Mesh imlantation for rectocele and/or cystocele should be banned because of the prevalence/incidence of associated complications, frequently serious.

In our hands it is about 2.5%. It depends on the mesh you use .

Thanks Eray ! What kind of complcations are you writing about ?

Regards.

Trans-obturator meshes like Prolfit and TVT-O are very dangerous for the pudendal nerve (and its branches) and for the obturator nerves. I have many patients who began severe neuralgia after these procedures.

Thanks Jacques. Your answer is very interesting !

This debate should not be reduced to a binary level, good or bad. Reasons should be given for an opinion, as Jacques has done. First, why do surgeons use mesh? It is to block descent. Mesh certainly does not correct the organ defect, as the cystocele remains on transperineal ultrasound during straining. Does mesh work? It depends what the anatomical defect is. Let's take cystocoele. A central or lateral defect with a good attachment of fascia to the cervix will respond well to a TOT-type mesh. However, if the cause of cystocoele is dislocation of the pubocervical fascia (musculoelastic layer of vagina) from the cardinal ligament and cervical ring (high or transverse defect), the cystocoele may recur with a TOT mesh. Sutures to the ring may or may not work, as the stresses on this part of the anatomy by downward vectors is very significant.

As regards pain I do not agree with Jacques that the meshes cause a problem with the pudendal nerve. I have seen many cases of pelvic pain after Perigee or anterior Prolift. These operations go nowhere near the pudendal nerve. Furthermore, the pain disappears when the arms are cut.

Invariably, we find that the arms of the Perigee are tight when the patients complain of pelvic pain, which can be very severe indeed.

I think that the cause is distension of the tissues by the mesh. The pelvic tissues are innervated by visceral nerves which are susceptible to stretching, hence disappearance of pain once the tension is released.

Such meshes, Apogee, Perigee, Prolift are anatomically incorrect as they reinforce level 2. The defects which cause the cystocele are at level 1, uterosacral ,cardinal, or for rectocele, level 3, perineal body. Ultrasound studies show that the vagina overlying the mesh does not move on straining. Such movements are important for urethral closure and micturition. We have seen many cases of "Tethered Vagina Syndrome" when the mesh prevents movement in the bladder neck area of vagina (look up "Tethered Vagina Syndrome" at www.pelviperineoogy org) : the patient loses sudden massive amounts of urine on getting up out of bed in the morning or on getting up off a chair, because the mesh causes severe fibrosis in the bladder neck area of the vagina.

SUMMARY

The question revolves around risks and balances. As Johan says "What type of complications are you talking about"? Severe life-altering complications, even at 2.5% require a serious look at the risks and benefits of mesh.

The other question is :how skilful is the surgeon?" Eray's group are clearly skilful surgeons with a good knowledge of anatomy, as a 2.5% complication is certainly as good or better than native tissue repair which also has its complicationsi.

We have addressed the problem in a different way, using the TFS to repair the actual damaged ligaments at levels 1&3. This leaves level 2 entirely free to move and the erosion rates are 1-3%, with rates of cure for cystocele, rectocele and apical prolapse.

cf . Sekiguchi Y1, Kinjo M, Maeda Y, Kubota Y. Int Urogynecol J. Reinforcement of suspensory ligaments under local anesthesia cures pelvic organ prolapse: 12-month results. 2013: Dec 7. DOI 10.1007/s00192-013-2281-x [Epub ahead of print]

I have at least 10 cases of real pudendal neuralgia and/or obturator neuralgia that began just after transobturator procedures (40 cases if I put the late onset cases). Of course the pudendal nerve itself is not in front of the obturator foramen but its clitoral branch YES. Look at the last publication of Dr Dellon. http://www.ncbi.nlm.nih.gov/pubmed/24667877

The presence of the mesh in the obturator muscle induces trigger points in this muscle. If this muscle is thigh and contracted it compresses the pudendal nerve itself => neuralgia.

For the obturator nerve just look at the work of JP Spinosa and you will underqstand how close the mesh is from the nerve. http://www.ncbi.nlm.nih.gov/pubmed/17868425

The risk of inducing these awful neuralgia is too high to continue using these methods because less agressive ones exist. Of course it is just my advice.

Jacques, thanks for your answer ! The more information we acquire, the nearer we will get to the truth, and nothing but the full truth.

Regards.

 The incidence of dyspareunia following mesh insertion is underestimated for the following reasons: 1. Complications are seldom reported in the literature; 2. It is a relatively minor, yet troublesome complication, as compared to e.g. perforation, followed by a fistula. Regards.

Mesh, in biologic or synthetic form, has not proven to be of any benefit in the posterior compartment of the vagina (Maher, Cochrane review 2011). Synthetic mesh (polypropylene) has been successfully used in the anterior and apical compartments of the vagina with good success. The complication rates cited in these two compartments averages about 10%, either trans-abdominally or trans-vaginally. In my institution, we see a lower rate of complications of about 4% which includes mesh exposures which are usually asymptomatic. Synthetic mesh, but not biologic mesh, has been shown to decrease recurrence incidence in the anterior compartment. Of course mesh exposure is not a complication you will see with native tissue repairs. Mesh in the anterior compartment seems to be well tolerated, and its benefits justify the risks in large cystoceles and recurrent cystoceles. I believe that most of the complications seen with meshes occur early in the surgeon's learning curve. Unfortunately, these complications have been attributed to mesh-only by attorneys and others, yet the data speaks differently

 From an anatomical perspective

Re nerve pain

Jacques is of course correct- nerve entrapment can be a problem. We have seen nerves in histological specimens on mesh removal. However, I don't think it is the only eplanation. We have to look at abnormal stretching of tissues, a "too tight mesh".

Re dyspareunia

Nature has created organ spaces between bladder & vagina and rectum and vagina for a reason, so they can move independently of each other.  Mesh fibroses these spaces, in many cases preventing independent movement. 

During intercourse, the vagina is stretched by the penis. If there is adequate elasticity and the vagina can be expanded, then here is no pain. If however, the penis has to stretch a vagina fibrosed to rectum, the pain can be severe. The etiology can be explained by the visceral nerve innervation of the pelvic organs- they are very sensitive to stretching.

Also sometimes severe pain can be experienced during defecation after mesh insertion. The same  explanation holds- an immobile anus is severely stretched by the anorectal opening vectors.

Thanks Joseph for your thoughtful comment !

Thanks Peter - your answer is excellently explained !

Very nice question, and very rich meal with a valuable information...thank you all.