“First do no harm” and the emerging story of the vaginal reconstructive mesh implant

Abstract

Contrary to popular belief, the words “first do no harm” are not actually in the Hippocratic oath but the above statement is. For this discussion I think the original correct version of the oath more accurately reflects my dilemma when I consider the use of vaginal reconstruction “mesh implants.” The question arises: Am I benefiting my patients or just being harmful and mischievous when I use an implant to reinforce a transvaginal repair? Why has there been this recent move toward using mesh implants? To quote my friend Bernard Haylen, “In terms of prolapse surgery, there has been at times a ‘holy grail’ mentality, a quest to achieve a prolapse repair with as close to 100% efficacy...” and this is where the problem starts. As a specialty, it is only within the last decade or two that we have reported the success rates of our surgeries to correct pelvic organ prolapse with painful accuracy. (At this point I would like to dismiss the use of mesh implants with an abdominosacrocolpopexy, as their use in this setting has been established). Currently, if we are completely honest, we have to acknowledge that using our traditional transvaginal surgical techniques the anatomic cure rates for correcting prolapse are less then stellar, with recurrence rates between 29 and 70% [1, 2]. This makes it very uncomfortable to discuss surgical options with the patient if we can only assure them that roughly one half to two third will get the anatomic or functional outcome that we as surgeons desire. Now this is not to say that we are not providing our patients any benefit. When we look closely at what our patients desire and how they perceive our surgical outcomes, it turns out that maybe we are too hard on ourselves. The same article that reported anatomic surgical failure rates between 54 and 70% (for three different techniques for an anterior colporrhaphy) also revealed that subjects were satisfied with their surgical outcomes as the overall symptom scores fell from 6.9 preop to 1.1 postop [1]. (The field of patient-focused outcomes is only in its infancy but will play a major role in pelvic reconstruction surgery). It was in the setting of accurately reporting our surgical success rates that we have began to look for techniques to improve on anatomical outcomes for pelvic organ prolapse corrective surgery, thus the mesh implant was introduced. Initially, they were used to reinforce vaginal repairs only in patient who were considered at high risk (i.e., recurrences or subjects with medical comorbidities such as dermatomyositis, obesity, etc.), but of late they have become a supplement to primary repairs as we seek to provide more efficacious correction of pelvic organ prolapse. Are these implants truly reducing recurrences and making our patients happy or are they introducing a whole new set of concern that we are yet to fully appreciate? I do not know the answer to this question but I know it needs to be addressed. One of the biggest concerns, as we introduce foreign bodies into the subepithelial layer of the vagina, are the rates of erosion or exposure of the mesh and how that influences patient’s perceptions of success. As we move toward anatomic cures, have we forgotten that first and foremost we want patients that are satisfied with their outcome? Rates Int Urogynecol J (2007) 18:983–984 DOI 10.1007/s00192-007-0357-1