Managing mesh exposure following vaginal prolapse repair: a decision analysis comparing conservative versus surgical treatment

Abstract

A decision analysis model was developed comparing conservative and surgical treatments in the management of synthetic mesh exposure following vaginal prolapse repair. We hypothesized that surgical excision would be favored. A Markov decision analysis model compared initial management with conservative versus surgical treatment allowing for the complexities of multiple attempts at conservative management and/or surgical mesh excision. Model assumptions were obtained from published literature or through surrogate values and expert consensus when not available in published resources. Transitions were made between Markov states at 6-week intervals and overall utility was compared over 2 years. Multiple one-way sensitivity analyses were performed. Initial surgical excision was favored, with an average yearly quality adjusted life year (QALY) value of 0.947 compared to 0.939 for conservative treatment. This difference is less than the published minimally important difference (MID) for utility values. One-way sensitivity analyses revealed that surgical excision is favored when the probability of being healed with conservative therapy is less than 80 % (base case 57.1 %) and when the probability of being healed from surgery is greater than 78 % (base case 93.2 %). Few thresholds confirmed model robustness. While our model favored surgical excision over conservative treatment in the initial management of mesh exposure following vaginal prolapse repair with synthetic mesh, the difference in QALYs between strategies was less than the MID. Therefore the strategies are likely similar overall. Individual patient characteristics may ultimately drive clinical decision-making for this surgical complication.