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Polypropylene Mesh

Polypropylene (PP) mesh is the most widely used synthetic biomaterial in reconstructive urology and urogynecology — dominant in midurethral slings for stress urinary incontinence (SUI) and sacrocolpopexy for apical pelvic organ prolapse (POP). It has been the most heavily studied, regulated, and litigated material in the field.

Material Properties & Classification​

PP is a synthetic, semi-crystalline thermoplastic. Contemporary slings and sacrocolpopexy meshes are macroporous, monofilament polypropylene — Amid Type I, the most biocompatible category, with pore sizes >75 μm permitting macrophage / fibroblast / vascular infiltration while resisting bacterial colonization.[1]

TypeStructureExampleRU/Urogyn Use
IMacroporous, monofilamentPolypropyleneStandard
IIMicroporousePTFE (Gore-Tex)Obsolete for POP/SUI
IIIMacro + micro, multifilamentPolyester (Mersilene)Not standard
IVSubmicronicSilasticNo

Pore size and weight matter. Lightweight, large-pore meshes (~28 g/m²) evoke less inflammation and fewer graft-related complications than heavier-weight (>44 g/m²) meshes. In sacrocolpopexy at ~8 years, lightweight PP had 7.3% vs 22.8% graft-related complications and 2.1% vs 18.8% reinterventions compared to heavier-weight PP.[2]

In vivo stability. PP was initially considered inert. Concerns about in vivo degradation based on "cracked" explant surfaces have been largely refuted — these surface changes appear to be adsorbed protein-formaldehyde coatings from fixation rather than true polymer degradation. Prospective studies demonstrate durability up to 17 years.[1][3]

Host response. PP evokes a less inflammatory or comparable host response than other synthetic and biologic meshes in animal models. The vaginal tissue niche — distinct hormonal, immune, and microbial environment — may amplify the inflammatory response, contributing to the complication signal specific to transvaginal placement.[4][5]

Clinical Applications​

Midurethral Slings (MUS) for SUI​

MUS is the most commonly performed surgical treatment for female SUI and is endorsed as gold standard by AUA, ACOG, AUGS, SUFU, and FIGO.[6][7][9][10] FIGO specifically states MUS is "considered safe and effective in the treatment of SUI, based on many high-quality scientific publications."[7]

  • Retropubic (TVT) — subjective cure 71–97% at ≤1 yr; higher bladder perforation, voiding dysfunction, and suprapubic pain.[6]
  • Transobturator (TVT-O, TOT) — subjective cure 62–98% at ≤1 yr; higher groin pain and SUI-recurrence reoperation.[6]
  • Single-incision mini-slings — shorter mesh, single vaginal incision, less postoperative pain.[6][20]

Short-term efficacy is similar between retropubic and transobturator routes (RR 0.98; 95% CI 0.96–1.00); long-term (>5 yr) subjective cure is also similar (retropubic 51–88%, transobturator 43–92%).[6] In the UK cohort of 95,057 women (Gurol-Urganci 2018), the 9-year overall reoperation rate was 6.9% (4.5% for SUI, 3.3% for sling removal).[8]

Sacrocolpopexy for POP​

Abdominal sacrocolpopexy (open, laparoscopic, or robotic) with PP mesh remains an accepted, effective apical-POP repair: 93% anatomic cure at 5 years vs 62% for cadaveric fascia lata (p = 0.02), and pooled superiority over vaginal native-tissue repair (OR 2.04; 95% CI 1.12–3.72).[11]

The 2019 FDA order halting transvaginal POP mesh does NOT apply to sacrocolpopexy or to SUI slings.[11]

Transvaginal POP Mesh — Effectively Withdrawn​

Transvaginal PP mesh kits for POP repair have been banned or severely restricted worldwide due to unacceptable complication rates (see Regulatory below).[11][12]

Other Reconstructive Uses​

  • Abdominal wall reconstruction adjacent to urologic reconstruction (e.g., after radical cystectomy with ileal conduit)
  • Rectopexy mesh (adjacent to but distinct from urogynecologic use)

Complications​

Mesh Erosion / Exposure​

  • MUS: AUGS quotes vaginal exposure of 1–2%, most managed by office trimming.[13] NY State cohort (n = 36,195): 7-year cumulative erosion 3.7%, reoperation 6.7%.[14]
  • Transvaginal POP mesh: exposure 11.8%, with 6.1% requiring surgical intervention.[12]
  • Sacrocolpopexy: CARE trial 7-year mesh complication rate (vaginal / visceral erosion, sacral osteitis) 10.5%, though many cases used non-Type I mesh.[11]

Risk factors for MUS erosion: prior pelvic surgery (OR 10.37), diabetes (OR 4.63), smoking (OR 3.38), obesity (OR 2.79), postmenopausal status (OR 2.34).[15]

Chronic Pain and Dyspareunia​

Pain is the leading reason for mesh removal, surpassing erosion. In one multicenter series, 34.6% of patients presenting with mesh complications had pelvic pain and 30% had dyspareunia.[12][16] Pain can become centralized and may not respond to mesh removal — up to 50% report persistent pain or dyspareunia after revision.[17]

Other​

Bladder perforation (retropubic > transobturator), voiding dysfunction and retention, urethral fistula (rare), infection, and de novo urgency incontinence.[10][18]

Management of Mesh Complications​

Per ACOG Committee Opinion No. 694:[17]

  • Asymptomatic exposure — surveillance only.
  • Small vaginal exposures (<1 cm) — local estrogen, observation, or in-office trimming.
  • Large exposures, visceral erosion, refractory pain — surgical excision in a high-volume center.
  • Persistent pain after revision — multimodal pain management; consider centralized-pain pathways.[16] Peripheral nerve neuromodulation has shown promise for refractory mesh-induced chronic pelvic pain in case reports.[19]

Regulatory History​

DateAction
Oct 2008FDA Public Health Notification: >1,000 adverse events over 3 years
Jul 2011FDA Safety Communication — transvaginal mesh for POP
Jan 2016FDA reclassifies transvaginal POP mesh to Class III
Nov 2017Australia TGA cancels approval of 2 transvaginal POP mesh types
Dec 2017UK NICE: transvaginal mesh only in research settings
Jul 2018FDA halts posterior-compartment transvaginal POP mesh
Sep 2018UK / Scotland suspends all transvaginal mesh (POP and SUI)
Dec 2018Australia TGA cancels all transvaginal mesh (POP and SUI)
Apr 2019FDA orders halt of all remaining transvaginal POP mesh in the US

Key distinctions:[11][12]

  • The 2019 FDA order applies only to transvaginal mesh for POP.
  • It does not apply to MUS for SUI or to transabdominal sacrocolpopexy mesh.
  • Complication rates for transvaginal PP mesh in POP were ~5× those for SUI or hernia repair.

International divergence persists: the UK and Australia banned MUS along with transvaginal POP mesh; the US and most other jurisdictions continue to permit MUS.[12][20]

Future Directions​

  • Lightweight, large-pore designs that maintain structural stability after tensioning to reduce pore collapse ("effective porosity") and downstream complications.[22][23]
  • 3D-printed patient-specific meshes leveraging pelvic imaging.[21]
  • Alternative materials including electrospun scaffolds and bioabsorbable composites.[21]
  • Mandatory mesh registries for longitudinal surveillance.[4]

See also: Absorbable Mesh, Coated / Hybrid Mesh, Autologous Rectus Fascia.

References​

1. American Urogynecologic Society. FAQ document by Providers on Mesh Midurethral Slings for Stress Urinary Incontinence. 2021.

2. Page AS, Cattani L, Pacquée S, et al. Long-Term Data on Graft-Related Complications After Sacrocolpopexy With Lightweight Compared With Heavier-Weight Mesh. Obstetrics and Gynecology. 2023;141(1):189-198. doi:10.1097/AOG.0000000000005021

3. Thames SF, White JB, Ong KL. The Myth: In Vivo Degradation of Polypropylene-Based Meshes. International Urogynecology Journal. 2017;28(2):285-297. doi:10.1007/s00192-016-3131-4

4. Abhari RE, Izett-Kay ML, Morris HL, Cartwright R, Snelling SJB. Host-Biomaterial Interactions in Mesh Complications After Pelvic Floor Reconstructive Surgery. Nature Reviews Urology. 2021;18(12):725-738. doi:10.1038/s41585-021-00511-y

5. Kelly M, Macdougall K, Olabisi O, McGuire N. In Vivo Response to Polypropylene Following Implantation in Animal Models: A Review of Biocompatibility. International Urogynecology Journal. 2017;28(2):171-180. doi:10.1007/s00192-016-3029-1

6. Wu JM. Stress Incontinence in Women. The New England Journal of Medicine. 2021;384(25):2428-2436. doi:10.1056/NEJMcp1914037

7. Lau HH, Davila GW, Chen YY, et al. FIGO Recommendations: Use of Midurethral Slings for the Treatment of Stress Urinary Incontinence. International Journal of Gynaecology and Obstetrics. 2023;161(2):367-385. doi:10.1002/ijgo.14683

8. Gurol-Urganci I, Geary RS, Mamza JB, et al. Long-term Rate of Mesh Sling Removal Following Midurethral Mesh Sling Insertion Among Women With Stress Urinary Incontinence. JAMA. 2018;320(16):1659-1669. doi:10.1001/jama.2018.14997

9. Committee on Practice Bulletins—Gynecology and the American Urogynecologic Society. ACOG Practice Bulletin No. 155: Urinary Incontinence in Women. Obstetrics and Gynecology. 2015;126(5):e66-e81. doi:10.1097/AOG.0000000000001148

10. Chughtai B, Barber MD, Mao J, et al. Association Between the Amount of Vaginal Mesh Used With Mesh Erosions and Repeated Surgery After Repairing Pelvic Organ Prolapse and Stress Urinary Incontinence. JAMA Surgery. 2017;152(3):257-263. doi:10.1001/jamasurg.2016.4200

11. Committee on Practice Bulletins—Gynecology and American Urogynecologic Society. Pelvic Organ Prolapse: ACOG Practice Bulletin, Number 214. Obstetrics and Gynecology. 2019;134(5):e126-e142. doi:10.1097/AOG.0000000000003519

12. Yeung E, Baessler K, Christmann-Schmid C, et al. Transvaginal Mesh or Grafts or Native Tissue Repair for Vaginal Prolapse. Cochrane Database of Systematic Reviews. 2024;3:CD012079. doi:10.1002/14651858.CD012079.pub2

13. American Urogynecologic Society. FAQ document by Patients on Mesh Midurethral Slings for Stress Urinary Incontinence. 2021.

14. Chughtai B, Mao J, Matheny ME, et al. Long-Term Safety With Sling Mesh Implants for Stress Incontinence. The Journal of Urology. 2021;205(1):183-190. doi:10.1097/JU.0000000000001312

15. Priyatini T, Saputra AND, Meutia AP. Patient-Related Risk Factors for Mesh Erosion Following Midurethral Sling Procedures: A Systematic Review and Meta-Analysis. International Urogynecology Journal. 2026. doi:10.1007/s00192-026-06519-5

16. Abbott S, Unger CA, Evans JM, et al. Evaluation and Management of Complications From Synthetic Mesh After Pelvic Reconstructive Surgery: A Multicenter Study. American Journal of Obstetrics and Gynecology. 2014;210(2):163.e1-8. doi:10.1016/j.ajog.2013.10.012

17. Committee on Gynecologic Practice. Committee Opinion No. 694: Management of Mesh and Graft Complications in Gynecologic Surgery. Obstetrics and Gynecology. 2017;129(4):e102-e108. doi:10.1097/AOG.0000000000002022

18. Ford AA, Rogerson L, Cody JD, Aluko P, Ogah JA. Mid-Urethral Sling Operations for Stress Urinary Incontinence in Women. Cochrane Database of Systematic Reviews. 2017;7:CD006375. doi:10.1002/14651858.CD006375.pub4

19. Martin S, Han E, Peters KM. A Novel Approach to Managing Post Retropubic Vaginal Sling Pain. Urology. 2020;137:196-199. doi:10.1016/j.urology.2019.11.008

20. Carter E, Johnson EE, Still M, et al. Single-Incision Sling Operations for Urinary Incontinence in Women. Cochrane Database of Systematic Reviews. 2023;10:CD008709. doi:10.1002/14651858.CD008709.pub4

21. Farmer ZL, Domínguez-Robles J, Mancinelli C, Larrañeta E, Lamprou DA. Urogynecological Surgical Mesh Implants: New Trends in Materials, Manufacturing and Therapeutic Approaches. International Journal of Pharmaceutics. 2020;585:119512. doi:10.1016/j.ijpharm.2020.119512

22. Jain T, Isayeva IS, Simon DD. Polypropylene Surgical Mesh Implants for Hernia and Pelvic Floor Disorders: A Materials Performance Perspective. Journal of Biomedical Materials Research Part A. 2025;113(8):e37970. doi:10.1002/jbm.a.37970

23. Knight KM, King GE, Palcsey SL, et al. Mesh Deformation: A Mechanism Underlying Polypropylene Prolapse Mesh Complications in Vivo. Acta Biomaterialia. 2022;148:323-335. doi:10.1016/j.actbio.2022.05.051