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Transvaginal mesh is a net-like implant used to treat pelvic organ prolapse and stress urinary incontinence in women. The product design and implantation technique contributed to serious complications, such as erosion and organ perforation.
Transvaginal mesh is usually made of plastic called polypropylene. The term “transvaginal” refers to the type of surgical technique used to implant the mesh – through the vagina.
This type of surgical mesh was created to permanently fix pelvic organ prolapse (POP) and stress urinary incontinence (SUI) – conditions that typically plague women after a hysterectomy, menopause or childbirth. Pelvic organ prolapse occurs when a woman’s pelvic muscles weaken and the pelvic organs — including the bladder, rectum and uterus — drop into the vagina.
Doctors can surgically place the mesh transvaginally or abdominally, but inserting the mesh through the vagina is quicker, easier and less invasive.
While these products were created to help women suffering from SUI and POP, not all of them are safe and reliable. The design and manufacturer-recommended implantation technique of some of these transvaginal mesh products contributed to serious complications such as infection, erosion of the vaginal tissues and organ perforation.
Reports of complications came too late for hundreds of thousands of women who already had mesh implanted.
Nearly 70,000 lawsuits filed by women injured by mesh are pending in the U.S. District Court for the Southern District of West Virginia. Additional lawsuits are pending in state courts.
First type of mesh used for SUI repair (sling or tape) is cleared for sale. These are followed by the first POP kits - the AMS Apogee and AMS Perigee.
SUI repair becomes more common with the release of Ethicon’s Tension-Free Vaginal Tape (TVT).
The first transvaginal mesh device, the ProtoGen Sling, is recalled over safety concerns.
The first surgical mesh product specifically designed for POP repair – Gynemesh PS – was released in 2002 by Johnson & Johnson’s Ethicon unit.
Transvaginal mesh is used to treat various health conditions cause by weakened pelvic muscles.
Manufacturers weave synthetic mesh materials together in several different shapes, depending on their intended use. When the fibers are woven together, pores are created on the surface of the material. According to the FDA, lightweight, large-pore mesh reduces the body’s inflammatory response.
This type of mesh is considered a permanent implant because it will remain in the body indefinitely. More than half of all mesh products approved by the FDA fall into this category. These products are made from synthetic materials like plastic or polyester. Polypropylene is the most popular material for manufacturers, and 91 percent of non-absorbable synthetic mesh is made of this plastic.
Absorbable mesh loses strength and degrades over time and is not intended as a long-term treatment. Ideally, the patient’s new tissue growth at the implant site helps to keep the repair strong.
These mesh products are natural and derived from animal tissue that has been specially disinfected for implanting in the human body. These products degrade over time and are usually made from cow (bovine) or pig (porcine) tissue.
This mesh is made from a combination of any of the above three categories.
Pelvic organ prolapse occurs when organs sag or fall into the vaginal canal because of weak pelvic muscles. Transvaginal mesh serves as a hammock beneath the organs to hold them up. Usually, the bladder, uterus, rectum or bowel is involved in the prolapse; the bladder is the most common organ affected.
Depending on the organs involved, surgeons may place the piece of mesh on the front, back or top wall of the vagina. The type of mesh used also varies in shape and size.
This type of surgery is usually performed transvaginally. In fact, three out of four surgeries to treat POP with mesh were done transvaginally in 2010.
Stress urinary incontinence occurs when the bladder leaks urine during moments of increased physical activity that increases pressure on the bladder. The mesh is used to support the urethra when pelvic muscles weaken.
Surgical treatment of SUI with mesh – usually called a bladder sling or vaginal tape – is the most common type of surgery used to correct the condition, and 80 percent of SUI mesh surgeries in 2010 were done through the vagina. Doctors use transvaginal placement of bladder slings because it is considered less invasive and the incisions are smaller.
After a hysterectomy, some women suffer from vaginal vault prolapse – where the vagina collapses in upon itself because of the removal of the uterus. Mesh is surgically implanted on the top of the vagina and sewn into connective tissues to hold the vagina in place.
Although transvaginal mesh surgery is simpler and less invasive than more traditional treatments for POP and SUI, it also carries a higher complication rate. In 2011, the FDA reported that it had received 4,000 reports of complications related to transvaginal mesh in the previous six years.
The agency previously reported in 2008 that complications from transvaginal mesh used for surgical treatment of POP were rare, but in 2011 it updated its statement and warned patients and doctors that they are not rare.
Severe complications like mesh erosion and organ perforation require surgery to fix. This surgery is referred to as revision surgery.
However, because synthetic surgical mesh was designed to stay in the body indefinitely, removal of the mesh is extremely difficult. The blood vessels and tissues grow around the mesh, requiring doctors to remove it in pieces, one surgery at a time.
Doctors who specialize in transvaginal mesh revision surgery are called urogynecologists. Urogynecologists receive special training in pelvic floor disorders like prolapse and incontinence and are experienced in performing revision surgeries.
|Other complications can include:|
|Pain||Recurrence of prolapse or incontinence|
|Nerve damage||Vaginal scarring|
|Infection||Vaginal shrinkage (via scar tissue)|
|Painful sexual intercourse||Neuro-muscular problems|
After mesh erodes through the vaginal wall, it can also harm other organs. Organ perforation occurs when the sharp edges of mesh cut into or perforate nearby organs such as the bladder. This can cause serious damage and requires surgery to correct.Learn More
Compounding the problem is that the FDA did not require transvaginal mesh manufacturers to conduct studies on these products in humans before they were implanted. Also, many of the products on the market today were approved based on the ProtoGen Sling, which was recalled in 1999 after the FDA found the device had a “higher than expected rate of vaginal erosion” and did “not appear to function as intended.”
Urogynecologist L. Lewis Wall wrote in an article in the American Journal of Obstetrics and Gynecology that the ProtoGen “had never been implanted in a human vagina prior to its clearance.” It wasn’t until independent doctors conducted their own clinical trials and studies revealing the risk of complications that the FDA decided to look more closely at transvaginal mesh.
In 2012, Rep. Edward Markey (D-Mass.) released a report designed to gain support for his recently introduced bill that would allow the FDA to refuse approval to medical devices that are based on products that have been or are in the process of being recalled.
The lawmaker illustrated the severity of the problem by introducing a victim of defective transvaginal vaginal mesh at a briefing to tell her story. The 50-year-old mother of three explained how the implant she received in 2008 has left her debilitated, unable to work and nearly homeless as her house is about to be foreclosed on.
|The FDA’s Activities and Role in Regulating Transvaginal Mesh|
|October 2008||FDA releases Public Health Safety Notification warning the public about complications of transvaginal mesh for SUI and POP, but says complications are rare.|
|July 2011||FDA updates its 2008 Public Health Safety Notification to say that complications are not rare. It also states that “it is not clear that transvaginal POP repair with mesh is more effective” than non-mesh repair and “may expose patients to greater risk.”|
|September 2011||FDA organizes the Obstetrics and Gynecology Devices Panel of the Medical Device Advisory Committee.|
|January 2012||Based on recommendations of the panel, the FDA orders manufacturers of transvaginal mesh products to conduct postmarket studies.|
|February 2012||FDA issues 95 postmarket study orders to 34 manufacturers of POP mesh products and 14 orders to 7 manufacturers of SUI mesh.|
|April 2014||FDA updates its Web page to include more information on adverse events and mesh used for SUI.|
|April 2014||FDA issues two proposed orders that would "reclassify surgical mesh for transvaginal pelvic organ prolapse (POP) from a moderate-risk device (class II) to a high-risk device (class III) and require manufacturers to submit a premarket approval (PMA) application for the agency to evaluate safety and effectiveness.”|
Women who received transvaginal mesh implants suffer many different types of side effects, physical mental and emotional. Several women say they felt alone and isolated by the physical symptoms because doctors and family members either didn’t believe them or thought the complications stemmed from some other health problem. It can also be difficult to know where to turn for treatment and what to expect from mesh removal surgery.
One of the best places to turn for support is the internet. Facebook alone has several support groups for women suffering from mesh complications. This can also be a good place to ask questions about symptoms and treatment. Some of the support groups are open to the public, while others are private.
A quick internet search will also pull up a variety of organizations, blogs and websites run by other women who experienced problems with mesh. Often, these mesh "survivors" post helpful articles and advice on how to cope with living with mesh before and after revision surgery.
Social media can be a powerful tool for raising awareness and finding support. Just like Facebook, Twitter can be a way to connect with other mesh survivors and avoid feeling isolated. Women who speak out against mesh often use Twitter to share their experiences and information.
When it comes to painful complications such as mesh erosion, doctors may or may not perform surgery. Mesh removal is notoriously difficult. One woman described it as "removing gum from your hair." The tissues grow around the mesh and harden, creating painful scar tissue. Only surgeons with special training — such as urogynecologists — can accomplish this difficult procedure while minimizing complications.
In some cases, if the risk of complications from surgery is too great, some doctors may opt to use alternative methods to mesh removal. Some of these treatments include:
After removing mesh, a woman will still face discomfort and pain while the tissue heals. But doctors will often have solutions to pain management. One of the biggest complications of mesh removal surgery is the formation of fistulas and scar tissue. The hardened tissue can cause pelvic pain and even nerve pain. Sometimes more surgery is required to remove these tissues.
Pelvic physical therapy is a surgery-free and drug-free treatment that can ease these symptoms. Gentle massage and exercises can facilitate healing and encourage knots of tissue in the pelvic area to loosen. Check for a pelvic floor therapist in your area.
Not all patients with stress urinary incontinence or organ prolapse will want or qualify for surgery. In these cases, doctors may use non-surgical methods to treat the problems first. If surgery is necessary, there are also techniques that do not use mesh.
Pessaries. A pessary is a small, plastic device inserted into the vagina to provide support to the organs and bladder. Doctors teach women how to insert a pessary, and it is recommended for women who still want children, do not want surgery or are not optimal candidates for surgery. These devices are typically made of inert plastic or silicone.
Pelvic Floor Therapy. In addition to Kegel exercises, a pelvic floor physical therapy can strengthen the pelvic muscles and improve prolapse or stress urinary incontinence in milder cases.
Surgery without Mesh. The patient's own tissue can also be used to support prolapse organs or a bladder.
Tens of thousands of women and their families filed lawsuits against the major mesh manufacturers after being injured by transvaginal mesh. Chief Judge Joseph R. Goodwin is overseeing six federal multidistrict litigations (MDLs) in the Southern District of West Virginia.
Christine Scott and her husband won a jury verdict of $5.5 million against C.R. Bard in 2012, and then in 2013, a jury ordered Ethicon to pay $11.11 million to Linda Gross for her injuries.
Laura Yaeger, an attorney who has extensive experience with transvaginal mesh lawsuits, told Drugwatch that more than 40 mesh products are involved in the federal lawsuits. Judge Goodwin set trial dates for each defendant, beginning in July 2013 with Bard. Several more trials are scheduled into 2016.
Linda Gross, who won an $11.11M verdict against Johnson & Johnson, was forced to have 18 revision surgeries. Unfortunately, revision surgery doesn’t guarantee that all symptoms will disappear.
Deborah Barba won a $100 million jury verdict against Boston Scientific after she claimed the company's Pinnacle and Advantage Fit mesh products caused her injuries that led to a number of surgeries. It was later reduced to $10 million by the judge.