To mesh or not to mesh: a review of pelvic organ reconstructive surgery

Pelvic organ prolapse (POP) is a major health issue with a lifetime risk of undergoing at least one surgical intervention estimated at close to 10%. In the 1990's, the risk of reoperation after primary standard vaginal procedure was estimated to be as high as 30 to 50%. Based on this estimate of recurrence and in order to reduce the risk of relapse, gynecological surgeons started to use mesh implants in pelvic organ reconstructive surgery with the emergence of new complications, also implying reoperations. With the success of mesh in reducing the risk of recurrence for abdominal hernia (75% reduction), it was hypothesized that its use could proffer similar benefits in POP surgery. Recent studies have nevertheless shown that the risk of POP recurrence requiring reoperation is lower than previously estimated, being closer to 10% rather than 30%. The development of mesh surgery, under considerable pressure and incentives from the marketing industry, was tremendous during the past decade, and preceded any studies supporting its benefit for our patients. Nowadays, randomized trials comparing the use of mesh to native tissue repair in POP surgery have shown better anatomical outcomes, but similar functional outcomes, and that meshes are associated with more complications, in particular for transvaginal mesh implants. POP is not a life-threatening condition, but a functional problem that impairs quality of life for women. The old adage “primum non nocere” is particularly appropriate when dealing with this condition which is currently admitted to be physiological with aging when situated above the landmark of the hymen and requires no treatment when asymptomatic. Each patient and each situation must be treated specifically and the use of mesh needs to be selective and appropriate. Mesh implants are probably an important tool in pelvic reconstructive surgery, but the ideal implant has yet to be found, and the indications for its use still requires caution and discernment. This review explores the reasons behind the introduction of mesh augmentation in pelvic organ prolapse surgery, and aims to clarify the risks, benefits, and above all the recognized indications for its use