reconstructive surgery of severe cystocele should
include repair of bladder herniation, correction of
coincident stress urinary incontinence without causing
obstruction, and retention or improvement of vaginal
depth and axis .
Historically, the use of synthetic nonabsorbable pros-
theses, recently reviewed by Birch , dates to the
beginning of the 20thcentury with the use of metallic
silver mesh as early as 1903, which was followed by the
use of nylon mesh in 1938, and Dacron (Mersilene) in
1956. Mersilene was a popular prosthetic material for
many decades, but its use is rapidly declining in favor
of polypropylene, which is now the most commonly used
synthetic product and was introduced as Marlex in
With the accumulating experience in general sur-
gery, more recent reports in the surgical literature has
suggested the routine use of synthetic prosthesis for all
primary hernia repairs. Luijendijk et al  reported
on the recurrence rates of inguinal hernias following
primary suture repair compared with augmented repair
employing a synthetic graft, with a 43% recurrence in
the suture repair group versus 24% in the mesh aug-
mented repairs after 3 years of follow-up. Surgical prin-
ciples for the correction of POP are similar to those
employed for abdominal wall hernias. Gynecologists
performing reconstructive pelvic floor surgery have begun
to adopt these surgical principles and are using a variety
of synthetic and biological products for both primary
and secondary prolapse surgeries. Nevertheless, great
care should be devoted to actual and theoretical short-
and long-term risks, many of which have not been fully
elucidated. In this review article, the characteristics of
the different prostheses, the use synthetic prostheses
for pelvic reconstructive surgery, and the associated
complications of prostheses are included.
Characteristics of Different Prostheses
The ideal prosthesis should be sterile, durable, noncar-
cinogenic, inexpensive, easily applied, and causes no
antigenic response but withstands remodeling by body
tissues . Current prostheses are either synthetic
(absorbable, nonabsorbable or mixed) or biological
(autologous, allograft or xenograft donor tissue) for
the purpose of integrating with the host tissue and
supporting the attenuated areas.
Synthetic absorbable and nonabsorbable materials
These implants differ not only with respect to the
material (polyethylene, polypropylene, polypropylene
terephthalate, Gore-Tex) but also in terms of structure
(woven, knitted), fiber type (monofilament, multifila-
ment, monofilament/multifilament), pore size, mechan-
ical properties, shape, and surface characteristics .
Most commercially available synthetic prostheses in
surgical fields are listed in the Table according to the
Amid classification .
Nonabsorbable materials: e.g. Prolene (Ethicon,
Somerville, NJ, USA), Marlex (Bard, Cranston, RI,
USA), Atrium (Atrium, Hudson, NH, USA), Gore-
Tex (Gore, Flagstaff, AZ, USA), Mersilene (Ethicon,
Somerville, NJ, USA), and Teflon (DuPont,
Wilmington, DE, USA), Cellgard (Hoechst-Celanese,
Charlotte, NC, USA).
Taiwan J Obstet Gynecol • June 2008 • Vol 47 • No 2
Vaginal total hysterectomy + anterior-posterior colporrhaphy
Tension-free vaginal mesh with procedural kits*
Vaginal repair of anterior, posterior compartment + mesh
Abdominal sacrocolpopexy ± mesh
Sacrospinous ligament suspension
Figure. The evolution of pelvic reconstructive surgeries.
*Include Prolift (Gynecare, Ethicon, Somerville, NJ, USA);
Perigee and Apogee (American Medical Systems, Minnetonka,
MN, USA); posterior intravaginal slingplasty (United States
Surgical, Tyco Healthcare, Norwalk, CT, USA); Nazca
(Promedon, Cordoba, Argentina).
Absorbable materials: e.g. Vypro, Vicryl (Ethicon,
Somerville, NJ, USA).
Biological materials are categorized as follows:
Xenograft: porcine small intestine submucosa (SIS;
Cook, Letchworth, UK), bovine pericardium, and
Pelvicol (Bard, Billerica, MA).
Allograft: dura mater, fascia lata.
Autologous material: rectus sheath, fascia lata, and
The newly developed absorbable material called SIS
(Cook, Lafayette, IN, USA) is also worth our attention
. SIS is a natural biomaterial harvested from the
porcine small intestine and made into a biocompatible
medical product. The emergence of absorbable material
may bring a new era; however, owing to limited number
of reports in the literature, the long-term effect remains
Since no ideal prosthesis with the various character-
istics is available, the search for the optimal prosthesis
Synthetic Prostheses for Pelvic
The efficacy of nonabsorbable synthetic prostheses
for abdominal sacrocolpopexy is assured by supportive
evidence . There have been many reports in the lit-
erature on the support of the middle compartment.
First described by Lane in 1962 , sacrocolpopexy has
undergone numerous modifications, including the type
of prosthesis used and placement onto the anterior
and posterior walls of the vagina. In a recent comprehen-
sive review of 98 articles on abdominal sacrocolpopexy,
the success rate, when defined as lack of apical pro-
lapse postoperatively, was 78–100% and when defined
as no postoperative prolapse, was 58–100%; the follow-
up duration for most studies ranged from 6 months to
3 years. The median rate for a second operation for
POP and/or stress urinary incontinence after abdomi-
nal sacrocolpopexy was 4.4% (range, 0–18.2%) .
Synthetic rather than biological prostheses for bridg-
ing the vagina to the sacrum was supported by a recent
randomized trial by Culligan et al , who asserted
that polypropylene mesh (91% cure) was better than
cadaveric fascia lata (68% cure) for abdominal sacro-
colpopexy (p=0.007) at 1 year of follow-up. There were
significant differences in favor of the polypropylene mesh
group at points Aa and C of the POP quantification
system, as well as overall prolapse stages . Fitzgerald
et al  also noted poor anatomic outcomes (the
failure rate of 83% by 17 months) when freeze-dried,
irradiated donor fascia lata was used for abdominal
Vaginal repair of the anterior and posterior
The data available on synthetic nonabsorbable pros-
theses are sparse and largely consist of small retrospec-
tive series with short-term follow-up. Julian  first
described anterior vaginal colporrhaphy with prosthetic
Taiwan J Obstet Gynecol • June 2008 • Vol 47 • No 2
Prosthetics in Pelvic Reconstructive Surgery
Table. Classification of synthetic prostheses
Type Fiber typePore size ComponentBrand names
Type I Monofilament
>75µmPolypropylene Prolene (Ethicon, Somerville, NJ, USA)
Marlex (Bard, Billerica, MA, USA)
Atrium (Atrium, Hudson, NH, USA)
<10µmePTFEGore-Tex (Gore, Flagstaff, AZ, USA)
Type III Multifilament
Polyethylene Dacron (Mersilene; Ethicone, Somerville, NJ, USA)
Teflon (DuPont, Wilmington, DE, USA)
SurgiPro (Autosuture, Tyco Healthcare,
Norwalk, CT, USA)
<1µmPolypropylene sheet Silastic (Dow Corning, Midland, MI, USA)
Cellgard (Hoechst-Celanese, Charlotte,
Vypro (Ethicon, Somerville, NJ, USA)
Vicyl (Ethicon, Somerville, NJ, USA)
reinforcement in 1996. The prospective study used
Marlex (Bard, Billerica, MA, USA), a type I monofila-
ment polypropylene prosthesis, which was randomly
allocated to 24 patients with anterior colporrhaphy with
or without prosthetic reinforcement, and showed suc-
cess rates of 100% and 66%, respectively, at 24 months’
follow-up; however, there was a high erosion rate of 25%
(4 /12) . A retrospective analysis by Flood et al 
of 142 women using Marlex revealed a success rate
(prolapse less than grade 1) of 100% at a mean follow-
up of 36 months, with no prosthetic-related complica-
tions. Dwyer and O’Reilly  used a polypropylene
prosthesis (Atrium) in the anterior and posterior com-
partments and showed a recurrence rate of 6%. de
Tayrac et al  reported a recurrence rate of 8% and
seven erosions (8.3%) using the polypropylene pros-
thesis Gynemesh (Gynecare, Ethicon, Somerville, NJ,
USA) on 87 women with a mean follow-up of 24 months.
The studies using polypropylene meshes to augment
the surgically corrected anterior vaginal prolapse showed
success rates of 87% , 91.6% , and 100% .
The researchers concluded that the use of nonabsorbable
prosthetic reinforcement appeared to be an effective
method of preventing prolapse recurrences; however,
the concerns included the short-term follow-up periods
and material erosion rates.
Owing to the limited number of reports on graft
augmentation in the posterior vaginal wall, the data
on the effects of graft augmentation on the bowel,
bladder and sexual function are limited. Milani et al
 reported a prospective observational cohort of
63 women who had conventional anterior (n=32) or
posterior (n=31) colporrhaphies augmented with poly-
propylene mesh. Both groups had excellent anatomic
outcomes at 12 months after surgery (94% with stage 0)
but had significant increases in the rates of dyspareu-
nia. Of those who had anterior mesh repairs, 20% had
worsening dyspareunia after their repairs, while 63% of
those who had posterior mesh repairs developed wors-
ening dyspareunia . The authors concluded that
while the studies showed good anatomic results with
the use of Prolene mesh for vaginal prolapse repairs,
the morbidity rates, however, were high . In addi-
tion, Deffieux et al  reported a comparable inci-
dence of de novo dyspareunia in patients with vaginal
erosion and those without it (9% vs. 11%; p=0.85).
The use of synthetic absorbable prostheses is a
response to the morbidity arising from the erosion rates
with the use of synthetic nonabsorbable prostheses.
Two prospective randomized controlled trials compared
synthetic absorbable prostheses, polyglactin 910 (Vicryl;
Ethicon, Somerville, NJ), with traditional transvaginal
repairs. Sand et al  studied 161 women (21 recurrent
and 140 primary), with significantly lower recurrence
rates found in the prosthetic-reinforced repair group
compared with the non-reinforced group (25% vs. 43%;
p=0.002) at 12 months of follow-up. Weber et al 
undertook a prospective three-armed randomized con-
trolled trial on 114 patients and found that absorbable
augmented meshes (polyglactin 910 mesh) did not im-
prove anatomic results at a mean follow-up of 23 months
(range, 4.5–44 months).
Tension-free vaginal mesh (TVM) techniques with
The TVM techniques with procedural kits, which include
disposable insertion needles, retrieval devices and pieces
of polypropylene mesh, are increasingly being adopted,
e.g. anterior, posterior and total Prolift (Gynecare,
Ethicon, Somerville, NJ, USA), Apogee and Perigee
(American Medical Systems, Minnetonka, MN, USA),
and Nazca (Promedon, Cordoba, Argentina). These
TVM techniques with procedure kits were designed
to offer a simple and efficient surgical technique, re-
duce the surgery time, shorten the learning curve, transfer
the anchoring arms simply and precisely, and simplify
the tension-free system. Also, the use of monofilament
macroporous polypropylene mesh improves tissue inte-
gration, promotes tissue ingrowth, and minimizes ero-
sion and exposition risk. Therefore, they potentially offer
a minimally invasive approach by the ergonomically
designed handle system. Based on a retrospective mul-
ticentric study, the perioperative and immediate post-
operative results demonstrated a failure rate (recurrent
prolapse even asymptomatic or low grade symptomatic
prolapse) of 4.7% (5/110) . The authors concluded
that the Prolift repair seems to be a safe technique to
correct POP. However, anatomic and functional results
of a long-term follow-up study has not confirmed the
effectiveness or safety of the procedure .
In summary, the synthetic prostheses for sacrocol-
popexy are well established yet remain controversial for
repairing isolated anterior and posterior compartment
defects. No long-term studies with sufficient patient
numbers have been conducted to conclude whether
synthetic or biological prostheses are superior for use
in vaginal surgery.
Complications of Use of Prostheses in
Pelvic Reconstructive Surgery
Mesh erosion remains a major concern in the use of
prostheses in pelvic reconstructive surgery. In the study
by Nygaard et al , the complications attributable
to erosion occurred in 3% of patients in 20 studies of
Taiwan J Obstet Gynecol • June 2008 • Vol 47 • No 2
abdominal sacrocolpopexy. The posterior placement
of prosthesis to the perineal body using a combined
abdominal and vaginal approach was associated with
a high sepsis and erosion rate (40%) .
Based on a retrospective study of 138 transvaginal
repairs of cystocele using Gynemesh or Gynemesh Soft
mesh, age was an independent predictive factor of vagi-
nal erosion (age, >70 years; odds ratio, 3.6; p=0.010).
On the contrary, cystocele stage of more than 2 (Baden
and Walker classification) was a protective factor against
vaginal erosion (odds ratio, 0.3; p=0.016) .
Mesh erosion differs in different types of prostheses
Erosion rates vary according to the different types of
prostheses. Early experience with type II and type III
synthetic prostheses for pelvic reconstructive surgery
was associated with a significantly high postoperative
mesh erosion rate of 20–30% after Dacron or Gore-Tex
use [15,31]. The woven, multifilament nature of these
mesh materials might cause limited host tissue ingrowths,
leading to erosions, draining sinuses and fistulae. More
recently, some concern has arisen about a relatively high
erosion rate (17%) seen with the intravaginal slingplasty
(United States Surgical, Tyco Healthcare, Norwalk, CT,
USA) sling material . The erosion rate decreased
to 0.5–5% by using type I synthetic prosthesis . The
erosion rate of the currently available synthetic pros-
thesis has been reported to be 0.5% for polypropylene,
3.1% for polyethylene terephthalate (Mersilene; Ethicon,
Somerville, NJ, USA), 3.4% for Gore-Tex (Gore, Flagstaff,
AZ, USA), 5.0% for polyethylene (Marlex; Bard, Billerica,
MA, USA), and 5.6% for Teflon (DuPont, Wilmington,
DE, USA) .
Mesh erosion differs in different approaches
Erosion rates also vary according to the different types
of approaches. Visco et al  retrospectively analyzed
Mersilene mesh erosion rates in 273 women who had
undergone sacrocolpopexy or sacral colpoperineopexy;
the overall risk of erosion was 3.2% for abdominal
sacrocolpopexy (median time to erosion, 15.6 months)
and 4.5% for abdominal sacral colpoperineopexy
(median time to erosion, 12.4 months), by introducing
the prostheses and sutures abdominally. Erosion rate
increased to 16% when sutures were placed vaginally
and attached to an abdominally introduced mesh dur-
ing sacral colpoperineopexy (median time to erosion,
9.0 months). When the mesh was introduced vaginally,
the erosion rate peaked at 40% (median time to ero-
sion, 4.1 months). The three most recent studies of
polypropylene mesh augmenting the surgical correction
of anterior vaginal prolapse reported an erosion rate
of 8.3–13% [23–25]. Deffieux et al  recommended
that vaginal mesh placement should be avoided for
women with moderate cystocele, and those with total
hysterectomy and vertical incision, if possible. Managing
vaginal erosion is simple and associated with a low rate
of morbidity. However, patients should be informed of
the risk of postoperative mesh erosion.
TVM techniques with procedural kits
Analyzing the first 100 TVM procedures with proce-
dural kits revealed a 17.5% erosion rate, which fell to
2.7% when T-shaped colpotomies, concomitant hyster-
ectomy and perineal incisions were avoided . In a
retrospective multicentric study of 110 patients, peri-
operative and immediate postoperative results showed
mesh exposure in five cases (4.7%), two of which required
surgical management . Granuloma without exposure
was found in three cases (2.8%) .
The choice for better prosthetic materials
The choices for better materials are of prime importance.
Synthetic prostheses types II and III have resulted in
unacceptably high rates of postoperative erosion and
should be abandoned. One of the potential advan-
tages of absorbable or biological prostheses is the low
erosion rate. If erosion occurs, conservative manage-
ment should be used and surgery is seldom required
. Although the reports in the literature are difficult
to interpret because of the diversity of studies and other
factors, synthetic grafts generally may have slightly
higher success rates but higher erosion rates, whereas
biological materials appear to be better tolerated with
lower erosion rates . Current evidence suggests that
the use of monofilament, macroporous polypropylene
has the lowest incidence of infection and erosion when
compared among the nonabsorbable meshes .
Unanswered Questions and Discussion
The evolution of newly developed prostheses offers a
new era in pelvic reconstructive surgery. However, some
unanswered questions remain: (1) Should prostheses
be considered for primary repairs, secondary repairs
or solely in patients with risk factors for recurrence
(diabetics, obesity, steroid use, chronic respiratory dis-
ease)? (2) No ideal prostheses with the various charac-
teristics are available now. Which prosthesis is optimal:
synthetic nonabsorbable, synthetic absorbable, mixed
synthetic or biological prostheses? (3) Do the benefits
of prostheses for pelvic reconstructive surgery out-
weigh their risk of complications? Therefore, further
well-designed randomized control trials as well as basic
studies are needed to answer these questions.
Taiwan J Obstet Gynecol • June 2008 • Vol 47 • No 2
Prosthetics in Pelvic Reconstructive Surgery
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Taiwan J Obstet Gynecol • June 2008 • Vol 47 • No 2