Do guns kill people or...? The mesh dilemma

Abstract

Many of the articles in this journal and others demonstratethe mixed messages of mesh augmented repairs for pelvicorgan prolapse. At this point, short-term data (2-yearfollow-up or less) suggest that its use for anteriorcompartment defects may provide an advantage over non-mesh augmented repairs [1, 2], but at what cost [3, 4]?Complications are certainly possible with any surgicalprocedure; but one of the most concerning complicationsthat can occur is worsening or de novo postoperative paindisorders. But are the complications of postoperative paincaused by the mesh kits or are they caused by thephysicians who are using them?I see many patients in my office sent from variousphysicians located throughout the Midwest with problems ofpostoperativepainafteramesh-augmentedtransvaginalrepairfor prolapse. Almost universally, these patients had a pelvicpain disorder that was either overt (i.e., patients who hadprolapsesurgerydonebecauseofthechiefcomplaintofpelvicpain described as pressure in the absence of prolapse beingpresent at the introitus or beyond) or had a more subtle pelvicpain disorder. These subtle pelvic pain disorders are oftencompensated for or tolerated by the patient for many years.These patients often have a history that is compatible withprimary dyspareunia or dysmenorrhea, vulvodynia, chronicconstipation, painful bladder syndrome, or fibromyalgia priortocomingtothesephysiciansaskingforsurgerytobedoneforprolapse. Clinicians must realize that 50-80% of patients withthese pelvic pain disorders have hypertonic pelvic floordysfunction and/or myofascial pain [5]. Attaching a piece ofmesh that then supports the prolapsed viscera at a single orpossibly four sites of attachments to these muscles that arealready spastic, hypertonic, and demonstrating dysfunctionand allodynia simply exacerbates and perpetuates theirchronic pain disorders.Wemustrememberthatprolapsedoesnotcausepelvicpain,especially when symptoms seem greater than the degree ofprolapse seen. If a patient has a history or findings compatiblewith pelvic floor tension myalgia and/or hypertonic dysfunc-tion we must avoid doing a surgery that involves attaching oranchoringthesupportoftheprolapsedorganstothesemuscles.This statement should not be surprising to any clinicianinvolved in the repair of pelvic organ prolapse because we allknow that procedures like sacro-spinous vaginal vault suspen-sions and posterior repairs done by techniques that involvelevatorplasty are often associated with both short-term andlong-term pain and often times dyspareunia for many yearspostoperatively.While these mesh kit procedures all involve attachmentto the pelvic floor muscles to anchor the entire repair, notall patients who undergo this procedure develop a signif-icant postoperative pelvic pain disorder. The use of musclesites seems to be intuitively a bad idea, but many of ourpatients tolerate this non-physiologic but anatomicallycorrect repair without problems. I contend that it is notthe mesh kit but the patient selection that is the key topreventing the induction of chronic myofascial pain and attimes causing these patients to become a pelvic cripple;unable to stand, sit, or have intercourse.Therefore, do guns kill people? No, people kill people.So we must avoid anchoring prolapsed organs to a fewmuscle sites in patients with pre-existing myofascialdysfunction and/or pelvic pain. These patients will bebetter served supporting their prolapse to the uterosacralligaments or the longitudinal ligament overlying the sacrum