Decisions to use surgical mesh in operations for pelvic organ prolapse: a question of geography?

Abstract

Introduction and hypothesis: Surgical mesh can reinforce damaged biological structures in operations for genital organ prolapse. When a method is new, scientific information is often contradictory. Individual surgeons may accept different observations as useful, resulting in conflicting treatment strategies. Additional scientific information should lead to increasing convergence. Methods: Based on data from the Swedish National Quality Register of Gynecological Surgery, all patients who underwent their first recurrent anterior compartment prolapse operation between 2006 and 2017 were included (2758 patients). Surgical mesh was used in 56.5%. We analyzed inter-county disparities in and patterns of mesh use over 12 years. To minimize confounding, we selected a group of highly comparable patients where similar decision patterns could be expected. Results: The use of mesh differed between counties by a factor of 11 (8.6–95.3%). Counties with low use of mesh continued with low use and counties with high use continued with high use. Conclusions: Decisions regarding how to interpret existing scientific information about mesh implants in the early years of mesh use have led to “communities of practice” highly influenced by geographical factors. For 12 years, these groups have made disparate decisions and upheld them without measurable change toward consensus. The scientific learning process has stopped—despite the abundance of new publications and the steady supply of new types of mesh. Ongoing disparity in surgeons’ choices in comparable patients has an adverse effect on clinical care. For the patient, this represents 12 years of a geographical lottery concerning whether mesh is used or not.