By Dr Ron Jewell, Obstetrician and Gynaecologist, Bunbury
Prolapse management has been upended by a Senate Inquiry. Where do we go to from here?
It is an interesting situation where a Senate Inquiry can be set up by an ex radio ‘shock jock’ to look into a complex medical situation. The Inquiry was made very emotive by describing women as ‘victims’. One patient who testified to the Inquiry was proven in the past to have Munchausen syndrome.
Certainly, there are women who have had real problems post mesh, particularly those who have fibromyalgia.
The situation is similar in Scotland. The ‘Prospect’ trial was run by an epidemiologist and published in the Lancet. It was meant to show that there was no advantage to mesh repair over native tissue repair with many more side effects but the groups and surgeons were not comparable. Many prominent pelvic surgeons have written to the Lancet attempting to point out the shortcomings of the ‘RCT’ but none of these articles or letters have been published.
Management of prolapse in post-mesh Australia has several aspects.
Prevention includes consideration of elective LUSCS in some women and caution with operative vaginal delivery. Use pessaries post-delivery and while breast feeding to give support to healing tissues.
Non-surgical management may be acceptance of prolapse without treatment, pelvic floor physiotherapy, and pessary management.
Physical modalities include ThermiVa (diathermy technology) and MonaLisa Touch (laser technology).
Other meshes are being trialled in various countries. Most meshes used in vaginal surgery were polypropylene. Research is being done on PVC mesh, platinum mesh and mesh which will change its properties with various physical agents used in the vagina. It can be made to absorb and to release antibiotics, amongst other functions.
The main problem with prolapse repair is that the vagina is a fibroelastic sheath, ideally with properties like a cycle tube. It has to be strong but distensible allowing a baby’s head to descend, allow faecal and urinary flow on either side and to allow sexual function. This function peaks early in the reproductive years.
The aim is to be able to do conventional repair, maintain elasticity and not have rigid scar tissue. Dr Andri Niewoudt from the Netherlands has done over 680 repairs and kept impeccable records; the concept is tissue regenerative surgery with meticulous dissection of tissue planes and haemostasis as well as using multiple fine monofilament sutures and no distention of tissues with local anaesthetics; no packs are needed. I attended one of his workshops in Belgium last year and have adopted his techniques with pleasing results thus far.
There are also many similar techniques used around the world – ‘site specific repair’ is one. The cosmetic gynaecologists also have other techniques which can be learned but have not had the same audit as Dr Andri Niewoudt.
Author competing interests: nil relevant disclosures.
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