The mess of the meshes- is there a way forward?

The debate on the pro’s and cons of synthetic implants in the resent press needs to be look at in the right context. One can only make sense out of the perfect storm if you realize a few facts:

1. The prolapsed vaginal wall is a symptom of an underlying disease. In itself is it not a diagnosis. Treatment should be directed at the disease and not the symptom.

2. “ All cystocoels are not the same” – patients needs to be clustered in groups that can be compared with one another. The different defects in the vaginal wall support system must be identified and surgical procedures for each need to be compared accordingly. The same apply to tissue reaction of different age groups- to compare a 29 year olds’ response to surgery with that of an eighty year old is impossible.

3. Due to different factors uniquely to pelvic surgery (e.g. poor tissue quality, intra-abdominal pressure effects on suture lines, absent tissue, scar tissue formation, etc.) one needs to realize that not all pathology will be able to be corrected at one sitting alone. Suboptimal results can be expected in some patients. Staged surgery is a real possibility. The surgical footprint done in primary surgery must never have the potential of permanent irreversible damage.

4. The role of implants should be to play a supportive role in pelvic floor surgery and not a primarily role. This supportive role will lay down the requirements –be it temporary or permanent support- that need to be fulfilled by the material to be used.

5. Reconstructive surgery is reconstruction of normal anatomy, and not creation of new “ innovative” anatomy. There is a reason why ligaments run into specific directions in the pelvis. For the same reason is there not place in normal anatomy for ligaments to follow non-traction lines e.g. from the peri-cervical ring to the sacro- spinous ligament.

In this Eureka moment a paradigm shift of the mind allows the eyes to see what it had previously been blind to. The vaginal wall topography takes on a new meaning. The presence and absence of the rugae tells what lies beneath, the lateral sulci on the anterior wall predict what lies beneath, the position of the cervix in the vaginal apex has its’ own tale, and the dimples on the lateral fornixes where the cardinal ligaments takes its’ origin from the vaginal wall provide information about the integrity of the cardinal-utero-sacral ligament complex.

By looking beyond the prolapsed vaginal wall to the underlying defect, one realizes what needs to be done. Rectifying the wrong by treating the disease and not the symptom will involves doing defect specific surgery and not covering the prolapsed wall with a blanket.

This is reconstructive surgery and not surgery with a potential of destruction