Mesh contraction: myth or reality?

doi:10.1016/j.ajog.2010.08.058

American Journal of Obstetrics and Gynecology

Volume 204, Issue 2, February 2011, Pages 173.e1-173.e4

Presented at the joint meeting of the International Continence Society and the International Urogynecological Association, Toronto, ON, Canada, Aug. 23-27, 2010.

https://doi.org/10.1016/j.ajog.2010.08.058 Get rights and content

Objective

Mesh implants are widely used in surgery for female pelvic organ prolapse. Mesh shrinkage is thought to be common and caused by immunological processes. In this longitudinal study, we examined mesh dimensions at 2 time points after implantation.

Study Design

We analyzed translabial 4-dimensional ultrasound (US) volume datasets of women seen 3-52 months after anterior compartment mesh. Datasets of first and last postoperative appointments were analyzed, with the operator blinded against all other data.

Results

Forty women were assessed at least twice, comprising 59.6 woman-years. Thirty-seven of 40 (93%) were satisfied at their last appointment. Eighteen of 40 considered themselves cured, and 18 of 40 felt improved. Objective recurrence (cystocele stage 2 or greater) was seen in 16 of 40. Midsagittal mesh length increased significantly (35.8 vs 32.7; P = .006), and coronal mesh diameters increased nonsignificantly (37.4 vs 36.6 mm; P = .44).

Conclusion

Over an observation period of almost 60 woman-years, we found no evidence of mesh contraction.

Section snippets

Materials and Methods

As part of an ongoing audit of prolapse surgery, we analyzed ultrasound volume datasets obtained from women attending follow-up appointments 3 months to 5 years after Perigee mesh placement at our hospital. Perigee mesh augmentation of anterior colporrhaphy had been performed in standardized fashion according to the manufacturer's instruction, with the difference that we remove the tail of the mesh entirely before implantation. This leaves an almost square piece of mesh between the anchoring

Results

Interobserver repeatability data (n = 20) showed moderate to excellent repeatability for the measures of mesh position and dimensions used by us (between M.E. and H.P.D., Table 1). Of a total of 63 women who were recipients of a Perigee mesh between May 2005 and March 2009, 40 women were identified whom we had assessed at least twice. In total, our data comprises 59.6 woman-years, exceeding the requirement of the power calculation by almost 20%.

Mean age at last follow-up was 63.7 (range, 34–83)

Comment

The increasing use of mesh in pelvic reconstructive surgery since the development of the Perigee transobturator mesh by Rane and Fraser in 2004 has caused major ongoing controversies in urogynecology. Mesh-related chronic pain and mesh erosion are significant complications that have attracted considerable attention lately.⁹

Ultrasound is the method of choice for assessing intravaginal mesh because polypropylene meshes are highly echogenic and very difficult to impossible to image with plain

References (19)

A.L. Olsen et al.
Epidemiology of surgically managed pelvic organ prolapse and urinary incontinence
Obstet Gynecol
(1997)
J. Whiteside et al.
Risk factors for prolapse recurrence after vaginal repair
Am J Obstet Gynecol
(2004)
H. Dietz
Pelvic floor ultrasound: a review
Am J Obstet Gynecol
(2010)
M. Garcia-Urena et al.
Differences in polypropylene shrinkage depending on mesh position in an experimental study
Am J Surg
(2007)
A. Bako et al.
Review of synthetic mesh-related complications in pelvic floor reconstructive surgery
Int Urogynecol J
(2009)
M. Fialkow et al.
Incidence of recurrent pelvic organ prolapse 10 years following primary surgical management: a retrospective cohort study
Int Urogynecol J
(2008)
H.P. Dietz et al.
Levator avulsion is a risk factor for cystocele recurrence
Ultrasound Obstet Gynecol
(2010)
H. Dietz
To mesh or not to mesh
Aust NZ J Obstet Gynaecol
(2009)
B. Feiner et al.
Efficacy and safety of transvaginal mesh kits in the treatment of prolapse of the vaginal apex: a systematic review
Br J Obstet Gynaecol
(2009)

There are more references available in the full text version of this article.

Cited by (44)

Pelvic organ prolapse meshes: Can they preserve the physiological behavior?
2021, Journal of the Mechanical Behavior of Biomedical Materials
Citation Excerpt :
Complications were classified by severity during the healing and at the time of sacrifice: hematoma, infection, mesh exposition, or erosion. Mesh contraction is often believed to cause pain and discomfort to the patient (Dietz et al., 2011). The shrinkage of the mesh was assessed by evaluating the contraction of the mesh prior to harvesting.
Implants for the cure of female genital prolapse still show numerous complications cases that sometimes have dramatic consequences. These implants must be improved to provide physiological support and restore the normal functionalities of the pelvic area. Besides the trend towards lighter meshes, a better understanding of the in vivo role and impact of the mesh implantation is required. This work investigates the mechanical impact of meshes after implantation with regards to the behavior of the native tissues. Three meshes were studied to assess their mechanical and biological impact on the native tissues. An animal study was conducted on rats. Four groups (n = 17/group) underwent surgery. Rats were implanted on the abdominal wall with one of the three polypropylene knitted mesh (one mesh/group). The last group served as control and underwent the same surgery without any mesh implantation.
Post-operative complications, contraction, mechanical rigidities, and residual deformation after cyclic loading were collected. Non-parametric statistical comparisons were performed (Kruskal-Wallis) to observe potential differences between implanted and control groups.
Mechanical characterization showed that one of the three meshes did not alter the mechanical behavior of the native tissues. On the contrary, the two others drastically increased the rigidities and were also associated with clinical complications. All of the meshes seem to reduce the geometrical lengthening of the biological tissues that comes with repetitive loads.
Mechanical aspects might play a key role in the compatibility of the mesh in vivo. One of the three materials that were implanted during an animal study seems to provide better support and adapt more properly to the physiological behavior of the native tissues.
Ultrasound in the assessment of pelvic organ prolapse
2019, Best Practice and Research: Clinical Obstetrics and Gynaecology
Citation Excerpt :
Position and mobility of vaginal wall mesh on Valsalva can be determined, as well as dislodgement of anchoring arms and prolapse recurrence. These meshes do not shrink in vivo, as sometimes claimed [26,27] Surgical technique certainly is important in determining mesh appearance and the likelihood of post-operative stress urinary incontinence [25]. Non-anchored mesh ('overlay techniques') has not been shown to be effective, and transobturator mesh strips seem to be more effective than plastic barbs in providing mid-vaginal support [28].
Imaging is increasingly being used in urogynaecology. Because of low cost and universal availability, ultrasound (US) is the most commonly used diagnostic modality, which allows the observation of manoeuvres such as Valsalva and pelvic floor muscle contraction in real time. The ability to see beyond surface anatomy is particularly important in the posterior compartment and in obstructed defecation where this method may replace defecation proctography. Imaging is especially useful in the form of 3D/4D multiplanar and tomographic translabial US, as these modalities give access to the axial plane and the levator ani. This allows assessment of both avulsion, i.e. major maternal birth trauma, and hiatal overdistension, i.e. ballooning. Both are major risk factors for both prolapse and prolapse recurrence. This review will outline current clinical utility, introduce recent research in the respective field and provide an overview of likely future utility of imaging in the investigation of pelvic organ prolapse.
Mechanical biocompatibility of highly deformable biomedical materials
2015, Journal of the Mechanical Behavior of Biomedical Materials
Citation Excerpt :
A recent investigation provides insights into the ex-vivo mechanical response of the human abdominal wall and the effect of mesh repair (Podwojewski et al., 2014). Current efforts are also directed towards the determination of the in vivo state of deformation of meshes after implantation (Dietz et al., 2011; Eisenberg et al., 2014; Endo et al., 2014; Guillaume et al., 2012; Svabik et al., 2011). The results of these studies could be used to validate the predictive capabilities of (multi-scale) mechanical models of mesh implants, including their interaction with a matrix of native tissue (Rohrnbauer et al., 2014; Rohrnbauer and Mazza, 2013).
Mismatch of mechanical properties between highly deformable biomedical materials and adjacent native tissue might lead to short and long term health impairment. The capability of implants to deform at the right level, i.e. similar to the macroscopic mechanical response of the surrounding biological materials, is often associated with dissimilar microstructural deformation mechanisms. This mismatch on smaller length scales might lead to micro-injuries, cell damage, inflammation, fibrosis or necrosis. Hence, the mechanical biocompatibility of soft implants depends not only on the properties and composition of the implant material, but also on its organization, distribution and motion at one or several length scales. The challenges related to the analysis and attainment of mechanical biocompatibility are illustrated with two examples: prosthetic meshes for hernia and pelvic repair and electrospun scaffolds for tissue engineering. For these material systems we describe existing methods for characterization and analysis of the non-linear response to uniaxial and multiaxial stress states, its time and history dependence, and the changes in deformation behavior associated with tissue in-growth and material resorption. We discuss the multi-scale deformation behavior of biomaterials and adjacent tissue, and indicate major interdisciplinary questions to be addressed in future research.
Assessment of Collagen-Coated Anterior Mesh Through Morphology and Clinical Outcomes in Pelvic Reconstructive Surgery for Pelvic Organ Prolapse
2014, Journal of Minimally Invasive Gynecology
To assess the morphologic features of anterior armed transobturator collagen-coated polypropylene mesh and its clinical outcomes in pelvic reconstructive surgery to treat pelvic organ prolapse.
Evidence obtained from several timed series with intervention (Canadian Task Force classification II-3).
Chang Gung Memorial Hospital, Taoyuan, Taiwan, China.
Between April 2010 and October 2012, 70 patients underwent surgery to treat symptomatic pelvic organ prolapse, stage III/IV according to the POP-Q (Pelvic Organ Quantification System).
Anterior armed transobturator collagen-coated mesh.
Measurement and Main Results: Morphologic findings and clinical outcome were measured. Morphologic features were assessed via 2-dimensional introital ultrasonography and Doppler studies. Clinical outcome was measured via subjective and objective outcome. Objective outcome was assessed via the 9-point site-specific staging method of the International Continence Society Pelvic Organ Prolapse Quantification before the operation and at 1-year postoperative follow-up. Subjective outcome was based on 4 validated questionnaires: the 6-item UDI-6 (Urogenital Distress Inventory), the 7-item IIQ-7 (Incontinence Impact Questionnaire), the 6-item POPDI-6 (Pelvic Organ Prolapse Distress Inventory 6), and the 12-item PISQ-12 (Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire), at baseline and at 12 months after the operation. Data were obtained for 65 patients who underwent the combined surgery and were able to comply with follow-up for >1 year. Ultrasound studies reveal that mesh length tends to shorten and decrease in thickness over the 1-year follow-up. Vagina thickness also was reduced. Neovascularization through the mesh was observed in <8.5% of patients in the first month and at 1 year, and was evident in approximately 83%. The mesh exposure rate was 6.4%. The recorded objective cure was 90.8% (59 of 65 patients), and subjective cure was 89.2% (58 of 65 patients) at mean (SD) follow-up of 19.40 (10.98) months. At 2 years, UDI-6, IIQ-7, and POPDI-6 scores were all significantly decreased (p < .001), whereas the PISQ-12 score was significantly increased (p = .01).
Ultrasound features suggest that the degeneration of collagen barrier may be longer than expected and that integration of collagen-coated mesh could occur up to 1 year. A substantially good clinical outcome was noted.
Translabial ultrasonography for evaluation of synthetic mesh in the vagina
2014, Urology
Citation Excerpt :
Dynamic US evaluation has been demonstrated in a number of similar conditions.12,16-18 The utility of US in evaluating suburethral slings or the synthetic mesh used for POP repair has been reported with a focus on the tension and position of transvaginal tape placement and its outcome.19-22 To our knowledge, we are the first to compare the information on mesh location obtained from translabial US with the intraoperative findings.
To compare the clinical and surgical findings using translabial ultrasonography (US) in the evaluation of symptoms after transvaginal synthetic mesh placement.
From 2009 through 2010, a retrospective observational study was conducted to evaluate patients presenting with complaints after transvaginal mesh implantation for the treatment of stress urinary incontinence or pelvic organ prolapse repair. The clinical and translabial US findings were compared with the intraoperative findings, with a focus on mesh location, erosion, and extrusion.
A total of 51 consecutive patients (mean age 59 years) were evaluated by history and physical examination, translabial US, and intraoperative findings. Using intraoperative findings as the reference standard, translabial US was able to predict the location of the sling in relationship to the urethra (6 distal, 25 mid-urethral, and 20 at the bladder neck), to differentiate between transobturator (n = 21) and retropubic (n = 30) slings, and to detect all anterior (n = 21) and posterior (n = 15) placed mesh. Translabial US was superior to physical examination in identifying mesh erosion into the periurethral fascia or sphincteric unit. US was inferior to physical examination in diagnosing vaginal extrusion but was superior for locating the mesh.
Translabial US can identify the mesh material used to treat stress urinary incontinence and pelvic organ prolapse. It provides additional information on sling type, mesh location, and morphology compared with the clinical findings and could help in surgical planning and counseling. Prospective clinical studies evaluating the reliability of this technique in larger patient populations are warranted.
Women's quality of life and sexual function after transvaginal anterior repair with mesh insertion
2013, European Journal of Obstetrics and Gynecology and Reproductive Biology
Citation Excerpt :
The evaluation of sexual activity six months after surgery may be short-term but all sexually active women resumed their sexual activity within 6–10 weeks postoperatively. There is a concern that further mesh shrinkage might cause dyspareunia, but Dietz et al. [26] concluded after analysing ultrasound volumes of 40 women followed-up for an average of 18 months, starting three months after Perigee mesh implantation, that there was no evidence of mesh shrinkage. Svabik et al. [27] found that intraoperative folding seems to be responsible for a large part of the difference between preoperative (in vitro) and postoperative measurements of mesh dimensions.
Current evidence about the impact of pelvic floor surgery on sexual function is conflicting. Only a few studies have reported with validated questionnaires on sexual function after transvaginal mesh repair, with a discrepancy in reported outcomes. The aim of this study was to prospectively explore the impact of anterior repair (AR) with mesh insertion on sexual function, quality of life and dyspareunia.
69 women with symptomatic stage II or greater prolapse exclusively of the anterior compartment participated in a prospective study on safety and efficacy of two mesh implantation techniques for anterior vaginal wall prolapse repair between September 2007 and May 2009. They were invited to complete the validated condition-specific short form of the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12) and quality of life (QoL) questionnaires (Pelvic Organ Prolapse (POP) Distress Inventory (POPDI), Urinary Distress Inventory (UDI), POP Impact Questionnaire (POPIQ), and Urinary Impact Questionnaire (UIQ)) pre-operatively and 6 months post-operatively. All data were processed and analyzed in Statistical Computing Environment R, version 2.9.1.
A significant decrease of Qol scores and a significant increase of PISQ-12 scores occurred after surgery. All sexually active women resumed sexual activity postoperatively. The majority of non-sexually active women remained sexually inactive. Postoperatively the frequency of pain during intercourse increased in 31% of cases and decreased or stayed unchanged in 69% of cases. The incidence of de novo dyspareunia after mesh repair was 4% while the incidence of dyspareunia slightly increased from 25% to 29% postoperatively.
The results of this study suggest no deterioration in sexual function, a significant improvement in quality of life and a low incidence of de novo dyspareunia six months after AR with mesh insertion. Despite these findings, the majority of non-sexually active women remain sexually inactive postoperatively. These conclusions should be confirmed in a longer follow-up.

View all citing articles on Scopus

: Cite this article as: Dietz HP, Erdmann M, Shek KL. Mesh contraction: myth or reality? Am J Obstet Gynecol 2011;204:173.e1-4.

: H.P.D. has acted as a consultant for American Medical Systems (Minnetonka, MN) and Continence Control Systems (Sydney, Australia); accepted speaker's fees from General Electric Medical Ultrasound (Sydney, Australia), American Medical Systems, and Astellas (Tokyo, Japan); and has benefited from equipment loans provided by General Electric, Bruel and Kjaer (Gentofte, Denmark), and Toshiba (North Ryde, Australia).

View full text

ResearchUrogynecologyMesh contraction: myth or reality?

Objective

Study Design

Results

Conclusion

Section snippets

Materials and Methods

Results

Comment

Obstet Gynecol

Am J Obstet Gynecol

Am J Obstet Gynecol

Am J Surg

Review of synthetic mesh-related complications in pelvic floor reconstructive surgery

Int Urogynecol J

Incidence of recurrent pelvic organ prolapse 10 years following primary surgical management: a retrospective cohort study

Int Urogynecol J

Levator avulsion is a risk factor for cystocele recurrence

Ultrasound Obstet Gynecol

To mesh or not to mesh

Aust NZ J Obstet Gynaecol

Efficacy and safety of transvaginal mesh kits in the treatment of prolapse of the vaginal apex: a systematic review

Br J Obstet Gynaecol

Research
Urogynecology
Mesh contraction: myth or reality?