Dennis Miller, MD

   I’m Dennis Miller of Milwaukee Urogynecology, a surgeon specializing in prolapse and incontinence, and  we are here today with Professor Bernard Jacquetin to discuss the  options for the surgical treatment of prolapse and incontinence. 
 
 We have noticed for years that repairs for prolapse are less than  perfectly successful and we are looking for ways to improve the success  rate without impacting on the untoward sequellian consequences of the  surgery.  Professor Jacquetin has been involved for over ten years in a  group that is dedicated toward developing new approaches to prolapse to  make them meet those goals.  Professor Jacquetin, what led you to look  for a change in your approach to prolapse over what you had done more  than ten years ago?
 
 

   Because, as you know, the reconstructive surgery is a challenging  problem because we have recurrence and we know that intervals between  recurrences are very often shorter and shorter.  By analogy with all  abdominal wall repairs we tried to use mesh to re-enforce those vaginal  tissues, which are relatively weak in problems of prolapse.  With  different products and trying to have a good hammock supporting pelvic  organs. Of course, we have some difficulties, as you know, mesh is a  foreign body and there is a problem with tolerance of this mesh, but the  long-term efficacy seemed very interesting.
 
 

 We have, in the  United States, been using mesh for about a year and, thus far, we have  had very good tolerability and I am very pleased in my patient  population that there have been very few erosions and very few untoward  consequences.  You have had a much longer experience.  What have you  noticed about the tolerability of the mesh?
 
 

  A big  improvement because ten years ago erosion rate was about 20%, very  terrible, and today, we are less than 5%, so I think on the problem of  tolerance, we are improving the technique but the stiffness of the  tissue after mesh is used is challenging.
 
 

 I have always had  the feeling that the biggest issue with mesh erosion was the type of  material that was used and I think in the past we failed to understand  the principles of what makes a tolerable mesh.  A monofilament  polypropylene mesh with a large pore size and a thin mil thickness seems  to be an important component toward improving that tolerability.  Did  you use other meshes before you used monofilament polypropylene?
 
 

  Yes, I used a lot of different meshes.  I might agree with you that probably this kind of new mesh is more appropriate.
 
 

 We also found  that the patient’s acceptance of mesh has been good.  I do not get a lot  of questions from patients about the use of mesh as an implant.  In  fact, I think that it has even been easier to get patients to accept  mesh than a bio material.  Cadaveric donor tissue usually took a  considerable explanation with patients before they would be willing to  accept it, but mesh they don’t have as many questions about.  Do you  find in France it is the same?
 
 

  Exactly  the same thing.  We propose to every patient the choice between  biological mesh or prosthetic mesh and they prefer prosthetic mesh.
 
 

 Our final concern  is the sexual dysfunction after prolapse surgery.  I have found that in  the traditional methods of my performing posterior repair for rectocele  correction that painful intercourse was a problem.  There are studies  that would suggest that maybe as high as 25% of patients will have  painful intercourse after these surgeries and the worry is that the  introduction of an implant could contribute to that.  At least in our  short one-year time period, we have actually found that sexual  dysfunction may be less because we are able to get a broader, less  narrowed repair.  But what have you found as far as sexual dysfunction  after the use of mesh?
 
 

  Yes, I  agree with you.  With traditional repair, we have to pose matter very  close and it is sometimes painful and with mesh, we can prevent this  destruction of tissue and pain.  But, on the other hand, sometimes even  mesh becomes very stiff and it could be a problem.
 
 

 Yes, we need more  information and we are all gathering our data together.  But, clearly,  we need to make advances over the traditional approaches for prolapse  which we know had unacceptably high failure rates.
 
 

 Well, thank you very much for talking to us about it. 

The                 usage of grafts in reconstructive surgery

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OBGYN.net Conference CoverageFrom the 24th Annual American Urogynecology Society Meeting, Hollywood, FL - September 2003

Surgical treatment of prolapse and incontinence

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Dennis Miller, MD

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Surgical treatment of prolapse and incontinence

Surgical treatment of prolapse and incontinence Video