Biologic mesh in pelvic organ prolapse
Biologic materials that are cross linked, or treated in an effort to improve strength and durability, tend to have inadequate elasticity and are not porous enough for adequate transmission of white blood cells and macrophages. Cross-linked biologics also may become encapsulated, which makes them more permanent and prone to erosion and other problems seen with the synthetic graft materials.
The non–cross-linked biologics are porous and do not present a barrier to white blood cells and macrophages. At least one of the available biologics in this category has an active antimicrobial component.
Most importantly, the non–cross-linked biologic materials give us much of what we are trying to achieve with augmentation, which is not to have a permanent prosthetic device but rather an extracellular matrix that acts like a cluster of stem cells, stimulating the body to regenerate tissue at the site of implantation.
I have used biologic mesh in approximately 200 surgeries over the past 5 years; many of these surgeries have been POP repairs. My success rate in terms of anatomic outcome and symptom resolution (anecdotally, per nonrandomized evaluation) has been about 85%. I have not hesitated to place biologic mesh concomitantly in both the anterior and posterior compartments, and I have used it to lengthen the vagina. I have not seen any infection or any rejection or allergic issues, and there have been no cases of erosion/exposure.
On occasion, a suture migrates through the vaginal epithelium and creates chronic discharge and/or pain. When the granulation tissue and the suture are both removed, the patient’s symptoms resolve. I have had two patients in whom the suture line has spontaneously opened along the anterior-posterior wall. In both patients, the vaginal discharge resolved once the tissue reepithelialized in 6-8 weeks.
Many patients today tell me immediately in their initial visit that they do not want mesh. It takes some time and thorough explanation to help each patient understand that adverse outcomes are associated mainly with the synthetic meshes, and that biologic materials are worth considering.
Dr. Faro is professor and vice chairman of ob.gyn. at Lyndon Baines Johnson Hospital and professor of obstetrics, gynecology, and reproductive sciences at the University of Texas, both in Houston. He has led infectious disease sections at Baylor College of Medicine and Louisiana State University, is a past president of the Infectious Diseases Society for Obstetrics and Gynecology, has published on postoperative and other infections, and has otherwise been an expert and leader in this realm of gynecologic care. *Dr. Faro is a scientific advisor for the research arm of Medical Diagnostic Laboratories in Hamilton, N.J.
*CORRECTION (11/25/13): A previous version of this story reported an incorrect financial disclosure of Dr. Sebastian Faro. This article has been updated.
