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Public Citizen Calls for Ban on Use of Vaginal Mesh for POP Repair

On August 25, 2011 Public Citizen, a consumer advocacy group representing more than 225,000 members and supporters nationwide, petitioned the Food and Drug Administration (FDA), pursuant to the Medical Device Amendments to the Federal Food, Drug, and Cosmetic Act, 21 U.S.C. §§ 360f and 360h, and 21 C.F.R. §§ 10.30, 810, and 895, to immediately:

(1) ban the marketing of all currently available non-absorbable surgical mesh products specifically designed and labeled for transvaginal repair of pelvic organ prolapse (POP) — which were used in an estimated 67,500 surgical procedures in the U.S. in 2010* — because these devices (a) offer no clinically significant benefits in comparison to surgical repairs for POP performed without placement of surgical mesh; and (b) have high rates of serious complications, many of which require additional surgical intervention and some of which are not amenable to surgical correction and result in permanent life-altering harm, therefore presenting “an unreasonable and substantial risk of illness or injury,” the standard for the FDA to institute proceedings to ban a device under the device law, 21 U.S.C. § 360f and 21 C.F.R. § 895.21(a);

(2) order all manufacturers of non-absorbable surgical mesh products specifically designed and labeled for transvaginal repair of POP to recall these products; and

(3) require that any non-absorbable surgical mesh product specifically designed and labeled for transvaginal repair of POP that is proposed for marketing in the future be classified as a class III device and be approved for marketing only under a pre-market approval application (PMA) that includes data from well-designed, prospective clinical trials that provide a reasonable assurance that the surgical mesh product is safe and effective.

Public citizen and the doctors supporting its petition to ban bladder sling mesh have focused their petition on seven different surgical mesh products that are marketed specifically for use on POP repair. These vaginal mesh products are the following:

  1. Gynecare Prolift Total, Anterior, and Posterior Pelvic Floor Repair Systems (Ethicon, Inc. — a Johnson & Johnson subsidiary)
  2. Gynecare Prolift +M Total, Anterior, and Posterior Pelvic Floor Repair Systems (Ethicon, Inc.)
  3. Gynemesh Prolene Soft Nonabsorbable Synthetic (Ethicon, Inc.)
  4. AMS Elevate Anterior and Apical Prolapse Repair System (American Medical Systems, Inc., Minnetonka, MN)
  5. Pinnacle Pelvic Floor Repair Kits (Boston Scientific Corp., Marlborough, MA)
  6. Avaulta Support System (C.R. Bard, Inc., Covington, GA)
  7. Polyform Synthetic Mesh (Proxy Biomedical, Ltd., Galway, Ireland)
Public Citizen’s petition was supported by two doctors who specialize in urogynecological surgery, Daniel S. Elliott, M.D. of the Department of Urology at the Mayo Clinic and L. Lewis Wall, M.D. of Washington University. Public citizen and many doctors believe that commercial interests related to surgical mesh kits for POP repair have taken precedence over patient safety and welfare. In a commentary criticizing the commercial pressures that have led to the proliferation in the use of commercial surgical mesh kits for POP repair, as well as to recent revisions to the American College of Obstetricians and Gynecologists (ACOG) Practice Bulletins on POP that resulted in a downplaying of the experimental nature of these commercial products, Dr. Wall noted the following:
“[Trocar]-and-mesh” device kits for the surgical correction of prolapsed female genitalia are now the rage. New variations on this theme arrive in the medical marketplace with stunning frequency. There is now virtually no cavity in the pelvis that cannot have an artificial mesh threaded through it with the use of a strong right arm and a long enough spike. Whether or not this surgical intervention is good for patients and not just good for surgeons’ pocketbooks and the balance sheets of surgical device manufacturers is as yet unknown because appropriately powered clinical trials with adequate follow-up have not yet been performed, but it is clear that powerful commercial interests are attempting to reshape the field of pelvic surgery for their financial benefit. Operations tied to specific commercial products are being carried out and promoted by groups who stand to benefit directly from their utilization, irrespective of whether or not the operation in question is in the patient’s best interests. This sad reality raises significant ethical questions for pelvic surgeons, for professional associations such as [ACOG], and for governmental regulators. We contend that these issues are not being adequately addressed…

There are clear differences between what is legal and what is ethical with regard to the use of surgical devices such as the ever-expanding number of [trocar]-and-mesh kits now marketed for the treatment of incontinence and prolapse. Unlike drugs—which must be shown by clinical trials to be both safe and effective prior to their release—current regulations in the USA do not require medical devices such as the mesh kits for incontinence surgery and prolapse repair to meet this burden of proof [1]. If the Food and Drug Administration decides that a device is “equivalent” to something that has already been cleared for release, it is allowed to enter the market. Independent clinical trials are not currently required. Thus, permission to allow a new device to enter the market is largely a political decision; but legal permission to market a device is not the same as using it in an ethical manner…

[ACOG] should throw its considerable weight behind efforts to bring the legal requirements for marketing new devices in line with our profession’s ethical obligations to our patients. New medical or surgical devices should not be allowed into the American or any other world market until there is definitive evidence of the devices’ safety and efficacy on the basis of properly designed, properly powered clinical trials. Rather than changing policy to accommodate enhanced reimbursement for ethically questionable practices, ACOG should push for more stringent regulatory control of the medical device industry.

Based on the review of all available peer-reviewed scientific literature and the FDA’s analysis of reports submitted to the MAUDE database, the Public Citizen says the following conclusions can be drawn about the use of transvaginal mesh bladder sling products:
  • Synthetic surgical mesh placed during transvaginal repair of POP commonly causes many serious adverse events.
  • Patients who undergo transvaginal POP repair with surgical mesh are subject to many mesh-related complications that do not occur in patients who undergo POP repair without mesh.
  • The most common complication caused by surgical mesh used in transvaginal POP repair is mesh erosion. This adverse event occurs in approximately 10% of women undergoing transvaginal POP repair with surgical mesh.
  • More than half of the women who develop mesh erosions from non-absorbable, synthetic mesh require surgical excision. Some women require two or more additional surgeries.
  • Some adverse events, such as mesh contraction, can be life-altering for some women. Some complications such as pain and dyspareunia may continue despite mesh removal.
  • New-onset stress urinary incontinence (SUI) has been reported to occur more frequently following transvaginal POP repair with mesh than repair without mesh.

Public Citizen therefore concludes that implantation of vaginal mesh products are not currently “ethically justified” and requests (1) that all current bladder sling mesh products in use be recalled, (2) that the FDA ban the use of these products, and (3) that any future products be subject to the full pre-market approval process including appropriate clinical trials.

If you or a loved one has already had a vaginal mesh product manufactured by Gynecare, Ethicon, Johnson & Johnson, C.R. Bard, American Medical Systems or Boston Scientific and have had mesh complications such as mesh erosion, contact a vaginal mesh lawyer today for a free consultation.

Public Citizen FDA Petition (.pdf)
Letter from Daniel S. Elliott, M.D. of the Department of Urology at the Mayo Clinic (.pdf)
Letter from L. Lewis Wall, M.D. of Washington University (.pdf)

 

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