Using Mesh or Grafts to Augment Repair

▸ Cut the mesh or graft to an appropriate size and do not lay it in too tightly. Remember that mesh and grafts can contract. Adjust the material loosely and remember that its role is to prevent descent of the prolapse, not to elevate or support the tissue. A little movement of the mesh is preferred and will minimize the risk of erosion and dyspareunia.

▸ Make sure the mesh or graft lies flat, and always consider apical support. Folds in the mesh will increase the risk of erosion. The risk of complications will also increase if too few or too many sutures are used to secure the mesh. The Capio ligature device (Boston Scientific Corp.) is a good tool for placing apical sutures without extensive dissection, but it is just one of a variety of tools you can use.

▸ Ensure good hemostasis. I recommend packing the vagina for 24 hours after a mesh procedure to reduce the risk of hematoma and subsequent abscess or erosion, as well as to help the vaginal epithelium bond to the underlying mesh. We use a standardized vaginal packing with estrogen cream.

▸ Use adequate estrogenation. Both pre- and postoperative vaginal estrogen is recommended. We usually begin vaginal estrogen cream at the 2-week postoperative visit and continue it for at least 3 months.

When you start your dissection, keep it thick. The strength of the repair is dependent on the mesh, not on the patient's own tissue, so it is better to keep a thicker vaginal skin. As a result, you will reduce the risk of erosion.