Mike: Hello, I'm Mike Clarke, podcast editor for the Cochrane Library. The Cochrane Collaboration has published more than 30 reviews on interventions for patients with pelvic organ prolapse. Of these, a series of 6 systematic reviews specifically relating to surgical management were first published in 2016. These are currently being updated, with the update for one, on transvaginal mesh or grafts in transvaginal prolapse surgery being published in March 2024. In this podcast, one of the co-authors, Professor Christopher Maher speaks with lead author, Dr Ellen Yeung, a consultant urogynaecologist who works in Brisbane, Australia about the latest findings.

Chris: Hi Ellen, thanks for taking the time to have a chat about our updated review. Firstly, could you explain to our listeners what pelvic organ prolapse is and say something about the surgical options for its management?

Ellen: Hi Chris. It's good to be here. Pelvic organ prolapse is a common condition affecting 1 in 2-3 women who have had children. It involves the descent of the pelvic organs such as the bladder, bowel or uterus (womb) into the vagina, causing symptoms of a lump or bulge sensation. It can affect bladder, bowel and sexual function. The traditional surgical option, native tissue surgery, uses stitches but is associated with high rates of recurrent prolapse, and an alternative is to use meshes or grafts. The surgery can be performed through the abdomen or through the vagina and can be conceptually split into the different areas of the vagina: the front – where the bladder sits; the back – where the bowel sits; and the top – where the uterus or end of the vagina sit if the women has had a previous hysterectomy.

Chris: You mentioned meshes and grafts, which are the subject of our review; could you say a little more about them and why this review is important?

Ellen: Grafts and meshes are made from permanent, absorbable or biological material and are used at the time of a prolapse surgery. They reinforce the tissues with the aim of reducing the failure rates seen with absorbable stitches. Our review specifically explores all prolapse surgeries that are conducted through the vagina in which a graft of any sort has been used.
Since the last version of this review, which was published in 2016, transvaginal meshes have been removed from the market in many countries. This was because of unacceptable complication rates for women undergoing these procedures. There have been several large international studies and studies from countries where mesh for prolapse surgery remains an option that have been published since 2016. Therefore, we wanted to evaluate all the currently available data and bring the review up to date.

Chris: Can you summarise what we've included in this update and how the findings are different from 2016?

Ellen: We now have 51 trials involving more than 7800 women comparing transvaginal meshes and grafts with native tissue (and other graft repairs) for repairing prolapse.
The evidence showed that whilst transvaginal meshes were associated with lower rates of recurrent prolapse and repeat surgery for prolapse compared with native tissue repairs, transvaginal mesh repairs was associated with higher morbidity including more bladder injury and stress incontinence. Women who underwent transvaginal mesh surgery were also more likely to require a subsequent surgery for prolapse, incontinence or mesh exposure, which is when the mesh comes through the vaginal skin or into an area where it was not originally placed. About one in nine women experienced mesh exposure and about half of these needed repeat surgery because of it.
Overall, the findings are similar to those from the 2016 review, but the larger studies and longer follow-up, sometimes up to 10 years, has improved the certainty of our results.

Chris: Although our certainty has increased, we had some concerns about the evidence. What were these?

Ellen: Whilst surgery for mesh exposure was well discussed in most of the studies, repeat surgery for mesh complications other than mesh exposure was poorly reported. In fact, only 1 trial looked at repeat surgery for pain as a mesh complication. Information on quality of life outcomes was also very patchy and was reported in only 9 of the 51 studies.
We also lack evidence to draw any conclusions for the use of transvaginal mesh in higher risk groups, such as women who have recurrent prolapse; or on whether the newer light-weight meshes might be a suitable alternative.

Chris: In summary, what's the take home message?

Ellen: Whilst the use of transvaginal mesh in prolapse repairs provides some benefits for clinical and surgical outcomes, there are significant associated risks and morbidity. Given the established concerns, if transvaginal mesh was to be considered for use, it should be done under the discretion of the local ethics committee and outcomes should be reported to national regulatory bodies.

Chris: Thank you, Ellen. I'll close by pointing listeners to the full version of the review. If they go to cochranelibrary.com and search for 'transvaginal mesh and prolapse', they'll find it easily, and they'll also find the other updates in this series on the surgical management of pelvic organ prolapse in the Library as these are published.