Laparoscopic mesh explantation and drainage of sacral abscess remote from transvaginal excision of exposed sacral colpopexy mesh

Diagnosis and management of complications following pelvic organ prolapse surgery using a synthetic mesh: French national guidelines for clinical practice

Complications associated with pelvic organ prolapse (POP) surgery using a synthetic non-absorbable mesh are uncommon (<5%) but may be severe and may hugely diminish the quality of life of some women. In drawing up these multidisciplinary clinical practice recommendations, the French National Authority for Health (Haute Autorité de santé, HAS) conducted an exhaustive review of the literature concerning the diagnosis, prevention, and management of complications associated with POP surgery using a synthetic mesh. Each recommendation for practice was allocated a grade (A,B or C; or expert opinion (EO)), which depends on the level of evidence (clinical practice guidelines).

PREOPERATIVE PATIENTS' INFORMATION

Each patient must be informed concerning the risks associated with POP surgery (EO).

HEMORRHAGE, HEMATOMA

Vaginal infiltration using a vasoconstrictive solution is not recommended during POP surgery by the vaginal route (grade C). The placement of vaginal packing is not recommended following POP surgery by the vaginal route (grade C). During laparoscopic sacral colpopexy, when the promontory seems highly dangerous or when severe adhesions prevent access to the anterior vertebral ligament, alternative surgical techniques should be discussed per operatively, including colpopexy by lateral mesh laparoscopic suspension, uterosacral ligament suspension, open abdominal mesh surgery, or surgery by the vaginal route (EO).

BLADDER INJURY

When a bladder injury is diagnosed, bladder repair by suturing is recommended, using a slow resorption suture thread, plus monitoring of the permeability of the ureters (before and after bladder repair) when the injury is located at the level of the trigone (EO). When a bladder injury is diagnosed, after bladder repair, a prosthetic mesh (polypropylene or polyester material) can be placed between the repaired bladder and the vagina, if the quality of the suturing is good. The recommended duration of bladder catheterization following bladder repair in this context of POP mesh surgery is from 5 to 10 days (EO).

URETER INJURY

After ureteral repair, it is possible to continue sacral colpopexy and place the mesh if it is located away from the ureteral repair (EO).

RECTAL INJURY

Regardless of the approach, when a rectal injury occurs, a posterior mesh should not be placed between the rectum and the vagina wall (EO). Concerning the anterior mesh, it is recommended to use a macroporous monofilament polypropylene mesh (EO). A polyester mesh is not recommended in this situation (EO).

VAGINAL WALL INJURY

After vaginal wall repair, an anterior or a posterior microporous polypropylene mesh can be placed, if the quality of the repair is found to be satisfactory (EO). A polyester mesh should not be used after vaginal wall repair (EO).

MESH INFECTION (ABSCESS, CELLULITIS, SPONDYLODISCITIS)

Regardless of the surgical approach, intravenous antibiotic prophylaxis is recommended (aminopenicillin + beta-lactamase inhibitor: 30 min before skin incision +/- repeated after 2 h if surgery lasts longer) (EO). When spondylodiscitis is diagnosed following sacral colpopexy, treatment should be discussed by a multidisciplinary group, including especially spine specialists (rheumatologists, orthopedists, neurosurgeons) and infectious disease specialists (EO). When a pelvic abscess occurs following synthetic mesh sacral colpopexy, it is recommended to carry out complete mesh removal as soon as possible, combined with collection of intraoperative bacteriological samples, drainage of the collection and targeted antibiotic therapy (EO). Non-surgical conservative management with antibiotic therapy may be an option (EO) in certain conditions (absence of signs of sepsis, macroporous monofilament polypropylene type 1 mesh, prior microbiological documentation and multidisciplinary consultation for the choice of type and duration of antibiotic therapy), associated with close monitoring of the patient.

BOWEL OCCLUSION RELATED TO NON-CLOSURE OF THE PERITONEUM

Peritoneal closure is recommended after placement of a synthetic mesh by the abdominal approach (EO).

URINARY RETENTION

Preoperative urodynamics is recommended in women presenting with urinary symptoms (bladder outlet obstruction symptoms, overactive bladder syndrome or incontinence) (EO). It is recommended to remove the bladder catheter at the end of the procedure or within 48 h after POP surgery (grade B). Bladder emptying and post-void residual should be checked following POP surgery, before discharge (EO). When postoperative urine retention occurs after POP surgery, it is recommended to carry out indwelling catheterization and to prefer intermittent self-catheterization (EO).

POSTOPERATIVE PAIN

Before POP surgery, the patient should be asked about risk factors for prolonged and chronic postoperative pain (pain sensitization, allodynia, chronic pelvic or non-pelvic pain) (EO). Concerning the prevention of postoperative pain, it is recommended to carry out a pre-, per- and postoperative multimodal pain treatment (grade B). The use of ketamine intraoperatively is recommended for the prevention of chronic postoperative pelvic pain, especially for patients with risk factors (preoperative painful sensitization, allodynia, chronic pelvic or non-pelvic pain) (EO). Postoperative prescription of opioids should be limited in quantity and duration (grade C). When acute neuropathic pain (sciatalgia or pudendal neuralgia) resistant to level I and II analgesics occurs following sacrospinous fixation, a reintervention is recommended for suspension suture removal (EO). When chronic postoperative pain occurs after POP surgery, it is recommended to systematically seek arguments in favor of neuropathic pain with the DN4 questionnaire (EO). When chronic postoperative pelvic pain occurs after POP surgery, central sensitization should be identified since it requires a consultation in a chronic pain department (EO). Concerning myofascial pain syndrome (clinical pain condition associated with increased muscle tension caused by myofascial trigger points), when chronic postoperative pain occurs after POP surgery, it is recommended to examine the levator ani, piriformis and obturator internus muscles, so as to identify trigger points on the pathway of the synthetic mesh (EO). Pelvic floor muscle training with muscle relaxation is recommended when myofascial pain syndrome is associated with chronic postoperative pain following POP surgery (EO). After failure of pelvic floor muscle training (3 months), it is recommended to discuss surgical removal of the synthetic mesh, during a multidisciplinary discussion group meeting (EO). Partial removal of synthetic mesh is indicated when a trigger point is located on the pathway of the mesh (EO). Total removal of synthetic mesh should be discussed during a multidisciplinary discussion group meeting when diffuse (no trigger point) chronic postoperative pain occurs following POP surgery, with or without central sensitization or neuropathic pain syndromes (EO).

POSTOPERATIVE DYSPAREUNIA

When de novo postoperative dyspareunia occurs after POP surgery, surgical removal of the mesh should be discussed (EO).

VAGINAL MESH EXPOSURE

To reduce the risk of vaginal mesh exposure, when hysterectomy is required during sacral colpopexy, subtotal hysterectomy is recommended (grade C). When asymptomatic vaginal macroporous monofilament polypropylene mesh exposure occurs, systematic imaging is not recommended. When vaginal polyester mesh exposure occurs, pelvic +/- lumbar MRI (EO) should be used to look for an abscess or spondylodiscitis, given the greater risk of infection associated with this type of material. When asymptomatic vaginal mesh exposure of less than 1 cm2 occurs in a woman with no sexual intercourse, the patient should be offered observation (no treatment) or local estrogen therapy (EO). However, if the patient wishes, partial excision of the mesh can be offered. When asymptomatic vaginal mesh exposure of more than 1 cm2 occurs or if the woman has sexual intercourse, or if it is a polyester prosthesis, partial mesh excision, either immediately or after local estrogen therapy, should be offered (EO). When symptomatic vaginal mesh exposure occurs, but without infectious complications, surgical removal of the exposed part of the mesh by the vaginal route is recommended (EO), and not systematic complete excision of the mesh. Following sacral colpopexy, complete removal of the mesh (by laparoscopy or laparotomy) is only required in the presence of an abscess or spondylodiscitis (EO). When vaginal mesh exposure recurs after a first reoperation, the patient should be treated by an experienced team specialized in this type of complication (EO).

SUTURE THREAD VAGINAL EXPOSURE

For women presenting with vaginal exposure to non-absorbable suture thread following POP surgery with mesh reinforcement, the suture thread should be removed by the vaginal route (EO). Removal of the surrounding mesh is only recommended when vaginal mesh exposure or associated abscess is diagnosed.

BLADDER AND URETERAL MESH EXPOSURE

When bladder mesh exposure occurs, removal of the exposed part of the mesh is recommended (grade B). Both alternatives (total or partial mesh removal) should be discussed with the patient and should be debated during a multidisciplinary discussion group meeting (EO).

Spondylodiscitis After Surgery for Pelvic Organ Prolapse: Description of a Rare Complication and Systematic Review of the Literature

Background: Spondylodiscitis can be a rare complication of gynecological surgery, typically of procedures involving the sacrum and the sacrospinous ligament. This report presents a case of spondylodiscitis arising after a laparoscopic sacrocolpopexy with a mesh. We also review the literature finding 52 cases of spondylodiscitis following sacrocolpopexy and (or) rectopexy with or without a mesh.

Methods: We performed a comprehensive search from the electronic databases MEDLINE (Pubmed), Scopus, Web of Science, Embase, CINAHL, and Google Scholar from 1990 to February 2021 in order to identify case reports or case series reporting on spondylodiscitis after rectopexy or sacrocolpopexy.

Results: We identified 52 total postoperative spondylodiscitis. We examined the mean age of patients, the surgical history, the time from initial surgery to spondylodiscitis, the presenting symptoms, the diagnostic tools, the medical and surgical treatment, the type of mesh used, the surgical access, and the possible causes of spondylodiscitis.

Conclusions: Diagnosis of spondylodiscitis may be challenging. From our review emerges that recurrent pelvic pain and lumbosciatalgia may be signals of lumbar spondylodiscitis. Magnetic resonance is the gold standard examination for spondylodiscitis. Surgical practice needs to be improved further in order to establish the best procedure to minimize the incidence of this complication. Awareness of symptoms, timely diagnosis, and treatment are fundamental to prevent irreversible complications.

Conservative Management of Spondylodiscitis after Laparoscopic Sacral Colpopexy: A Case Report and Review of Literature

Sacral colpopexy is one of the standard procedures to treat apical pelvic organ prolapse. In most cases, a synthetic mesh is used to facilitate the colposuspension. Spondylodiscitis is a rare but potentially serious complication that must be promptly diagnosed and treated, despite the lack of consensus in the management of this complication. We report one case of spondylodiscitis after a laparoscopic supracervical hysterectomy and sacral colpopexy treated conservatively. We also present a literature review regarding this rare complication. A conservative approach without mesh removal may be possible in selected patients (stable, with no vaginal lesions, mesh exposure or severe neurologic compromise). Hemocultures and culture of image-guided biopsies should be performed to direct antibiotic therapy. Conservative versus surgical treatment should be regularly weighted depending on clinical and analytical progression. A multidisciplinary team is of paramount importance in the follow-up of these patients.

The Emerging Role on the Use of Platelet-Rich Plasma Products in the Management of Urogynaecological Disorders

Background: The regenerative efficacy of platelet-derived products has been recently investigated in the treatment of pelvic floor disorders (PFDs). We aimed to synthesize the current evidence of platelet-rich plasma (PRP) products used in urogynaecological disorders including vaginal atrophy, pelvic organ prolapse (POP), urinary incontinence, vaginal fistulas and vaginal mesh exposure. Methods: A meticulous search of the currently available literature on the use of PRP for the management of PFDs was performed using 3 electronic databases. Results: PRP could be a feasible alternative modality for the management of vaginal atrophy with favourable outcomes in vaginal atrophy parameters and patients' satisfaction, especially when hormone therapy is contraindicated. In patients with POP, an increase in collagen concentration after PRP application was observed while the use of PRP resulted in improvement of stress urinary incontinence symptoms. A considerable proportion of vesicovaginal fistulas were treated after application of PRP-based injections. Conclusions: There is only limited evidence of the use of PRP for PFDs. Platelet-rich plasma appears to be a promising, easy to apply, cost-effective and feasible alternative therapeutic modality for the management of various urogynaecological disorders. Future randomized trials are needed to confirm the efficacy of PRP in the treatment of urogynaecological disorders.

Management of lumbar spondylodiscitis developing after laparoscopic sacrohysteropexy with a mesh: A case report and review of the literature

INTRODUCTION

Lumbar spondylodiscitis is a rare and severe complication of laparoscopic sacrohysteropexy with a polypropylene mesh. However, a case of lumbar spondylodiscitis following laparoscopic sacrohysteropexy has not been reported so far. We present a case of lumbar spondylodiscitis following laparoscopic sacrohysteropexy with a mesh. We also discuss 33 cases of lumbar spondylodiscitis following sacral colpopexy and (or) rectopexy with a mesh.

PATIENT CONCERNS

A 46-year-old woman with 3 previous vaginal deliveries underwent laparoscopic mesh sacrohysteropexy for stage III uterine prolapse. One month after surgery, the patient developed persistent symptoms, such as stiffness of the lumbosacral portion, low back pain (LBP), persistent swelling, pain between the right iliac crest and the buttock, inability to bend down, and pain in the right lower limb. Symptoms were alleviated by a nonsteroidal anti-inflammatory drug. However, in the last 7 days, symptoms worsened and she was unable to stand or walk. The patient had very limited leg mobility.

DIAGNOSIS

Blood routine examination, erythrocyte sedimentation rate, C-reactive protein, and magnetic resonance imaging (MRI) of the lumbar spine indicated lumbar pyogenic spondylodiscitis.

INTERVENTIONS

Removal of mesh and hysterectomy via laparoscopy were performed immediately, and antibiotics were given simultaneously. However, on the basis of MRI findings and persistent symptoms, debridement, laminectomy, spinal canal decompression, bone grafting, and internal fixation via pedicle screw placement were performed 5 months after laparoscopic sacrohysteropexy.

OUTCOMES

All symptoms were alleviated 5 days after the operation. The patient could stand in the erect position and raise her lower limbs within 2 weeks. She could resume her normal activities within 2 months after the operation, and her X-ray appeared normal.

CONCLUSION

Persistent LBP and radiating pain may be the signals of lumbar spondylodiscitis. MRI is the gold standard diagnostic examination for lumbar spondylodiscitis. Awareness of symptoms, such as LBP and radiating pain symptoms, timely diagnosis, mesh removal, and referral to orthopedists are important to prevent more severe complications. Surgical practice needs to be improved further and any other infections should be treated immediately as the most likely causes of lumbar spondylodiscitis are related to the mesh and other infections.

Pyogenic spondylodiscitis associated with sacral colpopexy and rectopexy: report of two cases and evaluation of the literature

Pyogenic spondylodiscitis includes a spectrum of spinal infections such as discitis, osteomyelitis, epidural abscess, meningitis, subdural empyema, and spinal cord abscess. This is a rare complication of sacral colpopexy, but can lead to devastating consequences for the patient. We present two cases of pyogenic spondylodiscitis following sacral colpopexy. In addition, we discuss 26 cases of pyogenic spondylodiscitis reported in the literature from 1957 to 2012. Techniques to decrease rates of infection include proper identification of the S1 vertebra, awareness of the suture placement depth at the level of the sacrum and at the vagina, and early treatment of post-operative urinary tract and vaginal infections. Awareness of symptoms, timely diagnosis and multidisciplinary approach to management is essential in preventing long-term complications.