CORR Insights®: Synthetic Mesh Reconstruction Improves Pelvic Floor Function and Quality of Life After Sacrectomy: A Preliminary Clinical Assessment

Where Are We Now? Pelvic floor reconstruction with mesh after sacrectomy has become an area of interest in addressing the structural and functional challenges posed by the removal of the sacrum for malignancies such as chordomas, sarcomas, or recurrent rectal carcinomas. Sacrectomy creates a large defect in the pelvic floor that can lead to hernias, pelvic organ prolapse, and functional impairments of adjacent organs such as the bladder and rectum. Pelvic floor dysfunction is most commonly encountered after gynecological surgery [7]. Synthetic mesh, particularly polypropylene mesh, has been used for reconstructing these defects in women with uterine prolapse because of its strength, flexibility, and ability to provide durable support [1]. However, in pelvic organ prolapse repair, sacrocolpopexy with mesh has been associated with a higher risk of revision surgery than native tissue repairs in some gynecological studies [1, 5]. But despite its potential utility, the use of synthetic mesh is not without controversy. Mesh-related complications such as infection, erosion into adjacent organs (such as the bladder or bowel), chronic pain, and dyspareunia have been reported in some patients [6]. Moreover, the success of these procedures is highly dependent on surgical expertise. The steep learning curve associated with mesh-based reconstructions highlights the importance of surgeon experience in minimizing complications, such as hernia, infection, and mesh failure, as well as in increasing the likelihood of normal pelvic organ function. In a paper published in this issue of Clinical Orthopaedics and Related Research®, Yan et al. [10] found that the 10 patients who received synthetic mesh reconstruction after sacrectomy for primary malignant sacral tumors reported better quality of life, reduced pelvic floor symptoms, and stronger pelvic muscle activity compared with the 16 patients without mesh reconstruction. There were no major differences in complication rates between groups; however, the sample size limits strong conclusions, and follow-up was not long enough to confirm an equal rate of reoperations in the longer term. And because this paper [10] represents a relatively large number of participants for a retrospective, comparative series of patients after sacrectomy, one can infer that the surgeons involved were highly experienced in the use of this approach. Based on these findings, surgeons might strongly consider using mesh as the primary reconstruction option after sacrectomy. Where Do We Need To Go? One critical area requiring further exploration is the long-term functional outcomes of pelvic floor reconstruction with mesh. Although short-term studies have demonstrated favorable anatomical results, there is limited evidence regarding how these reconstructions affect bladder function (such as continence or voiding efficiency), bowel function (for example, defecatory disorders or incontinence), and sexual health over time [4]. These functional parameters are essential for evaluating the overall success of reconstruction from a patient-centered perspective. Additionally, there is a need to understand whether complications such as chronic pelvic pain or late-onset mesh erosion increase as follow-up periods extend beyond 5 or 10 years. Another key area for investigation is the development of improved mesh materials. Current synthetic meshes are effective but far from ideal. Issues such as inflammation, adhesion formation, infection risk, and poor integration with host tissues highlight the need for innovation in biomaterials science [8]. How Do We Get There? To address these knowledge gaps and have a better understanding of the outcomes in pelvic floor reconstruction with mesh after sacrectomy, further research efforts are essential. However, randomized controlled trials comparing mesh-based reconstructions with alternative methods, such as autologous tissue flaps or biologic grafts after sacrectomy, are unlikely given the rarity of the procedures and the heterogeneity of the population with regard to age, comorbidities, level of sacrectomy, and tumor characteristics. Longer-term follow-up in retrospective series such as that by Yan et al. [10] could provide important information on surgical failures, delayed mesh erosion, and patient-reported outcomes, including function, quality of life, and pelvic organ function. Multicenter retrospective studies can increase study patient population sizes and potentially provide important insight; however, varying surgical approaches and pelvic floor reconstruction techniques across sarcoma centers will make pooling data challenging. Research into hybrid meshes that combine synthetic materials with biologic components, as well as fully resorbable meshes that dissolve over time, could provide promising new options for pelvic floor reconstruction [3]. These materials are designed to offer temporary support while the body heals, reducing the risk of long-term complications. Ideally, they would maintain enough strength during the healing period and then either integrate with natural tissue or safely degrade. Such innovations may help lower the chances of the adverse reactions often associated with permanent synthetic meshes, while still providing effective structural support for the pelvic floor after sacrectomy. The removal of the structural support of the pelvic organs has profound impact on patient quality of life, and any research into improving outcomes for sacrectomy patients will be welcomed by both patients and surgeons alike. Read This Next Learn how sacrectomy is a profound life-changing event [2]. Read patient testimonials on the impact of sacrectomy on quality of life related to loss of pelvic organ function [9].