Vaginal Mesh Contraction: Definition, Clinical Presentation, and Management

Mobility and stress analysis of different surgical simulations during a sacral colpopexy, using a finite element model of the pelvic system

INTRODUCTION AND HYPOTHESIS

We aim to analyze the combined influence of the size of the mesh, the number of sutures, the combined use of an anterior and posterior mesh, and the tension applied to the promontory, on the mobility of the pelvic organs and on the sutures, using a Finite Element (FE) model of the female pelvic system during abdominal sacral colpopexy.

METHODS

We used a FE model of the female pelvic system, which allowed us to simulate the mobility of the pelvic system and to evaluate problems related to female prolapse. The meshes were added to the geometrical model and then transferred to computing software. This analysis allowed us to compare the stress and mobility during a thrust effort in different situations.

RESULTS

The bigger the mesh, the less mobility of both anterior and posterior organs there would be. This is accompanied by an increase in stress at the suture level. The combination of a posterior mesh with an anterior one decreases mobility and stress at the suture level. There is a particularly relevant stressing zone on the suture at the cervix. The increase in the number of sutures induces a decrease in the tension applied at each suture zone and has no impact on organ mobility.

CONCLUSION

Our model enables us to simulate and analyze an infinite number of surgical hypotheses. Even if these results are not validated at a clinical level, we can observe the importance of the association of both an anterior and a posterior mesh or the number of sutures.

The Single-Incision Sling to Treat Female Stress Urinary Incontinence: A Dynamic Computational Study of Outcomes and Risk Factors

Dynamic behaviors of the single-incision sling (SIS) to correct urethral hypermobility are investigated via dynamic biomechanical analysis using a computational model of the female pelvis, developed from a female subject's high-resolution magnetic resonance (MR) images. The urethral hypermobility is simulated by weakening the levator ani muscle in the pelvic model. Four positions along the posterior urethra (proximal, midproximal, middle, and mid-distal) were considered for sling implantation. The α-angle, urethral excursion angle, and sling-urethra interaction force generated during Valsalva maneuver were quantitatively characterized to evaluate the effect of the sling implantation position on treatment outcomes and potential complications. Results show concern for overcorrection with a sling implanted at the bladder neck, based on a relatively larger sling-urethra interaction force of 1.77 N at the proximal implantation position (compared with 0.25 N at mid-distal implantation position). A sling implanted at the mid-distal urethral location provided sufficient correction (urethral excursion angle of 23.8 deg after mid-distal sling implantation versus 24.4 deg in the intact case) with minimal risk of overtightening and represents the optimal choice for sling surgery. This study represents the first effort utilizing a comprehensive pelvic model to investigate the performance of an implanted sling to correct urethral hypermobility. The computational modeling approach presented in the study can also be used to advance presurgery planning, sling product design, and to enhance our understanding of various surgical risk factors which are difficult to obtain in clinical practice.

To mesh or not to mesh: a review of pelvic organ reconstructive surgery

Pelvic organ prolapse (POP) is a major health issue with a lifetime risk of undergoing at least one surgical intervention estimated at close to 10%. In the 1990s, the risk of reoperation after primary standard vaginal procedure was estimated to be as high as 30% to 50%. In order to reduce the risk of relapse, gynecological surgeons started to use mesh implants in pelvic organ reconstructive surgery with the emergence of new complications. Recent studies have nevertheless shown that the risk of POP recurrence requiring reoperation is lower than previously estimated, being closer to 10% rather than 30%. The development of mesh surgery - actively promoted by the marketing industry - was tremendous during the past decade, and preceded any studies supporting its benefit for our patients. Randomized trials comparing the use of mesh to native tissue repair in POP surgery have now shown better anatomical but similar functional outcomes, and meshes are associated with more complications, in particular for transvaginal mesh implants. POP is not a life-threatening condition, but a functional problem that impairs quality of life for women. The old adage "primum non nocere" is particularly appropriate when dealing with this condition which requires no treatment when asymptomatic. It is currently admitted that a certain degree of POP is physiological with aging when situated above the landmark of the hymen. Treatment should be individualized and the use of mesh needs to be selective and appropriate. Mesh implants are probably an important tool in pelvic reconstructive surgery, but the ideal implant has yet to be found. The indications for its use still require caution and discernment. This review explores the reasons behind the introduction of mesh augmentation in POP surgery, and aims to clarify the risks, benefits, and the recognized indications for its use.

The impact of boundary conditions on surface curvature of polypropylene mesh in response to uniaxial loading

Exposure following pelvic organ prolapse repair has been observationally associated with wrinkling of the implanted mesh. The purpose of this study was to quantify the impact of variable boundary conditions on the out-of-plane deformations of mesh subjected to tensile loading. Using photogrammetry and surface curvature analyses, deformed geometries were accessed for two commercially available products. Relative to standard clamping methods, the amount of out-of-plane deformation significantly increased when point loads were introduced to simulate suture fixation in-vivo. These data support the hypothesis that regional increases in the concentration of mesh potentially enhance the host׳s foreign body response, leading to exposure.

Complications of pelvic organ prolapse surgery and methods of prevention

INTRODUCTION AND HYPOTHESIS

The aim was to review complications associated with pelvic organ prolapse surgery.

METHODS

Every 4 years and as part of the Fifth International Collaboration on Incontinence we reviewed the English-language scientific literature after searching PubMed, Medline, Cochrane library and Cochrane database of systematic reviews, published up to January 2012. Publications were classified as level 1 evidence (randomised controlled trials [RCT] or systematic reviews), level 2 (poor quality RCT, prospective cohort studies), level 3 (case series or retrospective studies) and level 4 (case reports). The highest level of evidence was utilised by the committee to make evidence-based recommendations based upon the Oxford grading system. Grade A recommendation usually depends on consistent level 1 evidence. Grade B recommendation usually depends on consistent level 2 and/or 3 studies, or "majority evidence" from RCTs. Grade C recommendation usually depends on level 4 studies or "majority evidence from level 2/3 studies or Delphi processed expert opinion. Grade D "no recommendation possible" would be used where the evidence is inadequate or conflicting and when expert opinion is delivered without a formal analytical process, such as by Delphi.

RESULTS AND CONCLUSIONS

Transvaginal mesh has a higher re-operation rate than native tissue vaginal repairs (grade A). If a synthetic mesh is placed via the vaginal route, it is recommended that a macroporous polypropylene monofilament mesh should be used. At sacral colpopexy mesh should not be introduced or sutured via the vaginal route and silicone-coated polyester, porcine dermis, fascia lata and polytetrafluoroethylene meshes are not recommended as grafts. Hysterectomy should also be avoided (grade B). There is no evidence to recommend routine local or systemic oestrogen therapy before or after prolapse surgery using mesh. The first cases should be undertaken with the guidance of an experienced surgeon in the relevant technique (grade C). Expert opinion suggests that by whatever the surgical route pre-operative urinary tract infections are treated, smoking is ceased and antibiotic prophylaxis is undertaken. It is recommended that a non-absorbable synthetic mesh should not be inserted into the rectovaginal septum when a rectal injury occurs. The placement of a non-absorbable synthetic mesh into the vesicovaginal septum may be considered after a bladder injury has been repaired, if the repair is considered to be satisfactory. It is possible to perform a hysterectomy in association with the introduction of a non-absorbable synthetic mesh inserted vaginally, but this is not recommended routinely.

Imaging of slings and meshes

The popularity of imaging in pelvic floor medicine continues to increase. Among the various modalities, ultrasound is superior as it is cheap, safe, easily accesible and simple, resulting in high patient compliance. It is the only technique that allows imaging of modern wide-weave polypropylene sling or mesh implants, and imaging of such implants is commonly required due to the popularity of surgical techniques that involve the placement of slings and meshes. This review article will discuss the role of translabial ultrasound in the evaluation of synthetic implants used in the treatment of urinary incontinence and pelvic organ prolapse.

Three-dimensional transperineal ultrasound for imaging mesh implants following sacrocolpopexy

OBJECTIVE

To characterize, using three-dimensional (3D) transperineal ultrasound, the appearance, position and dimensions of mesh implants following minimally invasive abdominal sacrocolpopexy.

METHODS

In women who underwent sacrocolpopexy, mesh was evaluated at rest and on maximal Valsalva, on all 3D orthogonal planes and rendered views. Mesh dimensions were obtained by 3D processing in the midsagittal and coronal planes (anterior, posterior and sacral arm) and were analyzed offline, the operator blinded to clinical data.

RESULTS

Overall, 62 women, mean age 58.4 (range, 42-79) years were evaluated at a median of 9 (range, 1-26) months following surgery. The anterior arm of the mesh was caudal to the lowermost point of descent of the anterior compartment in 56 (90.3%) women, was equally positioned in five (8.1%) and was cranial in one. The posterior arm was caudal in 44 (71%) women, was equally positioned in 16 (25.8%) and was cranial in two (3.2%). The Y connection and the sacral arm of the mesh could not be adequately seen because of physical limitations of ultrasound (lower resolution at greater depth), large recurrent rectoceles, echogenic stools or folding of mesh remnants. Folding of the mesh was seen in 46 (74.2%) women, folding of the anterior arm in five (8.1%) and folding of the posterior arm in 23 (37.1%). Folding occurred caudally in 26 (41.9%) women, proximally in 11 (17.7%) and in both areas in nine (14.5%). There were no erosions.

CONCLUSION

Mesh visualization following minimally invasive abdominal sacrocolpopexy procedures using transperineal 3D/four-dimensional (4D) ultrasound is feasible. Studies are needed to evaluate the correlation between ultrasound measures and prolapse recurrence or mesh erosion.

Comparison of vaginal mesh repair with sacrospinous vaginal colpopexy in the management of vaginal vault prolapse after hysterectomy in patients with levator ani avulsion: a randomized controlled trial

OBJECTIVE

To compare the efficacy of two standard surgical procedures for post-hysterectomy vaginal vault prolapse in patients with levator ani avulsion.

METHODS

This was a single-center, randomized interventional trial, of two standard surgical procedures for post-hysterectomy vaginal vault prolapse: Prolift Total vs unilateral vaginal sacrospinous colpopexy with native tissue vaginal repair (sacrospinous fixation, SSF), during the period from 2008 to 2011. Entry criteria included at least two-compartment prolapse, as well as complete unilateral or bilateral levator ani avulsion injury. The primary outcome was anatomical failure based on clinical and ultrasound assessment. Failure was defined clinically, according to the Pelvic Organ Prolapse Quantification system, as Ba, C or Bp at the hymen or below, and on translabial ultrasound as bladder descent to 10 mm or more below the lower margin of the symphysis pubis on maximum Valsalva maneuver. Secondary outcomes were evaluation of continence, sexual function and prolapse symptoms based on validated questionnaires.

RESULTS

During the study period, 142 patients who were post-hysterectomy underwent surgery for prolapse in our unit; 72 of these were diagnosed with an avulsion injury and were offered participation in the study. Seventy patients were randomized into two groups: 36 in the Prolift group and 34 in the SSF group. On clinical examination at 1-year follow-up, we observed one (3%) case of anatomical failure in the Prolift group and 22 (65%) in the SSF group (P < 0.001). Using ultrasound criteria, there was one (2.8%) failure in the Prolift group compared with 21 (61.8%) in the SSF group (P < 0.001). The postoperative POPDI (Pelvic Organ Prolapse Distress Inventory) score for subjective outcome was 15.3 in the Prolift group vs 21.7 in the SSF group (P = 0.16).

CONCLUSION

In patients with prolapse after hysterectomy and levator ani avulsion injury, SSF has a higher anatomical failure rate than does the Prolift Total procedure at 1-year follow-up.

Symptom resolution after operative management of complications from transvaginal mesh

OBJECTIVE

Complications from transvaginal mesh placed for prolapse often require operative management. The aim of this study is to describe the outcomes of vaginal mesh removal.

METHODS

A retrospective review of all patients having surgery by the urogynecology group in the department of obstetrics and gynecology at our institution for a complication of transvaginal mesh placed for prolapse was performed. Demographics, presenting symptoms, surgical procedures, and postoperative symptoms were abstracted. Comparative statistics were performed using the χ or Fisher's exact test with significance at P<.05.

RESULTS

Between January 2008 and April 2012, 90 patients had surgery for complications related to vaginal mesh and 84 had follow-up data. The most common presenting signs and symptoms were: mesh exposure, 62% (n=56); pain, 64% (n=58); and dyspareunia, 48% (n=43). During operative management, mesh erosion was encountered unexpectedly in a second area of the vagina in 5% (n=4), in the bladder in 1% (n=1), and in the bowel in 2% (n=2). After vaginal mesh removal, 51% (n=43) had resolution of all presenting symptoms. Mesh exposure was treated successfully in 95% of patients, whereas pain was only successfully treated in 51% of patients.

CONCLUSION

Removal of vaginal mesh is helpful in relieving symptoms of presentation. Patients can be reassured that exposed mesh can almost always be successfully managed surgically, but pain and dyspareunia are only resolved completely in half of patients.

LEVEL OF EVIDENCE

III.

Effectiveness of Hyalobarrier and Seprafilm to prevent polypropylene mesh shrinkage: a macroscopic and histological experimental study

INTRODUCTION AND HYPOTHESIS

Polypropylene (PP) mesh shrinkage represents a serious complication, as a significant cause of pain and recurrence of pelvic organ prolapse or ventral hernias, frequently requiring several surgical interventions. The retraction seems to be caused by the host, in response to the implantation, through the occurrence of periprosthetic adhesions and fibrosis. We hypothesized that avoiding the postoperative adhesions can prevent PP mesh shrinkage.

METHODS

Sixty rats were randomly assigned to three groups. A standardized hernia defect was induced on the abdominal wall, which was repaired using an extraperitoneal PP mesh alone (group 1), with application of a hyaluronate carboxymethylcellulose-based bioresorbable membrane (Seprafilm, group 2), or an auto-cross-linked polysaccharide hyaluronan-based solution (Hyalobarrier gel, group 3). Eight weeks after the procedure, a repeat laparotomy was performed. After scoring the adhesion and measuring the mesh surface, a microscopic study of the prosthesis-host tissue interfaces was performed.

RESULTS

Group 1 displayed a median shrinkage of 29% of the mesh. The Seprafilm group (p = 0.0238) and Hyalobarrier gel group (p = 0.0072) displayed a significantly smaller reduction of 19.12 and 17 %, respectively. Control group 1 displayed a significantly greater adhesion score (30.40) than the Seprafilm (11.67, p = 0.0028) and Hyalobarrier gel groups (11.19, p = 0.0013). The fibrosis was reduced in the Hyalobarrier gel group only.

CONCLUSION

This experimental study revealed that Hyalobarrier gel and Seprafilm can prevent PP mesh shrinkage and postoperative adhesions. They might be integrated in a mesh size-saving strategy, which should preserve the quality and durability of the surgical repair and limit the postoperative pain.

Outcomes following treatment for pelvic floor mesh complications

INTRODUCTION AND HYPOTHESIS

Our aim was to determine symptoms and degree of improvement in a cohort of women who presented following treatment for vaginal mesh complications.

METHODS

This study was a follow-up to a multicenter, retrospective study of women who presented to four tertiary referral centers for management of vaginal-mesh-related complications. Study participants completed a one-time follow-up survey regarding any additional treatment, current symptoms, and degree of improvement from initial presentation.

RESULTS

Two hundred and sixty women received surveys; we had a response rate of 41.1 % (107/260). Complete data were available for 101 respondents. Survey respondents were more likely to be postmenopausal (p = 0.006), but otherwise did not differ from nonrespondents. Fifty-one percent (52/101) of women underwent surgery as the primary intervention for their mesh complication; 8 % (4/52) underwent a second surgery; 34 % (17/52) required a second nonsurgical intervention. Three patients required three or more surgeries. Of the 30 % (30/101) of respondents who reported pelvic pain prior to intervention, 63 % (19/30) reported improvement, 30 % (9/30) were worse, and 7 % (2/30) reported no change. Of the 33 % (33/101) who reported voiding dysfunction prior to intervention, 61 % (20/33) reported being at least somewhat bothered by these symptoms.

CONCLUSIONS

About 50 % of women with mesh complications in this study underwent surgical management as treatment, and <10 % required a second surgery. Most patients with pain preintervention reported significant improvement after treatment; however, almost a third reported worsening pain or no change after surgical management. Less than half of patients with voiding dysfunction improved after intervention.

Indications, contraindications, and complications of mesh in surgical treatment of pelvic organ prolapse

Women are seeking care for pelvic organ prolapse in increasing numbers and a significant proportion of them will undergo a second repair for recurrence. This has initiated interest by both surgeons and industry to utilize and design prosthetic mesh materials to help augment longevity of prolapse repairs. Unfortunately, the introduction of transvaginal synthetic mesh kits for use in women was done without the benefit of level 1 data to determine its utility compared with native tissue repair. This report summarizes the potential benefit/risks of transvaginal synthetic mesh use for pelvic organ prolapse and recommendations regarding its continued use.

Translabial ultrasonography for evaluation of synthetic mesh in the vagina

OBJECTIVE

To compare the clinical and surgical findings using translabial ultrasonography (US) in the evaluation of symptoms after transvaginal synthetic mesh placement.

METHODS

From 2009 through 2010, a retrospective observational study was conducted to evaluate patients presenting with complaints after transvaginal mesh implantation for the treatment of stress urinary incontinence or pelvic organ prolapse repair. The clinical and translabial US findings were compared with the intraoperative findings, with a focus on mesh location, erosion, and extrusion.

RESULTS

A total of 51 consecutive patients (mean age 59 years) were evaluated by history and physical examination, translabial US, and intraoperative findings. Using intraoperative findings as the reference standard, translabial US was able to predict the location of the sling in relationship to the urethra (6 distal, 25 mid-urethral, and 20 at the bladder neck), to differentiate between transobturator (n = 21) and retropubic (n = 30) slings, and to detect all anterior (n = 21) and posterior (n = 15) placed mesh. Translabial US was superior to physical examination in identifying mesh erosion into the periurethral fascia or sphincteric unit. US was inferior to physical examination in diagnosing vaginal extrusion but was superior for locating the mesh.

CONCLUSION

Translabial US can identify the mesh material used to treat stress urinary incontinence and pelvic organ prolapse. It provides additional information on sling type, mesh location, and morphology compared with the clinical findings and could help in surgical planning and counseling. Prospective clinical studies evaluating the reliability of this technique in larger patient populations are warranted.

Impact of rectopexy on sexual function: a cohort analysis

PURPOSE

Laparoscopic ventral rectopexy (LVR) is an established surgical technique for the treatment of both rectal prolapse and symptomatic rectoceles. It is, however, not known whether LVR influences sexual function (SF). The aim of this study was, therefore, to determine the impact of this procedure on the SF of patients.

METHODS

All female patients after LVR procedure in a single institution were identified and were sent a questionnaire concerning SF. This addressed sexual activity, satisfaction, preoperative SF, and the impact of surgery on SF. Furthermore, the PISQ-12 validated sexual functioning questionnaire was sent to all female patients.

RESULTS

A total of 217 patients were sent a questionnaire. These patients underwent LVR for rectal prolapse, symptomatic rectocele, or enterocele between 2004 and 2011. Mean age was 62 years (range 22-89). Mean follow-up was 30 months (range 5-83). Response rate was 64 % (139 patients). The number of sexual active patients dropped from 71 to 54 % after surgery. The number of patients being satisfied with their SF remained relatively equal; 91 % of patients before and 85 % of patients after surgery. Forty-three percent of patients stated that the LVR procedure did not influence their sexual function, in 16 % of patients, the procedure positively influenced their SF, and in 13 % of respondents, SF decreased after surgery. The mean PISQ-12 score postoperatively was 34 out of 48.

CONCLUSIONS

The impact of LVR on SF of patients seems limited in this cross-sectional study in a large cohort of patients.

Short-term surgical outcomes and characteristics of patients with mesh complications from pelvic organ prolapse and stress urinary incontinence surgery

INTRODUCTION AND HYPOTHESIS

Surgical treatment of pelvic organ prolapse (POP) and stress urinary incontinence (SUI) can include the use of synthetic materials. Placement of synthetic materials into the vaginal wall, through either the vagina or the abdomen, includes the risk of complications such as vaginal wall extrusion or pain. There is little data regarding outcomes following treatment of mesh complications.

METHODS

A retrospective chart review of patients who underwent excision of mesh placed for POP or SUI between 1 January 2001 and 31 October 2012 was performed at the University of Virginia. Chart abstraction queried patient demographics, clinical history, physical examination, pre- and post-excision symptoms, and operative findings. The International Continence Society (ICS) and International Urogynecological Association (IUGA) classification system was used to define the nature and location of mesh complications.

RESULTS

A total of 57 patients (26 mid-urethral slings, 23 transvaginal prolapse, 9 intraperitoneal prolapse) with the diagnosis of mesh extrusion into the vaginal wall were analyzed. Twenty-five (average 2.8 cases/year) original mesh surgeries occurred between January 2001 and January 2010 and 41 (average 20.5 cases/year) occurred after January 2010. The most common presenting patient complaints were chronic pelvic pain (55.9 %), dyspareunia (54.4 %), and vaginal discharge (30.9 %). At a 6-week post-operative visit, 57.3 % of patient's symptoms were completely resolved and 14.6 % were improved.

CONCLUSION

Clinicians should be cognizant of the variable presentations of post-operative vaginal mesh complications. Mesh excision by experienced pelvic surgeons is an effective and safe treatment for these complications; however, a significant number of patients may have persistent symptoms following surgery.

The role of vaginal mesh procedures in pelvic organ prolapse surgery in view of complication risk

Synthetic transvaginal mesh has been employed in the treatment of pelvic organ prolapse for more than a decade. As the use of these devices increased during this period so did adverse event reporting. In 2008, the Food and Drug Administration (FDA) Public Health Notification informed physicians and patients of rising concerns with the use of synthetic transvaginal mesh. Shortly thereafter and in parallel to marked increases in adverse event reporting within the Manufacturer and User Device Experience (MAUDE), the FDA released a Safety Communication regarding urogynecologic surgical mesh use. Following this report and in the wake of increased medical industry product withdrawal, growing medicolegal concerns, patient safety, and clinical practice controversy, many gynecologists and pelvic reconstructive surgeons are left with limited long-term data, clinical guidance, and growing uncertainty regarding the role of synthetic transvaginal mesh use in pelvic organ prolapse. This paper reviews the reported complications of synthetic transvaginal mesh with an evidence-based approach as well as providing suggested guidance for the future role of its use amidst the controversy.

High risk of complications with a single incision pelvic floor repair kit: results of a retrospective case series

INTRODUCTION AND HYPOTHESIS

The aim of this study was to retrospectively assess the extent and severity of the post-operative complications associated with the Pinnacle Pelvic Floor Repair Kit.

METHODS

This is a descriptive analysis of 23 consecutive women who had a prolapse repair with either an anterior (n = 19) or posterior (n = 4) Pinnacle kit. The clinical records of all these patients were available for analysis. Pre-operative data and intra-operative complications were noted. All post-operative complications and repeat surgical interventions were recorded. In addition to pelvic floor symptoms, we looked specifically for pelvic pain and mesh contraction, exposure, extrusion or erosion. Complications were classified according to the joint IUGA/ICS system.

RESULTS

Seventy percent (n = 16) of our cohort experienced at least one complication. All, except one, were following an anterior Pinnacle. 10 patients (43 %) had a tender vaginal mesh prominence, including a contraction band anteriorly or at the vaginal apex. Six (26 %) complained of associated buttock, groin or vaginal pain, while the tenderness was only detected during vaginal examination in 4 (16 %) patients. Three (13 %) patients required vaginal mesh excision for severe pain and one required a second procedure. Three patients (13 %) had vaginal mesh exposure and 8 (35 %) developed de novo stress incontinence. Two patients (8 %) developed symptomatic recurrent prolapse, one following mesh excision owing to large mesh exposure. Another patient had an anterior compartment prolapse above and below a tender contracted anterior vaginal mesh.

CONCLUSIONS

The Pinnacle kit was associated with a high incidence of post-operative complications in this small series.

Mesh retraction correlates with vaginal pain and overactive bladder symptoms after anterior vaginal mesh repair

INTRODUCTION AND HYPOTHESIS

The aim of the present study was to determine possible correlations between mesh retraction after anterior vaginal mesh repair and de novo stress urinary incontinence (SUI), overactive bladder (OAB), and vaginal pain symptoms.

METHODS

One hundred and three women with symptomatic prolapse of the anterior vaginal wall, stages 3 and 4 based on the Pelvic Organ Prolapse Quantification (POP-Q) system, underwent Prolift anterior™ implantation. At a 6-month follow-up, the patients were interviewed for de novo SUI, OAB, and vaginal pain, and underwent an introital/transvaginal ultrasound examination to measure the mesh length in the midsagittal plane.

RESULTS

Mesh retraction was significantly larger in a subgroup of patients (n = 20; 19.4 %) presenting de novo OAB symptoms on the follow-up assessment compared with those without this complication (5.0 cm vs. 4.3 cm; p < 0.05). Mesh retraction was also significantly larger in a subgroup of patients (n = 23; 22.3 %) reporting postoperative vaginal pain compared with the women who did not report any postoperative vaginal pain (5.3 cm vs. 4.2 cm; p < 0.01). A significant correlation was found between mesh retraction and the severity of vaginal pain (R = 0.4, p < 0.01). Mesh retraction did not differ between patients with de novo SUI symptoms and those without this complication.

CONCLUSIONS

Mesh retraction assessed on ultrasound examination after anterior vaginal mesh repair may correlate with de novo OAB symptoms and vaginal pain.

Transvaginal mesh surgery for pelvic organ prolapse: one-year outcome analysis

OBJECTIVE

The aim of the study was to assess the role of Prolift + M (PP-PG) vaginal mesh surgery to correct uterovaginal prolapse not only from an anatomic but also a subjective (patient's) standpoint.

METHODS

A prospective cohort of subjects treated with transvaginal mesh for prolapse between April 2009 and November 2010 was analyzed. A composite score that included subjective criteria of absence of a bothersome bulge and objective criteria based on Pelvic Organ Prolapse Quantification lower than stage II was used to assess treatment success.

RESULTS

Transvaginal mesh was performed in 157 subjects (age, 64.7 ± 11.6 years; body mass index, 28.5 ± 4.8 kg/m) for pelvic organ prolapse. Five anterior mesh surgeries (3.2%), 48 posterior mesh surgeries (30.6%), and 104 total mesh surgeries (66.2%) were performed in subjects with stage II or greater degrees of prolapse. Stage II prolapse was noted in 44 subjects (28.0%), 91 subjects (58.0%) had stage III prolapse, and 22 subjects (14.0%) had stage IV prolapse. The mean follow-up was 13 months. Our composite success score was 88.1%. Pure anatomic success based on Pelvic Organ Prolapse Quantification lower than stage II was 94%. The mean operative time was 117.8 ± 42.4 minutes. The mean intraoperative blood loss was 106.1 ± 116.4 mL. There were 3 cases (2.2%) of mesh exposure in the vagina. There were no visceral injuries. The incidence of de novo dyspareunia was 6%.

CONCLUSION

Transvaginal PP-PG mesh surgery is safe and effective with few postoperative morbidities.

Pearls and pitfalls of mesh surgery

OBJECTIVES

This article attempts to offer balanced insight into the use of transvaginal mesh for pelvic organ prolapse especially in the light of the negative publicity in recent times. The role of transvaginal mesh has been in the limelight for a number of reasons and it is important to address this issue in an objective, fair, and balanced manner. The conventional approach to prolapse surgery has undergone a paradigm shift and the principles of mesh replacement surgery sharply contrast with many traditionally held beliefs. This has created a new set of challenges that has revealed a sharp division of opinion among specialists and sub-specialists alike.

CONCLUSION

The article is an attempt to explain how mesh surgery can be safely and efficiently performed in carefully selected cases and is based on the combined wisdom of some of the leading surgeons in the sub-specialty today.

Managing vaginal mesh exposure/erosions

PURPOSE OF REVIEW

To review the known causes, presentation, and management of synthetic mesh exposure and other healing abnormalities associated with transvaginal implantation for pelvic organ prolapse.

RECENT FINDINGS

The recent restriction of mesh used in urogynecology to type 1 monofilament/macroporous mesh has led to recognizable patterns of healing abnormality development. Excision of exposed or contracted mesh segments usually leads to symptom resolution. There are various surgical techniques recognized to reduce the risk of exposure development. Pain, when associated with mesh use, may be more challenging to manage and may persist in a small percentage of patients. Surgeons should be aware of recently recognized risk factors for exposure development and carefully select patients for mesh implantation based on risk:benefit assessment.

SUMMARY

The use of synthetic mesh implanted transvaginally for urogynecologic indications is associated with recognized risks, including exposure (approximately 10%) and contraction which can usually be managed successfully with local estrogen, in-office trimming, or surgical excision of the exposed or contracted segment.

Ureteral injury during vaginal mesh excision: role of prevention and treatment options

Vaginal mesh kits are increasingly used in vaginal prolapse repair. Mesh erosion, infection, and pain may necessitate removal, which can lead to urinary tract injury. We describe 2 cases of ureteral injury at the time of mesh excision. Surgeons must recognize the possibility of ureteral injury and treatment modalities available.

Complications of vaginal mesh surgery

PURPOSE OF REVIEW

Mesh used for slings and pelvic organ prolapse (POP) repair has resulted in increased efficacy. Yet, the benefits of a more durable repair must be weighed against such risks as vaginal mesh extrusion and erosion and increased dyspareunia, and pelvic pain. We review the current literature on complications seen with the use of vaginal mesh for both stress urinary incontinence and POP.

RECENT FINDINGS

The use of mesh in midurethral slings results in similar efficacy but less morbidity compared with nonmesh sling techniques. The use of mesh in abdominal sacrocolpopexy may result in lower rates of mesh complications compared with transvaginal mesh prolapse repairs. In 2011, the Food and Drug Administration issued an updated safety communication stating that serious complications associated with transvaginal mesh for POP repair are not rare. Yet, certain patients do benefit from the use of transvaginal mesh for POP repair.

SUMMARY

Better-controlled data are needed to answer questions regarding outcomes, complications, and quality of life after transvaginal mesh prolapse procedures. The surgeon and the patient must have a proper informed consent discussion about the risks, benefits, alternatives, and indications for the use of mesh.

Mesh-related complications in urogynecology - a multidisciplinary challenge

Diagnoses of complications in women who underwent pelvic floor surgery using meshes and the multidisciplinary management of these cases at two national referral urogynecological centers between January and June 2011 are presented in a series of cases of mesh complications, which provide an indication of the wide range of symptoms and, at times, the long time span over which they may be encountered. Complications included infection, erosion (extrusion/exposure), fistulas, perforation into the surrounding organs (such as urethra, bladder and/or bowel), chronic pelvic pain (often radiating into buttocks, groins and/or thighs), dysuria, dyschezia, voiding difficulties, constipation, stool evacuation difficulties, de novo overactive bladder, urinary and fecal incontinence and prolapse recurrences. Although meshes have the ability to provide adequate anatomical support, the emergence of such a multitude of complications has resulted in restrictions for their use, as well as being a multidisciplinary challenge.

Prevention of complications related to the use of prosthetic meshes in prolapse surgery: guidelines for clinical practice

The objective of the study was to provide guidelines for clinical practice from the French College of Obstetrics and Gynecology (CNGOF), based on the best evidence available, concerning adverse events related to surgical procedures involving the use of prosthetic meshes. French and English-language articles from Medline, PubMed, and the Cochrane Database were searched, using key words (mesh; pelvic organ prolapse; cystocele; rectocele; uterine prolapse; complications; adverse event; sacral colpopexy; extrusion; infection). As with any surgery, recommendations include perioperative smoking cessation (Expert opinion) and compliance with the prevention of nosocomial infections (regulatory recommendation). There is no evidence to recommend routine local or systemic estrogen therapy before or after prolapse surgery using mesh, regardless of the surgical approach (Grade C). Antibiotic prophylaxis is recommended, regardless of the approach (Expert opinion). It is recommended to check for pre-operative urinary tract infection and treat it (Expert opinion). The first procedure should be undertaken under the guidance of a surgeon experienced in the relevant technique (Grade C). It is recommended not to place a non-absorbable synthetic mesh into the rectovaginal septum when a rectal injury occurs (Expert opinion). Placement of a non-absorbable synthetic mesh into the vesicovaginal septum may be considered after suturing of a bladder injury if the suture is considered to be satisfactory (Expert opinion). If a synthetic mesh is placed by vaginal route, it is recommended to use a macroporous polypropylene monofilament mesh (Grade B). It is recommended not to use polyester mesh for vaginal surgery (Grade B). It is permissible to perform hysterectomy associated with the placement of a non-absorbable synthetic mesh placed by the vaginal route but this is not routinely recommended (Expert opinion). It is recommended to minimize the extent of the colpectomy (Expert opinion). The laparoscopic approach is recommended for sacral colpopexy (Expert opinion). It is recommended not to place and suture meshes by the vaginal route when a sacral colpopexy is performed (Grade B). It is recommended not to use silicone-coated polyester, porcine dermis, fascia lata, and polytetrafluoroethylene meshes (Grade B). It is recommended to use polyester (without silicone coating) or polypropylene meshes (Grade C). Suture of the meshes to the promontory can be performed using thread/needle or tacks (Grade C). Peritonization is recommended to cover the meshes (Grade C). If hysterectomy is required, it is recommended to perform a subtotal hysterectomy (Expert opinion). Implementation of this guideline should decrease the prevalence of complications related to surgical procedures involving the use of prosthetic meshes.

Complications of synthetic slings used in female stress urinary incontinence and applicability of the new IUGA-ICS classification

OBJECTIVES

To analyze different complications of synthetic suburethral slings, and to apply the new "IUGA-ICS classification of complications directly related to the insertion of prosthesis (meshes, implants, tapes) and grafts in female pelvic floor surgery" to the list of complications, check its applicability, and give suggestions regarding possible improvements.

STUDY DESIGN

This study is an analysis of complications of synthetic suburethral slings. Data on type of complication, time interval between the insertion of the prosthesis and the onset of symptoms of complication, type and nature of prosthesis, and management process were documented. Additional descriptions of the sling position in relation to lower urinary tract, shrinkage or prominence of the prosthesis, and intra-operative nature of the prosthetic material were collected for analysis.

RESULTS

From the year 2003 to 2010, 376 women with complications of synthetic suburethral slings were managed surgically and the data were analyzed. Overactive bladder (OAB) at 54%, lower urinary tract obstruction (48%), vaginal exposure (19%), and pain (14%) were the most frequent complications. Infection, fistulae, urinary tract penetration, and groin/thigh pain were other complications. The new IUGA-ICS classification could be applied to most of the types of complications, a notable exception being de novo development of overactive bladder. Also category 4B of IUGA-ICS classifications encompasses a wide clinical variety of complications and may need reconsideration.

CONCLUSION

De novo OAB seems to be the commonest complication of synthetic suburethral slings, followed by obstruction, vaginal exposure, and long term pain. The new IUGA-ICS classification on complications has good general applicability; some minor changes may be useful in the future.

Computer modeling informs study design: vaginal estrogen to prevent mesh erosion after different routes of prolapse surgery

INTRODUCTION AND HYPOTHESIS

Many clinicians use perioperative vaginal estrogen therapy (estradiol, E(2)) to diminish the risk of mesh erosion after prolapse surgery, though supporting evidence is limited. We assessed the feasibility of a factorial randomized trial comparing mesh erosion rates after vaginal mesh prolapse surgery (VM) versus minimally invasive sacral colpopexy (MISC), with or without adjunct vaginal estrogen therapy.

METHODS

A Markov state transition model simulated the probability of 2-year outcomes of visceral injury, mesh erosion, and reoperation after four possible prolapse therapies: VM or MISC, each with or without estrogen therapy (E(2)). We used pooled estimates from a systematic review to generate probability distributions for the following outcomes after each procedure: visceral injury, postoperative mesh erosion, and reoperation for either recurrent prolapse or mesh erosion. Assuming different assumptions for E(2) efficacies (50 and 75 % reduction in erosion rates), Monte Carlo simulations estimated outcomes rates, which were then used to generate sample size estimates for a four-arm factorial trial.

RESULTS

While E(2) reduced the risk of mesh erosion for both VM and MISC, absolute reduction was small. Assuming 75 % efficacy, E(2) decreased the risk of mesh erosion for VM from 7.8 to 2.0 % and for MISC from 2.0 to 0.5 %. Total sample sizes ranged from 448 to 1,620, depending on power and E(2) efficacy.

CONCLUSIONS

The required sample size for a trial to determine which therapy results in the lowest erosion rates would be prohibitively large. Because this remains an important clinical issue, further study design strategies could include composite outcomes, cost-effectiveness, or value of information analysis.

Controversies in the management of mesh-based complications: a urology perspective

Since the introduction of the synthetic midurethral sling, several transvaginal mesh delivery systems have been developed for treating stress incontinence and pelvic organ prolapse. Widespread use of these "kits" has introduced a new dilemma of mesh-specific complications that female pelvic surgeons must manage. Differing treatment techniques have been described and controversy exists as to which method is preferred for vaginal mesh extrusion, mesh perforations, pelvic pain, and dyspareunia. This article addresses the differing management strategies for mesh complications after reconstructive surgery and highlights the available literature on the success of each option.

Vaginal Rejuvenation: An In-Depth Look at the History and Technical Procedure

This article is a comprehensive review of the pelvic cosmetic procedure, vaginal rejuvenation. The review covers the inception, evolution, and challenges involved with the operation. Comparison with the classic procedures from which it was derived as well as similar current procedures designed for pelvic organ prolapse are covered. Indications, patient selection, expected outcomes, and technical aspects of the operation itself are addressed.

Beyond the complications: medium-term anatomical, sexual and functional outcomes following removal of trocar-guided transvaginal mesh. A retrospective cohort study

INTRODUCTION AND HYPOTHESIS

The aims of this study were to assess the anatomical, sexual and functional outcomes of women undergoing surgical intervention for complications of the trocar-guided transvaginal mesh (TVM) procedure.

METHODS

This was a retrospective analysis of a clinical database of women who had developed a complication following a TVM procedure. This included dyspareunia, mesh erosion, urinary symptoms, mesh contraction and prolapse recurrence. Pre- and post-operatively, we assessed the women for prolapse, stress incontinence, urgency, defecatory difficulty, digitation, pain, dyspareunia and apareunia. We also recorded the Pelvic Organ Prolapse Quantification (POP-Q) score. The TVM was removed and a Biodesign graft was used in the majority of cases to prevent further prolapse. Follow-up was at 6 weeks, 6 months, 1 and 2 years.

RESULTS

In our cohort of 21 women, 18 required surgery for pain and/or dyspareunia; 20 women had reached the 6-week follow-up at the time of analysis. At 6 weeks, two women still had pain and required a second intervention. Fifteen women had reached a 6-month follow-up and only one woman had persistent pain requiring repeat surgery. Of the 15 women, 7 were sexually active and in 6 cases the dyspareunia had resolved completely with 1 woman retaining an element of pain at intercourse. Six women had been seen at 12 months and all four of the sexually active women had no dyspareunia. There were no symptoms relating to prolapse in any of the women at 6 weeks, 6, 12 or 24 months.

CONCLUSIONS

We report satisfactory outcomes following removal of a complicated TVM kit.

Mesh complications in female pelvic floor reconstructive surgery and their management: A systematic review

We reviewed the incidence, predisposing factors, presentation and management of complications related to the use of synthetic mesh in the management of stress urinary incontinence and pelvic organ prolapse repair. Immediate complications, such as bleeding, hematoma, injury to adjacent organs during placement of mesh and complication of voiding dysfunction are not discussed in this review, since they are primarily related to technique. A PubMed search of related articles published in English was done from April 2008 to March 2011. Key words used were urinary incontinence, mesh, complications, midurethral sling, anterior prolapse, anterior vaginal repair, pelvic organ prolapse, transvaginal mesh, vault prolapse, midurethral slings, female stress urinary incontinence, mesh erosion, vaginal mesh complications, and posterior vaginal wall prolapse. Since there were very few articles dealing with the management of mesh-related complications in the period covered in the search we extended the search from January 2005 onwards. Articles were selected to fit the scope of the topic. In addition, landmark publications and Manufacturer and User Facility Device Experience (MAUDE) data (FDA website) were included on the present topic. A total of 170 articles were identified. The use of synthetic mesh in sub-urethral sling procedures is now considered the standard for the surgical management of stress urinary incontinence. Synthetic mesh is being increasingly used in the management of pelvic organ prolapse. While the incidence of extrusion and erosion with mid-urethral sling is low, the extrusion rate in prolapse repair is somewhat higher and the use in posterior compartment remains controversial. When used through the abdominal approach the extrusion and erosion rates are lower. The management of mesh complication is an individualized approach. The choice of the technique should be based on the type of mesh complication, location of the extrusion and/or erosion, its magnitude, severity and potential recurrence of pelvic floor defect.

Surgical management of mesh-related complications after prior pelvic floor reconstructive surgery with mesh

INTRODUCTION AND HYPOTHESIS

The objective of this study is to evaluate the complications and anatomical and functional outcomes of the surgical treatment of mesh-related complications.

METHODS

A retrospective cohort study of patients who underwent complete or partial mesh excision to treat complications after prior mesh-augmented pelvic floor reconstructive surgery was conducted.

RESULTS

Seventy-three patients underwent 30 complete and 51 partial mesh excisions. Intraoperative complications occurred in 4 cases, postoperative complications in 13. Symptom relief was achieved in 92% of patients. Recurrence of pelvic organ prolapse (POP) occurred in 29% of complete and 5% of partial excisions of mesh used in POP surgery. De novo stress urinary incontinence (SUI) occurred in 36% of patients who underwent excision of a suburethral sling.

CONCLUSIONS

Mesh excision relieves mesh-related complications effectively, although with a substantial risk of serious complications and recurrence of POP or SUI. More complex excisions should be performed in skilled centers.