Safety And Effectiveness Of Synthetic And Biological Mesh In Pelvic Organ Prolapse Repair(Cases Report And Literature Review)

Background: Pelvic organ prolapse is a highly prevalent condition in the female population, which impairs the health-related quality of life of affected individuals. About11% of women will require surgery by the age of 80 years and there is an estimated 31%rate of prolapse recurrence after surgery; with 2% of women becoming symptomatic. In an effort to improve outcomes in transvaginal prolapsed repairs, multiple biologic and synthetic graft materials have been introduced to complement, reinforce or replace native tissue in reconstructive surgical procedures. The use of mesh has been limited by mesh related complications including stiffness, chronic pain, exposure through the vaginal wall and erosion into adjacent structures, inciting the FDA to issue two public health notices warning against mesh use – the first in 2008 warning of serious complications associated with mesh use and the second in 2011 warning that complications are not rare events. In addition to the well-reported risks of erosion, exposure, and extrusion, synthetic meshes set a problem from an infection point of view as well. Not uncommonly, synthetic grafts are found upon removal to be covered with biofilms – matrices produced by bacteria or fungi that colonize the material and house the organisms. Biofilm formation can lead to both acute, significant infection and long-term chronic infection. Biologic meshes are safer froman infection standpoint and have the advantage of being histologically similar to the recipient tissue and also the ability of remodeling tissue in vivo. Furthermore, when compared to methods that do not use implants; the use of biological grafts may decrease the recurrence rate as the repairs will not depend on weakened native tissue for support.Despite the paucity of resilient evidence, the available literature suggests biological grafts are thought to be safe and effective in the surgical treatment of pelvic organ prolapse.Objective: To review the available data and determine the safety and effectiveness of the synthetic and biological mesh in the management of pelvic organ prolapse.Design: a review.Methodology: Pub Med was searched for relevant articles in which biologic grafts were used to reinforce anterior, posterior, or apical prolapse repair. Articles were limited to clinical use. Relevant articles were identified, sorted by type of graft(cross-linked or noncross linked biologic), and then reviewed for incidences of erosion, pain, and infection, as well as persistence or recurrence of the original defect. These adverse events were chosen as they were referenced as the three most common complications in FDA’s report. The safety and effectiveness of synthetic mesh products were also reviewed for the same factors as biologic grafts(e.g., erosion, recurrence) by examining the references cited in FDA’s report. Data is gathered mostly about transvaginal biological mesh using the search terms transvaginal mesh.Cases presentation: A 47-year-old woman who diagnosed with the recurrent infection of anterior vaginal wall, and a 58-year-old post-menopausal woman who presented with urinary retention; after they underwent Pelvic organ prolapse surgery using synthetic mesh,were reported.Conclusion: To improve outcomes in transvaginal prolapsed repairs, multiple biologic and synthetic graft materials have been introduced to complement, re-inforce, or replace native tissue in reconstructive surgical procedures. Non-absorbable synthetic mesh products are permanent implants that provoke a foreign body response. Non-cross linked biologic grafts remodel into normal host tissue, thereby reducing long-term foreign body response, and donot leave behind foreign material that may have to be removed at a later date.Complications associated with the use of biological grafts in Pelvic organ prolapse repairs include graft erosions, which usually do not require surgery for repair and seem to be less morbid than the synthetic mesh erosions.The use of synthetic grafts has shown better anatomical cure rates but is associated with high graft-related complications. These complications may be lessened by absorbable mesh,although efficacy seems to decrease. Recurrence of Pelvic organ prolapse associated with non-absorbable synthetic mesh requires removing the mesh or attempting surgical intervention while the mesh is in place, while a non-cross linked biologic graft is intended to eventually be reabsorbed by the body. Several reports on biological grafts have shown better results with lower graft-related risks. Although limited data exist, the literature reveals that transvaginal Pelvic organ prolapse repair with mesh appears to result in fewer prolapses following surgery in comparison to non-mesh repair procedures using only native tissues. In the meantime, transvaginal placement of synthetic mesh should be used carefully and sparingly, with proper attention paid to patient selection and technique to reduce as much as possible the risk of erosion and pain. In either case, more attention should be paid to the prevention of postoperative infections. Postoperative infection is an underappreciated risk with pelvic reconstructive surgery overall, and the use of synthetic mesh significantly increases this risk. Biologics are safer from an infection standpoint, but proper prevention –including evaluating each patient’s vaginal microflora immediately preoperatively and treating patients accordingly.