Vaginal prolapse is the condition where the organs contained by the vaginal structure, such as the uterus, rectum, bladder, urethra and the small bowel begin to fall out of their normal position. This is due to the weakening or
breakage of the muscles and skin tissue, called fascia, that make up the vaginal walls. There are five different categories of vaginal prolapse.
There is prolapse of the rectum called rectocele (figure one), prolapse of the bladder called cystocele (figure two), herniated small bowel called enterocele (figure three), prolapsed uterus (figure four) and vaginal vault prolapse (figure five).
Symptoms of prolapse include pelvic pressure and discomfort and problems with urination, defecation and sexual functions .
Medical treatment, such as surgery with a prolapse mesh prevents the continual falling of the organs, and helps support the vaginal wall structures .
Other forms of treatment include estrogen replacement therapy, at home treatments such as activity modification and insertion of a pessary and kegel exercises .
The most common surgery for repairing prolapse is Laproscopic surgery which is minimally invasive using thin instruments and cameras. For vaginal vault prolapse the entry point is through the vagina, or more commonly the abdomen.The technique used is called vaginal vault suspension, where the surgeon attaches the vagina to strong tissue in the pelvis or to the sacrum (a bone located at the base of the spine) . A prolapsed uterus is usually corrected with a hysterectomy. Cystocele and rectocele are corrected through the vagina, where the the surgeon makes an incision in the vaginal wall then pushes the fallen organ up and secures the vaginal wall so the organ remains in place. Laproscopic bladder suspension or a modified Bursh procedure may be used to correct a cystocele .
The steps used for prolapse repair with mesh include general or regional anaesthetic. Then incisions are made in the vagina in either the front or back walls or both depending on the type of prolapse, with stitches to strengthen the supporting tissue.The mesh is then placed under the vaginal skin with the purpose and hopes that tissue will grow into the mesh within three to four weeks. The incision is then closed with biodegradable sutures that dissolve in one or two weeks.After the surgery, for one or two days a catheter is inserted into the bladder to drain urine, as well as a material pack that is placed into the vagina to stop bleeding .
There are several prolapse repair meshes on the market such as, Popmesh™ by Caldera, Timesh™ by PFM, Avaulta by Bard, Polyform™ by Boston Scientific, Gynecare by Ethicon, and IntePro® Lite. The IntePro® Lite, one of the commonly used meshes, is made of knitted monofilament polypropylene. It is manufactured by American Medical Systems (AMS). It is lightweight and pliable to reduce bunching and offers better conformity with the body. The mesh features large pores and open edges for fibrous tissue integration.
The IntePro® Lite mesh is used in a variety of different areas, but for prolapse repair AMS uses the mesh in Elevate (a prolapse repair system). Elevate is a minimally invasive comprehension solution to treat apical and posterior defects. The video below shows how Elevate is performed in a patient.
Video: http://www.amselevate.com/posterior/ *The video is the 1st one in the middle of the page, It is titled Animation Video.
Below is another video showing the Surelift prolapse repair system made by Neomedic:
The low density of the mesh allows for less implanted foreign material as well as more pliable for better vaginal mobility. The mesh helps the patient feel more anatomically correct. The apical procedure has a 95.1% anatomic efficiency and the posterior procedure has a 94.5 % anatomic efficiency. A study was done by AMS found that 99.2% of people surveyed that had the procedure would recommend to a friend and 97.7% achieved some or a lot of improvement after the procedure. The use of mesh in the reconstruction of a vaginal prolapse has pros and cons that are listed below.
- The use of IntePro® Lite repair mesh allows for more flexibility and comfort more vaginal mobility.
- Feels more anatomically correct to the patient.
- Sexual function possible after a mesh prolapse repair.
- Less recurrence of a vaginal prolapse.
- Puts less tension on tissue and provides more support.
- Not sure of the long-term effects of using the mesh as well as how long the mesh will last.
- Like any surgery non-healing, infection or failure can occur.
- Pain can occur where the mesh was inserted, but can be fixed by a surgeon.
- Sometimes mesh can stick out and be seen outside the vaginal area.
- Should only be used for a significant prolapse, not mild injuries.
Other companies have come up with similar prolapse systems that use mesh. Ethicon has a repair system called GYNECARE PROLIFT that uses a partially absorbable, wide pore, polypropylene mesh. Barb also has a system called Avaulta Plus that again uses a monofilament polypropylene mesh for support in the prolapse repair. Though not specified by the companies, it seems that all of the meshes used for prolapse repair are knitted structures that are made very porous so as to allow cell integration.
Though the pros and cons listed above are specific to IntePro® Lite, they are pretty much the same if not exactly the pros and cons of other systems. The pros and cons of using mesh in prolapse repair is dependent on many factors. The surgeon is a major factor on whether or not the mesh will work and not cause problems later on. If the surgeon is experienced and positions the mesh correctly, the mesh is a great fix. The patient is also another factor in the success of a prolapse repair. If the patient is prone to infection or very sensitive in that area then pain and complications can occur after the fact. The type of mesh used in the repair is also a strong factor. It seems though that most patients are satisfied with the end results and mesh continues to be used in prolapse repairs.References:
 Jones, K.A. (2009). Tensile properties of commonly used prolapse meshes. Int Urogynecol J, 2009(20), 847–853.