Transvaginal pelvic organ prolapse (POP) repair with simultaneous sling implantation for stress urinary incontinence (SUI) is associated with the highest risks of repeat surgery and mesh erosion requiring management, according to a new study. Sling for SUI alone was associated with the lowest risks of complications.

“There is evidence for a dose-response relationship between the amount of vaginal mesh used and subsequent mesh erosions and other complications, leading to repeated surgery,” Art Sedrakyan, MD, PhD, of Weill Cornell Medical College in New York, and colleagues wrote in JAMA Surgery, published online ahead of print.

The amount of mesh used increased with each of the following 4 procedures examined:

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  •      transvaginal POP repair with mesh and concurrent sling (vaginal mesh plus sling group)
  •       transvaginal POP repair with mesh and no concurrent sling (vaginal mesh group)
  •       transvaginal POP repair without mesh but concurrent sling for SUI (POP sling group)
  •       sling for SUI alone (SUI sling group)

Using a comprehensive New York State database, the investigators examined the incidence and timing of complications among 41,604 women (average age 56.2) who underwent 1 of the procedures during 2008 to 2012.

Over 1 year of follow up, clinically relevant mesh erosions occurred in 2.72% of the vaginal mesh plus sling group vs 1.57% of the SUI sling group. Repeated surgery with concomitant erosion diagnosis followed the same pattern: vaginal mesh plus sling group 2.13% vs SUI sling group 1.16%. The vaginal mesh group (1.95%) and POP sling group (1.90%) had similar risks of mesh erosion. The SUI sling group had the shortest time to repeated surgery (median 123 days), despite their low rate of complications. Patient age did not influence the results. The severity of POP or SUI could not be assessed.

Regardless of study findings, clinical practice may not change dramatically because patients with SUI and POP often seek to correct both problems in a single surgery, Bhumy A. Davé, MD, and Anne-Marie Boller, MA, MD, FACRS, pointed out in an accompanying editorial. In addition, the study excluded abdominal or laparoscopic POP repairs with sling, procedures that have only grown in popularity in recent years, which is a limitation.

Further investigation of mesh amounts is warranted. “Does placing a sling at the same time as opposed to later increase the risk of mesh-related complications?” Dr Davé and Dr Boller asked. “A study answering this question would guide treatment decisions and reflect a scenario in which the dose response would be clinically important.”

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1. Chughtai B, Barber MD, Mao J, et al. Association Between the Amount of Vaginal Mesh Used With Mesh Erosions and Repeated Surgery After Repairing Pelvic Organ Prolapse and Stress Urinary Incontinence. JAMA Surg. doi:10.1001/jamasurg.2016.4200. [Epub ahead of print].