Various surgical procedures are available for pelvic floor reconstruction in women, including the transvaginal approach, laparotomy, laparoscopic or robot-assisted approach. Among them, the transvaginal approach is associated with short operation time, length of stay and recovery time 14,15. The synthesized mesh has attracted high attention and dispute in recent years, but it is the reconstruction technique that best corresponds with anatomy in pelvic floor surgery, since the mesh shape accords with the human pelvic floor. In addition, the application of mesh in pelvic floor reconstruction also conforms to the findings by Gutman R et al. in literature that the uterine preservation technique is the feasible surgical treatment option for prolapse of uterus, because it can best preserve the original anatomical structure and statics of the pelvic floor16.
In a study that applies TVM placement to treat POP, a conclusion is drawn through two sets of parallel, multi-center randomized controlled trials that, neither mesh or transplant material can great improve the postoperative effect, quality of life and adverse reaction within a short period of time; at the same time, over 1/10 patients have developed mesh placement-related complications 17. However, that research includes not only the POP patients, but also patients with urinary incontinence. By contrast, only patients with POP alone were enrolled in this study, which could eliminate the selection bias to some extent.
Mesh exposure and invasion are the most common complications after TVM placement. According to previous literature report, the mesh exposure rate ranges from 1.4–36% 18,19,20,21,22, while in the Cochrane review 1, the mesh exposure rate is 12%, and 8% patients require further surgical treatment. In our study, only 2 (2.2%) patients had asymptomatic recurrence during postoperative follow-up ,but no further treatment was selected owing to little impact on quality of life. Another 3 (3.6%) patients had mesh exposure, all of them were diabetics whose blood glucose could not be well controlled after surgery; among them, 2 patients had obvious symptoms, who had improved after surgical removal of the exposed mesh and topical application of estrogen ointment. It is generally believed that, the incidence of mesh exposure is related to the thin vagina mucosa separation, excessive tension, infection, vaginal wall atrophy, and early sexual life. Similarly, some research indicates that, diabetes will increase the mesh exposure rate by 7 folds; besides, the anterior vaginal wall is subject to a higher risk of mesh exposure than the posterior wall 23. Therefore, internal medicine complications such as diabetes and hypertension were strictly controlled before surgery in this study, and the internal medicine diseases were positively controlled during the perioperative period, which were of great significance to the expected surgical wound healing, prevention of wound infection and reduction of mesh exposure rate. The sugrical procedure of Avaulta and Pop-Up has no significant difference. In the design of the puncture needle, Avaulta only uses the wire lasso connection method, while the application of Pop-Up is lock connection which was easier in practice. There is a plastic film covering outside the Pop-Up .Although it can reduce the tissue injury during the puncture process, there is no conspicuous difference in postoperative recurrence and complications.
Postoperative dyspareunia is a symptom affected by multiple factors. Typically, any transvaginal surgical procedure, regardless of the use of mesh or not, will lead to vaginal scar formation, which will subsequently result in loss of elasticity and vaginal malformation, thereby causing dyspareunia. According to the Cochrane review, the incidence of dyspareunia after surgery is 4–5%, while the use of mesh will make little difference, which may be related to the vaginal approach 1. In this study, only 2 (2.2%) patients had postoperative dyspareunia, which was suggested to be related to early sexual life of patients.
The experience, skills and number of operation of the surgeon are the key factors determining whether the operation will success. As proved by Kelly24 et al., about 5% POP women undergoing TVM placement required a second operation within 10 years to treat the mesh complications. For surgeons that carry out at least 14 operations annually, the risk of a second operation can be minimized24. Nonetheless, it should be pointed out that, surgical technique plays a crucial role in mesh corrosion, since the incidence of mesh corrosion varies from studies. For instance, a multi-center randomized controlled trial about TVM suggested that, the incidence of mesh exposure varied from 0–100% 3. In order to avoid complications and reduce the risk of recurrence, we summarized some key points during TVM. Hydrodissection beneath vaginal adventitia is crucial to preserve the capillary network within the vaginal adventitia and for well separating the anterior wall of the vagina from the bladder and ureter, thereby reducing the risk of bladder or uteter damage. At the same time, attention should be paid to the flat placement of the mesh to avoid the formation of folds, otherwise it is easy to form a local cavity causing infection; and we use normal saline instead of diluted adrenaline, so as to avoid the increase of intraoperative blood pressure and increase the burden of the heart. After operation, the vagina was filled with Iodophor gauze for 48 hours to prevent hematoma. The surgical procedure becomes easier and more feasible thanks to the application of mesh box, which has reduced the experience requirement on surgeons in such pelvic floor surgery. However, only after completing sufficient theoretical and technical training, and being experienced in vaginal surgery, can the surgeons perform the pelvic floor surgery. Given that TVM use has dropped precipitously in the USA due to medicolegal issues related to class action lawsuits against the manufacturers of the TVM kits, the use of TVM can be further optimized through the following aspects: First, the indications of TVM should be further refined. For patients with relatively high risk of anesthesia and surgery, TVM should be given priority to avoid re-surgery due to recurrence. In addition, 3D printing technology 25can be used when training young doctors and patients for pre-operative communication. The printout of the patient's pelvic floor structure not only allows the patient to understand the surgical procedure and risks more directly, but also allows young doctors to re-learn the pelvic floor organ structure from 2D to 3D
Our study has some limitations. We acknowledge the limited number of patients included in this study and its retrospective nature. Due to the influence of traditional concepts, the sexual activity of elderly women seems lower than other regions, and preoperative sexual life only accounts for 5.6%. The limited number of patients could not fully reflect the influence of TVM on dyspareunia .In addition, not all women undergoing pelvic organ prolapse repair at our institution enrolled in the database