Sur­gi­cal mesh deemed un­safe for one med­i­cal prob­lem con­tin­ues to be used for an­other.

New Zealand Listener - - CONTENTS - by Ruth Ni­chol

Sur­gi­cal mesh deemed un­safe for one med­i­cal prob­lem con­tin­ues to be used for an­other.

Vag­i­nal mesh can no longer be used to treat New Zealand women with pelvic or­gan pro­lapse (POP) after Med­safe re­moved four POP mesh prod­ucts from the mar­ket in Jan­uary. That de­ci­sion, which ef­fec­tively bans the use of vag­i­nal mesh to treat POP, was made due to safety con­cerns. The mesh has been as­so­ci­ated with se­ri­ous, long-term com­pli­ca­tions such as chronic pain, in­fec­tion, vag­i­nal bleed­ing and bowel prob­lems.

How­ever, the ban does not ap­ply to vag­i­nal mesh used to treat stress uri­nary in­con­ti­nence

(SUI) – in­vol­un­tary uri­na­tion caused by phys­i­cal move­ment or ac­tiv­ity such as cough­ing, sneez­ing, run­ning or heavy lift­ing.

This year, up to 1400 Kiwi women with SUI will have what’s known as a mid-ure­thral sling made of polypropy­lene mesh im­planted through their vagina to sup­port their ure­thra or blad­der neck.

But the grow­ing in­ter­na­tional con­tro­versy about the use of vag­i­nal mesh to treat both POP and SUI – it’s been de­scribed as “the new thalido­mide” be­cause of its some­times-dev­as­tat­ing con­se­quences – means they face a dif­fi­cult de­ci­sion: to have surgery or not?

“Ev­ery pa­tient who comes to see me brings it up, and I have to go through the ev­i­dence with them,” says Dr Lynsey Hay­ward, a urog­y­nae­col­o­gist at Mid­dle­more Hos­pi­tal.

As far as she’s con­cerned, the ev­i­dence for mid-ure­thral slings is con­vinc­ing. She sup­ports Med­safe’s de­ci­sion to stop the use of vag­i­nal mesh to treat POP, say­ing there are much more ef­fec­tive, non­mesh sur­gi­cal op­tions avail­able. How­ever, she de­scribes mid-ure­thral slings as a “very dif­fer­ent an­i­mal” and has no qualms about us­ing them for pa­tients who have not re­sponded to non-sur­gi­cal

It’s been de­scribed as “the new thalido­mide” be­cause of its some­times dev­as­tat­ing re­sults.

treat­ments for SUI. These in­clude pelvic floor phys­io­ther­apy, weight loss and con­ti­nence pes­saries.

“I would use mid-ure­thral slings as a first-line sur­gi­cal treat­ment for my pa­tients and so would my col­leagues.”

Hay­ward rec­om­mends us­ing retrop­u­bic slings, which are in­serted through an in­ci­sion in the front wall of the vagina, rather than tran­sob­tu­ra­tor slings, which are in­serted through two small cuts at the top of each thigh. She says retrop­u­bic slings have fewer com­pli­ca­tions and are also eas­ier to re­move.

“If I had stress uri­nary in­con­ti­nence I would ab­so­lutely have a retrop­u­bic mid-ure­thral sling.”

Hay­ward also sup­ports the Min­istry of Health’s de­ci­sion to de­velop a cre­den­tialling sys­tem for sur­geons in­sert­ing the slings; she rep­re­sents the Royal Aus­tralian and New Zealand Col­lege of Ob­ste­tri­cians and Gy­nae­col­o­gists on the cre­den­tialling com­mit­tee. In the mean­time, the min­istry has told district health boards to stop of­fer­ing the surgery if their sur­geons don’t meet Aus­tralian cre­den­tialling guide­lines. These in­clude a re­quire­ment to per­form at least 10 pro­ce­dures a year, which is likely to limit the avail­abil­ity of the surgery at smaller re­gional hos­pi­tals.

“It’s clear from stud­ies that high-vol­ume sur­geons who are ex­pe­ri­enced and used to do­ing the surgery have a much lower com­pli­ca­tion rate than those who are only do­ing it oc­ca­sion­ally,” says Hay­ward. “That would ap­ply to any surgery – any surgery at all.”

Mesh Down Un­der, a sup­port and ad­vo­cacy group for peo­ple in­jured by mesh, also sup­ports the cre­den­tialling process, though – not sur­pris­ingly – it takes a more cau­tious ap­proach to the use of mid-ure­thral slings to treat SUI. Co-founder Carmel Berry is less con­vinced by the data than Hay­ward and says there is not yet much in­for­ma­tion about the long-term ef­fects of the slings.

“Some peo­ple are fine for three or four years, then all kinds of prob­lems start to arise.”

She doesn’t nec­es­sar­ily be­lieve the slings should be banned, but does think they should be used only as a last re­sort – and only when women are aware of all the pos­si­ble com­pli­ca­tions. “The pro­viso is that the pa­tient must be fully con­sented.”

She’s help­ing to write a Min­istry of Health in­for­ma­tion doc­u­ment about the dif­fer­ent op­tions for SUI treat­ment and their pos­si­ble com­pli­ca­tions, which will have to be signed by both the pa­tient and the sur­geon be­fore surgery goes ahead.

Berry says women who do opt to have a mid-ure­thral sling in­serted should also have a plan in place so that any post-op­er­a­tive prob­lems are fixed as quickly as pos­si­ble.

“Some­thing I’ve learnt re­cently is that if you’re in pain at six weeks post-op­er­a­tively, you’re prob­a­bly al­ways go­ing to be in pain un­less you get it taken out.”

Dr Lynsey Hay­ward, top; Carmel Berry.

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