By Dr Fred Busch, Obstetrician and Gynaecologist
The development of pelvic mesh products was not the profession’s ‘finest hour’. Women face many barriers when seeking treatment after things have gone wrong following mesh pelvic organ prolapse (POP) repair surgery. Getting diagnosed can be very difficult, and most of the care is poorly co-ordinated and mainly in the private sector, which costs the women impacted.
It is unfortunate mid-urethral slings (MUS) have often been included in criticism of synthetic implants since MUS carry less risk (when comparing with most other available continence surgeries) and should be seen as a separate entity from mesh used for POP repair. The mean total complication rate for mesh POP repair is 20-40% while for MUS it is 4% at 24 months following surgery.
Media attention around mesh for pelvic floor repair has caused unnecessary concern and fear amongst Australian women seeking treatment for stress urinary incontinence (SUI), a common and debilitating condition. When conservative measures fail, MUS is often the best option.
There are three types of MUS:
- Retropubic (RPR) such as TVT. The incisions are vaginal and just above the pubic bones.
- Transobturator (TOR) such as TVT-O and Obtryx-II. The incisions are vaginal and in the groins.
- Single incision slings (SIS). The incision is vaginal.
RANZCOG supports the use of traditional MUS (RPR and TOR) for the surgical treatment of SUI. Currently available SIS have not demonstrated equivalent efficacy to traditional MUS and should only be used in properly conducted clinical trials in selected women. The TGA has removed SIS from the Australian Register of Therapeutic Goods.
In patients who are willing, a trial of conservative management in the form of pelvic floor exercise therapy (PFE) should be attempted. Where there is mixed incontinence, anticholinergics should be offered. Overall, the efficacy of PFE is around 40% and MUS around 70-80% in treating SUI. While weight loss significantly reduces the number of incontinence episodes in obese women, studies report similar efficacy rates for MUS in obese and non-obese patients.
The efficacy of RPR and TOR are similar in the short to medium term but some evidence suggests that in the longer term (> 5 years) RPR are more effective. Further long-term studies are required.
The risk of bladder perforation with MUS is 4-5%; provided the complication is identified, long term sequelae are uncommon. The risk of tape exposure is around 2% (compared to 3-18% with mesh for prolapse repair).
Post-operative voiding dysfunction occurs in 20-47% of MUS and there are data suggesting that TOR halves the risk compared to RPR. However, the requirement of urethrolysis is less than 3%. TOR MUS have a higher risk of groin pain which is usually transient. When intrinsic sphincter deficiency is found on urodynamic studies, RPR has a greater chance of success.
While women considering MUS surgery should be appropriately counselled, they may also be reassured that the likelihood of complications, including chronic pelvic pain and dyspareunia, is much less likely than with mesh POP repair. It is incumbent on the surgeon to communicate clearly and be as confident as possible that their patient is making an informed decision when contemplating MUS surgery.
Author competing interests: No relevant disclosures.
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