Interpretation
The use of mesh for pelvic reconstructive surgery has come under intense
scrutiny over the last decade. Mesh complications have become an
increasing concern for patients. In 2008, the Food and Drug
Administration (FDA) issued a Public Health Notification regarding the
adverse events related to the use of surgical mesh in
urogynecology.2 In 2011, the FDA issued an update
noting that serious complications associated with surgical mesh for
transvaginal repair of prolapse is not rare.2Subsequently, in 2012, the FDA issued orders to conduct post-market
surveillance studies to address the safety and effectiveness of
transvaginal mesh prolapse repairs. In 2016, surgical mesh for
transvaginal prolapse repair was reclassified from Class II to Class
III. In 2017, all urogynecologic mesh was reclassified from Class I to
Class II. Finally, in 2019, vaginal mesh kits were removed from the
market.9 Although this did not include mesh used for
sacrocolpopexy and mid-urethral slings, studies have shown that the
rates of prolapse and incontinence surgeries using mesh have decreased
during this time.10
A recent review of the available literature on autologous fascia
prolapse repairs showed that there have been only six case
series.7 Several series reported on the use of
pedicled rectus fascia flaps.11–13 One retrospective
study that included free rectus fascia graft compared outcomes between
mesh, Pelvicol xenograft, and autologous fascia for abdominal
sacrocolpopexy but only had 15 patients in the autologous fascia
group.8 The authors concluded that recurrence was more
likely with a Pelvicol graft but was equivalent for mesh and autologous
graft. Oliver et al. reported a series of 19 patients with excision of
sacrocolpopexy mesh with replacement of a free rectus fascia
graft.14 Seth et al. reported a case series of 7
patients who underwent autologous rectus fascia sacrocolpopexy and
sacrohysteropexy with free Y grafts. Mean follow-up was 16 months with
all patients having durable results at last
follow-up.7 Another alternative to mesh sacrocolpopexy
is allograft fascia. However, there have been studies that reported
significant early failure rates with sacrocolpopexy using allograft
fascia.15,16 Antigenicity, immune response, and
post-harvest preservation techniques are all factors that affect graft
remodeling and thus the success and function of an allograft, but that
do not negatively affect autologous fascia grafts.
This cohort provided subjective and objective outcome data on an
alternative to mesh sacrocolpopexy. To our knowledge, this was the
largest cohort available with long-term follow-up. Our low retreatment
rate for prolapse was consistent with those noted in studies using mesh
graft. Our postoperative ileus or SBO rate was comparable to slightly
lower than that seen in the 2 year data from the CARE trial (5.3% vs
6.8%). In addition, the use of this autologous graft eliminated the
10.5% complication rate of mesh erosion noted in the CARE
trial.4 One concern with harvesting autologous rectus
fascia is the risk of incisional hernias. In the SISTer trial, hernias
occurred in 1.2% of patients who underwent a rectus
fascia pubovaginal sling for treatment of
incontinence.17 There were no cases of incisional
hernias in our cohort. Mean length of stay in our cohort was 2.2 days
and this is a notable disadvantage of the procedure compared to
minimally invasive sacrocolpopexy with mesh grafts with a mean length of
stay less than 24 hours.18 Prolonged length of stay
has been associated with increased hospital-acquired infections,
decreased mobility and longer postoperative recovery
time.19,20 As such, there has been a trend across all
surgical specialties to develop protocols and techniques that aid in
shortening length of stay.21,22 The ongoing COVID-19
pandemic has further pushed this goal to decrease hospital exposures and
led to same-day discharge after pelvic reconstructive surgery with good
outcomes.23 The advent of ERAS programs have aided in
this goal. We did see a decrease in length of stay in patients that
underwent surgery after standardized ERAS protocols were initiated at
our hospital.