Laparoscopic removal of intravesical mesh following pelvic organ prolapse mesh surgery

Design, mechanical and degradation requirements of biodegradable metal mesh for pelvic floor reconstruction

Pelvic organ prolapse (POP) is the herniation of surrounding tissue and organs into the vagina and or rectum, and is a result of weakening of pelvic floor muscles, connective tissue,...

Early experience of transabdominal and novel transvaginal robot-assisted laparoscopic removal of transvaginal mesh

Background Mesh removal following transvaginal mesh placement has typically involved transvaginal, open pelvic, laparoscopic or a combination of approaches. Robotic pelvic mesh removal has been described in a small number of cases only. This study aims to determine the feasibility and safety of using robot-assisted laparoscopic surgery in removal of pelvic mesh via trans-abdominal and novel trans-vaginal approach. Materials and methods This is a prospective case series study on women who underwent transabdominal or transvaginal robot-assisted removal of pelvic mesh. Women were offered participation in this study if they were over the age of 18 with pelvic mesh and a clinical indication for mesh removal. Alternative surgical options including conventional open removal of mesh were discussed and offered to patients. The primary outcome of this study is the rate of successful removal of mesh and the 30-day complication rates. Ethics approval was obtained for this study. Results Thirty patients were included in this study. Median age was 62. Median operative and console time was 240 and 148 minutes, respectively. Concomitant reconstructive procedures were performed in 40% of patients. Complete or near-complete mesh removal was achieved in 83.3% of patients. For the remaining patients, partial removal of mesh was performed as planned pre-operatively. Three Clavien-Dindo grade 3b complications resulted from mesh removal: concomitant ureteric and bladder injury, omental bleed and groin wound infection. Conclusion This study presents the early experience of robotic-assisted removal of transvaginal mesh with a transvaginal or transabdominal approach and demonstrated feasibility of removal of both retropubic and transobturator MUSS as well as trans-vaginal prolapse meshes with transobturator and sacrospinous mesh arms. Further studies are required to expand understanding on the learning curve, operating times, complication rates and functional outcome of this operation.

Outcome of vaginal mesh reconstructive surgery in multiparous compared with grand multiparous women: Retrospective long-term follow-up

We aimed to compare the long-term surgical outcome and complications of multiparous and grand multiparous women undergoing reconstructive surgery with vaginal mesh implants for repair of pelvic organ prolapse. This retrospective, long-term follow-up (28.17±20.7 months) comprised 113 women who underwent surgical reconstructive surgery with vaginal polypropylene mesh in a high parity rate population medical center. The women were divided into 2 groups (multiparous and grand multiparous) and each group was evaluated for objective and subjective surgical outcome. Patient demographics and surgical data were retrieved from electronic medical records. Outcome measure included POP-Q exam as objective outcome and validated Pelvic Floor Distress Inventory questionnaire (PFDI) to assess subjective outcome. Average age of patients was 62±7.9 (range 42–83) years. Average parity was 5.6±3.1 (range 1–14). There were 54 (47.7%) multiparous women and 59 (52.3%) grand multiparous women. The grand multiparous women were younger than the multiparous women and had a significantly higher degree of prolapse. At the last follow-up, the only significant difference was related to symptoms of an overactive bladder. In conclusion, long-term follow-up demonstrates that vaginal mesh surgery in grand multiparous women offers anatomical and subjective cure rates comparable to multiparous women.

Sacral colpopexy: long-term mesh complications requiring reoperation(s)

INTRODUCTION AND HYPOTHESIS

Sacral colpopexy (SC) is a classic procedure used for the surgical treatment of pelvic organ prolapse. Although the procedure boasts excellent success rates, there are risks of complications and reoperation may be required. The purpose of this study was to evaluate the extent of complications following SC, requiring reoperation(s), and to describe the reoperations performed.

METHODS

A retrospective monocentric study of patients who were operated on following a mesh complication after SC was conducted, at Lille University Hospital, between January 2007 and January 2013. Information relating to medical and surgical history, SC surgical technique, type of complication, and reoperation techniques was gathered.

RESULTS

Twenty-seven patients required surgery for complications after SC. Nineteen patients were treated for vaginal mesh exposures (VME), four for intravesical mesh (including one with VME), one for ano-rectal dyschezia, one for spondylodiscitis with a VME, one for mesh infection, and one for vaginal fistula communicating with a collection in the ischio-coccygeal muscle. The median time between the initial SC and the first reoperation was 3.9 ± 5.7 years. The median operating time was 40 ± 95 min, and the length of hospital stay was 3.0 ± 3.0 days. Ten patients needed several interventions.

CONCLUSION

This case series provides a description of surgical interventions for complications related to sacral colpopexy. These complications may be serious and occur years after the initial surgery.

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.

Robotic removal of eroded vaginal mesh into the bladder

Vaginal mesh erosion into the bladder after midurethral sling procedure or cystocele repair is uncommon, with only a few cases having been reported in the literature. The ideal surgical management is still controversial. Current options for removal of eroded mesh include: endoscopic, transvaginal or abdominal (either open or laparoscopic) approaches. We, herein, present the first case of robotic removal of a large eroded vaginal mesh into the bladder and discuss potential benefits and limitations of the technique.