Surgical treatment of prolapse and incontinence

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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?

Prof Bernard Jacquetin, MD: 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.

Dennis Miller, MD: 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?

Prof Bernard Jacquetin, MD: 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.

Dennis Miller, MD: That’s our greatest concern.

Prof Bernard Jacquetin, MD: Yes.

Dennis Miller, MD: 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?

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

Dennis Miller, MD: 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?

Prof Bernard Jacquetin, MD: Exactly the same thing. We propose to every patient the choice between biological mesh or prosthetic mesh and they prefer prosthetic mesh.

Dennis Miller, MD: 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?

Prof Bernard Jacquetin, MD: 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.

Dennis Miller, MD: 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.

Prof Bernard Jacquetin, MD: I agree with you.

Dennis Miller, MD: Well, thank you very much for talking to us about it.

  For another view point see: The usage of grafts in reconstructive surgery