The first principle in mesh repair is the recognition that in most cases, POP can be treated successfully without mesh, thus avoiding the risk of mesh-related complications. Mesh surgery is chosen only after weighing the risks and benefits of surgery with mesh versus all surgical and nonsurgical alternatives [6–8]. The specific technique with each of the mesh kits is beyond the scope of this chapter, but the general guiding principles are discussed below.

Appropriate positioning of the patient is important to have adequate access for needle insertions and movement of trocars. It is incumbent on the surgeon to ensure correct patient positioning. There are no requirements for any special instruments and it is preferable to keep instrumentation simple and to bare minimum. Usually, a Scott retractor or the Lone Star retractor is helpful.

With trocar-based kits, it is good practice to mark the surface anatomy of the obturator foramen, adductor longus tendon, pubic tubercle, ischiopubic ramus and ischial tuberosities before the incision. Additionally, it is useful to mark the bladder neck. Incising below the bladder neck potentially reduces the incidence of postoperative voiding dysfunction. In addition, a gynecologic pelvimetry helps to assess the subpubic angle for adequacy of access and the accessibility of the ischial spines and the sacrospinous ligaments. These are the important landmarks that need to be identified prior to any kind of pelvic floor reconstruction.

Procedure usually starts with hydrodissection with local anesthetic (Marcaine 0.5 %) mixed with diluted epinephrine (1 in 200,000). This helps in developing the natural avascular tissue plane and facilitates full-thickness vaginal dissection. Fluid in the space between the viscus and vaginal wall helps to define the correct plane of dissection (Fig. 16.3). A combination of sharp and blunt dissection carried out in this plane ensures the fascia is left attached to the vaginal wall rather than to the viscus [9]. This ensures that the mesh lies directly in apposition with the prolapsing organ, reducing the chance of vaginal mesh extrusion.

Anchorage of the mesh to a strong pelvic floor support is pivotal to the success of mesh replacement surgery. The sacrospinous ligament fulfills the role of an “anchor,” being relatively avascular, sturdy, with a fixed anatomical location and a well-circumscribed boundary, identifiable even in obese women. The sacrospinous ligament is approached anteriorly in mesh kits and this requires some degree of relearning and is a key skill in mesh repair [10]. To ensure a “four-point anchorage” in the anterior compartment, the needle is inserted through the obturator internus muscles and sacrospinous ligaments on either side, essentially mimicking the original “arcus-to-arcus” support of fascial bladder hammock. Intraoperative cystourethroscopy should be performed as a part of the standard operating protocol to detect inadvertent needle injury or mesh placement.

In posterior mesh placement, needle is inserted via incisions posterior to the anus, passed through ischiorectal fossa and directed towards the ischial spine to be anchored to the sacrospinous ligament complex. Rectal examination is done to rule out rectal injury, following trocar insertion and repeated at the end of the surgery.

It is recommended the mesh is trimmed to the size of the prolapse (Fig. 16.4) and placed in a “tension-free” manner. This reduces the risk of pain-related complications with mesh contracture. There is no need to excise vaginal skin prior to vaginal closure in mesh surgery. Minor trimming for purposes of aligning the edges is acceptable. A two-layered vaginal closure can make vaginal mesh exposure less likely and reduce dead space preventing hematomas. (Rane A., personal communication, 2010).

At the end of the mesh repair, there may be considerable residual laxity of the vaginal skin unlike in native tissue repairs. This in fact denotes appropriate mesh tensioning [9, 11, 12]. Mesh surgery factors in the concept of “vaginal remodeling” that allows surrounding tissues to restructure in much the same way as the vagina involutes following vaginal birth [11].

The major issue with mesh repair is its use without adequate training. Proper training in the use of mesh devices is ideally a three-staged procedure: didactic training and cadaveric workshops, followed by preceptor training at the trainer’s operating facility, and finally proctoring at the trainee’s own hospital. Reference to the local college/Urogynecological society guidelines will ensure ongoing training, quality control, audit, and peer review. It is also important that mesh surgery be performed as per protocol established by the manufacturer, as any deviations from the accepted technique can cause complications and is medicolegally indefensible.

Several initial prospective and retrospective cohort studies using mesh kits, showed good anatomical success rates in the range of 80–100 % with follow-up over 3–24 months [13–17]. Studies with medium- and long-term follow-up and randomized controlled trials (RCT) comparing mesh versus fascial repair, showed variable results. In an one year RCT, comparing objective outcomes of mesh versus fascial repair of all compartments, there was an overall recurrence of 63 % in mesh compared to 70 % with no mesh. Most recurrences occurred in the anterior compartment – 46 % in mesh and 60 % with native tissue [18]. In a RCT comparing anterior colporraphy with mesh, objective assessment at the end of a year showed a success rate of 61 % with mesh and 35 % with colporraphy [19]. Other RCTs comparing the mesh with standard colporraphy have shown failure rates in the range of 9–28 % with mesh [20, 21]. In one long-term outcome analysis of vaginal mesh with native tissue repair in the anterior compartment, the 5-year cumulative risk of any repeat surgery was significantly higher for vaginal mesh, 15.2 % compared to 9.8 %, but risk of surgery for recurrent prolapse was similar [22]. In the posterior compartment, fascial repairs have been shown to give excellent results and there is no evidence to support the use of mesh in posterior repair [23].

The secondary outcomes of cohort studies and RCTs started to highlight the complications rates with mesh. In the RCT by Sokol et al., mesh exposure was reported in 15 % and no statistically significant difference between mesh and native tissue with respect to new-onset dyspareunia [18]. In the study by Altman, the rates of bladder perforation and intraoperative bleed were higher in the mesh group, with mesh exposure rate of 3.2 % [19]. It was the complication profile with mesh repair, lack of evidence for optimal management of these complications and long-term sequelae related to mesh complications that constrained its use. In view of the increasing concerns about mesh-related complications, the US FDA issued statements related to mesh use in prolapse surgery [6, 7].