Why I still use Transvaginal Mesh in prolapse surgery

I am aware that most of the developed countries have stopped using mesh trans-vaginally. Then why am I still using it? I stick to the use of mesh out of our observations of general gynecological practice in the last nearly 54 years and vaginal use of mesh in the recent 15 years.

The occasions I use mesh vaginally are:

1. Recurrent or massive genital prolapse
2. Laparoscopic Khanna Sling

Genital Prolapse: If the prolapse is recurrent or massive, what I have found is native tissue repair does not hold and give as good a result as with mesh. The other option that many people employ, viz laparoscopic sacrocolpopexy may not be possible in many of these women who are elderly and with comorbidities . The reason for abandoning mesh by the developed countries was the warning by FDA, following which most of the manufacturers have stopped production of mesh kits. What we do is to use self-cut mesh from the mesh sheets available in the country. This makes it so much cheaper and we use reusable trocars. This makes the surgery affordable.

We have been using mesh since 2008 but have the data for the period 2015 onwards. The practice has changed over the years due to change in the availability and type of mesh. Earlier we had macroporous soft mesh sheets. The ones that are available at present are not as soft as the earlier version (Hexapro) but is equally porous. We get supple vaginal walls after mesh overlay.

The complication of erosion or exposure was the most common. We have done an average of 30 cases of prolapse mesh surgery per year. Earlier there were isolated complications – one erosion into bladder, one erosion into bowel, and one case of ureteric damage needing reimplantation. These happened when we didn’t have enough supply of the soft product. We had to mix the soft central core with the not so soft tails and the problem happened at the junction of these different types. Since we stopped joining up the different types of mesh in the last four years, there was no case of erosion or exposure.

Laparoscopic Khanna Sling for Nulliparous prolapse 

This is a technique we developed converting the open method of cervical sling by Brigadier Khanna to a laparoscopic technique using a combined approach – vaginal and laparoscopic.

Vaginally we amputate excess length of cervix, if present, and develop flaps around the cervix and anchor the tape to the posterior aspect of the cervix. If cervix was amputated, Stumdorf stitch is used to cover the raw area. The mesh (30 x1.2 cms) is anchored to the back of the cervix and the tape ends are put into the Pouch of Douglas. Then, using the laparoscope these ends are pulled out to the anterior abdominal wall on either side close to the lateral end on the inguinal ligament. Care must be taken to take the mesh strip between layers of the broad ligament without injuring adjacent vessels. Also, the tape on the pelvic side wall has to be superficial to the ureter. The lateral ends of the mesh are then anchored to the lateral ends of inguinal ligaments close to its insertion to the anterior superior iliac spine.

TOT: We routinely use trans-obturator tape with macroporous mesh cut into 30 x 1 cm pieces, plasma sterilized and used with reusable trocars. There was one case of failure of relief of symptoms. No case of erosion into urethra or bladder or need for prolonged catheterisation. We have used the mesh like this for more than 10 years.