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.