One in five women undergoes urogynecologic surgery

Dr. David M. Jaspan comments: Direct to consumer advertising has enabled more women to feel comfortable discussing incontinence with their health care providers, which is great. Industry had inundated general ob.gyn. offices with the opportunity to attend short courses to learn "mesh procedures," which may not have been great. Therefore, I am not surprised that the numbers of women with private insurance undergoing urogynecologic surgery are so high.

These advanced procedures should be undertaken by those surgeons with sufficient training and experience to properly counsel women about the risk and benefit of a native tissue repair, compared with a graft placement. In addition, surgeons should have a volume of experience and training that qualifies them to provide this detailed counseling and should perform an appropriate preoperative evaluation to determine the absolute need for a procedure. More procedures may have brought more risk to women.

I applaud the American College of Obstetricians and Gynecologists for the 2011 ACOG Committee Opinion #513, which says, "Surgeons performing complex pelvic floor reconstructive surgery should have adequate experience and training in native tissue repairs as well as repairs using mesh augmentation specific to each device, should have a thorough understanding of pelvic anatomy, and should be able to counsel patients regarding the risk/benefit ratio on the use of mesh compared with native tissue repairs" (Obstet. Gynecol. 2011;118:1459-64).

In its 2011 Safety Communication, the Food and Drug Administration said that transvaginal placement of surgical mesh for POP is of "continuing serious concern." In the document, the FDA restated its 2008 recommendation that health care providers "inform patients about the potential for serious complications and the effect on quality of life, including pain during sexual intercourse, scarring, and narrowing of the vaginal wall in POP repair using surgical mesh; and provide a copy of the patient labeling from the surgical mesh manufacturer if available."

The FDA also made several new recommendations for health care providers in its report:

• Surgeons should recognize that, in most cases, POP can be treated successfully without mesh, thus avoiding the risk of mesh-related complications.

• Surgeons should choose mesh surgery only after weighing the risks and benefits of surgery with mesh versus all surgical and nonsurgical alternatives.

• Removal of mesh may involve multiple surgical procedures and significantly impair the patient's quality of life. Complete removal of mesh may not be possible and may not result in complete resolution of complications, including pain.

Patient counseling needs to include discussion of alternative native tissue repair and the fact that synthetic mesh is permanent, according to ACOG. Other issues to discuss include that vaginal bleeding, pain, and dyspareunia may be related to vaginal mesh; Patients reporting such symptoms should undergo a thorough vaginal exam, including an exam under anesthesia if necessary.

Dr. David M. Jaspan is chairman of ob.gyn. for the Einstein Health Care Network in Philadelphia. He was asked to comment on Dr. Wu's study. Dr. Jaspan said that he had no financial disclosures.

Remember to ask about pelvic floor issues

Dr. Meadow Maze Good comments: This is a well done and important study that highlights the magnitude of pelvic floor disorders in women. Previous studies indicate that women delay or do not seek care for pelvic floor disorders and incorrectly think that these problems are a normal result of aging.

These data presented at the American Urogynecologic Society meeting by Dr. Wu and her colleagues reinforce the need for increased public awareness and education regarding pelvic floor disorders as well as available treatment options, including nonsurgical and surgical options. Additionally, this study points out that the physicians treating women of all ages including the primary care provider (family practice physicians and obstetrician/gynecologists) should query women about possible pelvic floor symptoms, including incontinence, prolapse, and sexual function.

It is especially important for the ob.gyn. to ask their patient about these symptoms if there is planning underway for a hysterectomy for other causes. This is an exciting time for the newly board-certifiable field of female pelvic medicine and reconstructive surgery. As the aging population of women with prolapse and incontinence increases, fellowship programs are graduating physicians knowledgeable in this specific field who are dedicated to taking care of women with these treatable conditions.

Meadow Maze Good, D.O., is a fellow in female pelvic medicine and reconstructive surgery at the University of Texas Southwestern Medical Center, Dallas. Dr. Good, who is also the chair of the Junior Fellow Congress Advisory Council of the American Congress of Obstetricians and Gynecologists, was asked to comment on Dr. Wu's study. She said she had no relevant financial disclosures.