AUA & CUA Mesh Position Statement (2019)

See Original 2019 CUA Statement and Original 2019 AUA Statement

Includes content from 2017 CUA Statement on Mesh

Transvaginal mesh for female SUI

• In transvaginal synthetic mesh midurethral sling procedures, surgeons place a long narrow strip of mesh under the urethra in a tension free manner using trocars passed via the retropubic or transobturator route
• Suburethral synthetic polypropylene mesh sling placement is the most common surgery currently performed for SUI.
  • Extensive data exist to support the use of synthetic polypropylene mesh suburethral slings for the treatment of female SUI, with similar efficacy but less morbidity than conventional non-mesh sling techniques
  • Advantages of synthetic mesh midurethral sling:
    • Shorter operative time/anesthetic need
    • Reduced surgical pain
    • Reduced hospitalization
    • Reduced voiding dysfunction
• CUA
  • Position: an extensive body of literature supports the routine use of full length transvaginal retropubic or transobturator mesh slings for SUI
    • Potential rare, but serious complications that may not be fully correctable even with additional surgery:
      • Injury to other structures during trocar passage
      • Intraoperative placement or post-operative migration of the mesh into the urethra or bladder
      • Vaginal or pelvic pain
    • Serious adverse events, such as ureteral injury, fistula, pelvic pain, and wound complications requiring reoperation, can also occur with traditional nonmesh-based SUI procedures.
    • Transvaginal mesh slings should not be used in women with:
      1. Urethral diverticulum
      2. Urethrovaginal fistula
      3. Urethral injury
      4. Prior transvaginal mesh complication (such as pain or mesh erosion).
    • Numerous organizations support the use of full-length midurethral mesh slings for SUI
  • Recommendations for surgeons placing transvaginal mesh for female SUI
    • When a transvaginal SUI procedure is offered to a patient, they must be informed of potential procedure-specific and mesh-specific complications. The 2014 Health Canada Advisory should be disclosed to patients.
    • Surgeons performing these procedures should be adequately trained in SUI surgery and specifically trained in the sling technique they use. They should be capable of recognizing, diagnosing, and treating potential mesh-related complications associated with their procedure.
• AUA
  • Mesh-related complications can occur following polypropylene sling placement, but the rate of these complications is acceptably low.
  • It is the AUA's opinion that any restriction of the use of synthetic polypropylene mesh suburethral slings would be a disservice to women who choose surgical correction of SUI.
  • The AUA also feels that intra-operative cystoscopy should be performed during all synthetic sling procedures to identify urinary tract injury.
  • The AUA strongly agrees that prior to selecting mid-urethral synthetic sling procedures for the surgical treatment of stress incontinence in women, physicians must discuss the specific risks and benefits of mesh, as well as alternative to a mesh sling.
• FDA
  • The FDA believes that the benefit-risk profile of mesh used to treat SUI remains favorable

Transvaginal mesh for POP

• CUA
  • Position: the use of transvaginal mesh for prolapse repair does not appear to be supported by the current evidence, and its use should be restricted to specialized pelvic floor surgeons and specific clinical situations.
    • Placement of transvaginal mesh may still be indicated in select cases; for example, in the setting of recurrent prolapse in which an abdominal sacrocolpopexy is contraindicated.
• FDA
  • There are no FDA-approved surgical mesh products for transvaginal repair of prolapse
  • The FDA believes that the benefit-risk profile of transabdominal mesh to treat POP remains favorable

• Health Canada issued a Notice to Hospitals in 2010 (and updated in 2014) regarding the use of transvaginal mesh for the treatment of female SUI and POP.
  • The statement regarding the use of transvaginal mesh for prolapse states that there may be a higher rate of complications compared to traditional operations, which do not use synthetic mesh.
  • The statement regarding the use of transvaginal mesh for prolapse and stress incontinence specified that these procedures may lead to complications, which may not be fully correctable with additional surgery, and that surgeons should have adequate training in transvaginal mesh and be familiar with the device warnings and techniques.

Questions

1. What is the CUA/AUA's position on the use of mesh in pelvis surgery?

Answers

1. What is the CUA/AUA's position on the use of mesh in pelvis surgery?
   1. Midurethral sling: both CUA and AUA support it's use
   2. Pelvic organ prolapse:
      1. Transvaginal: CUA: only in special situations; AUA: no FDA-approved products
      2. Transabdominal: CUA: not mentioned; AUA: FDA supports use