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Landmarks in vaginal mesh development: polypropylene mesh for treatment of SUI and POP


Vaginal meshes used in the treatment of stress urinary incontinence (SUI) and pelvic organ prolapse (POP) have produced highly variable outcomes, causing life-changing complications in some patients while providing others with effective, minimally invasive treatments. The risk:benefit ratio when using vaginal meshes is a complex issue in which a combination of several factors, including the inherent incompatibility of the mesh material with some applications in pelvic reconstructive surgeries and the lack of appropriate regulatory approval processes at the time of the premarket clearance of these products, have contributed to the occurrence of complications caused by vaginal mesh. Surgical mesh used in hernia repair has evolved over many years, from metal implants to knitted polymer meshes that were adopted for use in the pelvic floor for treatment of POP and SUI. The evolution of the material and textile properties of the surgical mesh was guided by clinical feedback from hernia repair procedures, which were also being modified to obtain the best outcomes with use of the mesh. Current evidence shows how surgical mesh fails biomechanically when used in the pelvic floor and materials with improved performance can be developed using modern material processing and tissue engineering techniques.

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Fig. 1: Milestones in the development of PPL mesh as a material used in pelvic floor repair.
Fig. 2: Mesh positioning in relation to muscle and fascia in incisional hernia repair.
Fig. 3: The most common sites of surgical mesh implantation in the pelvic floor.
Fig. 4: The industrial process used to produce monofilament PPL mesh compared with a tissue engineering process called electrospinning.
Fig. 5: The basic mechanical properties of a material determined by uni-axial mechanical testing.


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The authors thank The Urology Foundation and the Rosetrees Trust for supporting Naside Mangir. They also gratefully acknowledge the Republic of Turkey, The Ministry of National Education for funding Betül Aydemir Dikici with a PhD studentship grant.

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N.M. researched data for the article, all authors made substantial contributions to discussions of the content. N.M., B.A.D. and S.M. wrote the manuscript and N.M., C.R.C. and S.M. reviewed and edited the manuscript before submission.

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Correspondence to Sheila MacNeil.

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Competing interests

C.R.C. has been involved in the development of bio-engineered alternatives to conventional synthetic sling materials with Symimetic Ltd. N.M., B.A.D. and S.M.N. declare no competing interests.

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Nature Reviews Urology thanks P. Moalli and L. Zhu for their contribution to the peer review of this work.

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Mangir, N., Aldemir Dikici, B., Chapple, C.R. et al. Landmarks in vaginal mesh development: polypropylene mesh for treatment of SUI and POP. Nat Rev Urol 16, 675–689 (2019).

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