Results provide first step toward treatments to help with tissue strength
Innovations in Obstetrics & Gynecology - Fall 2018
SHERIF EL-NASHAR, MD, PhD
Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, UH Cleveland Medical Center; Associate Professor of Obstetrics and Gynecology, Case Western Reserve University School of Medicine
The use of mesh and mesh-augmented repair in pelvic reconstructive surgery has been in the headlines this year for all the wrong reasons. While there are still safe and valid gynecologic indications for the use of mesh, some patients want an alternative. An even smaller subset of prolapse patients wants to preserve the uterus while not using mesh.
Sherif El-Nashar, MD, PhD, a member of the Division of Female Pelvic Medicine and Reconstructive Surgery in the Department of Obstetrics and Gynecology at University Hospitals Cleveland Medical Center, has performed several non-mesh, uterine-sparing procedures for apical vaginal-uterine prolapse.
Dr. El-Nashar answers four questions about this innovative procedure.
What are the indications for mesh?
Pelvic reconstructive surgeons still use mesh today for indications that include advanced and recurrent prolapse and urinary incontinence. Mesh is considered the gold standard for the treatment of advanced and recurrent prolapse, according to Dr. El-Nashar. Additionally, a mesh sling released into the market during the 1990s replaced a more complex surgery for stress urinary incontinence that required creating a sling from the patient’s own tissue through a low abdominal incision.
What is the non-mesh, uterine-sparing procedure?
A number of patients have reservations about the use of mesh, despite its currently safe indications and use. Prolapse patients who do not want to use mesh have the option of undergoing native tissue repair with a hysterectomy.
“I learned the vaginal approach for treating prolapse during my fellowship, and there is a lot of supporting evidence that this native tissue repair is a very reasonable option,” Dr. El-Nashar says. “But there is the issue of removing the uterus. We remove it during pelvic reconstructive surgery not because it is a problem, but because it makes the surgery more technically feasible.”
Some patients who opt for native tissue repair do not want the uterus removed. For a very select patient group, Dr. El-Nashar performs a non-mesh, uterine-sparing procedure for apical prolapse with a modified McCall culdoplasty and uterosacral colpo-hysteropexy. This treats a prolapse patient without mesh and allows her to keep her uterus.
What patients qualify for the procedure?
Dr. El-Nashar has a frank discussion with all of his patients about the uses of mesh in gynecology, the U.S. Food & Drug Administration communications on mesh and the surgical options prolapse patients have available to them.
“We are here to offer patients options,” he says. “It is their decision to select the surgical procedure and we are here to help them make informed decisions. After discussing the commonly utilized surgeries, some patients will decide they like the vaginal approach to prolapse treatment and want to keep the uterus.”
When Dr. El-Nashar and the patient reach this point, the non-mesh, uterine-saving approach enters the conversation. While the approach is innovative, the components of the procedure remain more or less the same. The main difference is the uterus will still be in place. This requires evaluation of the uterus, and continued care with PAP smears and regular follow-up visits as indicated for other women who did not have a hysterectomy.
Why does UH offer this procedure?
The national trend is to use mesh and preserve the uterus during prolapse surgery. The procedure Dr. El-Nashar is performing is only offered to a very small, well-selected group of patients. However, future clinical research at UH Cleveland Medical Center could help make this particular option more available to patients across the country.
“As patients have success with this option, the next step is to further test outcomes of this surgical approach in a prospective fashion in a clinical trial,” he says.
UH is performing the procedure now because physicians like Dr. El-Nashar understand the importance of patient preference. “From our perspective as surgeons,” he says, “we have to educate patients about their options and let them decide. There is no one-size-fits-all solution.”