Transvaginal Excision of Mesh Erosion Involving the Bladder After Mesh Placement Using a Prolapse Kit: A Novel Technique

Endoscopic management of transvaginal mesh kit bladder extrusion: A case report and literature review

Objective:

A rare complication of transvaginal synthetic mesh kits is bladder mesh extrusion. Treatment options include abdominal or vaginal surgical mesh excision or endoscopic mesh vaporization. There are very few published studies detailing endoscopic management. This unique case describes how repeated endoscopic mesh vaporization may be required as mesh extrusion may progress.

Methods:

A 71-year old female with a history of pelvic organ prolapse managed with an anterior transvaginal mesh kit presented years later with persistent urgency incontinence and recurrent acute cystitis. Cystoscopy eventually revealed bladder calculi adherent to extruded mesh. The stones and extruded mesh were vaporized using the Holmium laser on three occasions over 3 years.

Results:

Our approach offered a minimally invasive technique with short recovery, no use of a catheter post-operatively and maintained original prolapse repair; however, these patients may be at risk of mesh extrusion recurrence.

Conclusion:

Bladder extrusion of transvaginal pelvic organ prolapse kit mesh is thankfully a rare complication. With no current consensus for treatment of bladder mesh extrusion, the decision to perform complete mesh excision versus endoscopic treatment should be based on the degree and location of the extrusion, the risk of major complications, mesh extrusion recurrence and the patient’s desired outcomes, including recovery time and risk for prolapse recurrence. Endoscopic vaporization of extruded pelvic organ prolapse mesh likely has a higher recurrence rate than vaginal or abdominal excision. The risks and benefits are important to discuss during counseling and informed consent in these difficult cases.

Level of evidence:

4

Do we have adequate data to construct a valid algorithm for management of synthetic midurethral sling complications? ICI-RS 2019

BACKGROUND

Synthetic midurethral sling (MUS) procedures, purported for the last two decades as the gold standard surgical treatment for stress urinary incontinence, have been in creasingly scrutinized in recent years with regard to the rate and severity of complications.

METHODS

During the International Consultation on Incontinence Research Society meeting held in Bristol, UK, in 2019, a multidisciplinary panel held a think tank and discussed the contemporary evidence pertaining to the classification, investigation, and treatment of MUS complications.

RESULTS

The current classification system of mesh-related complications was discussed, and shortcomings were identified. The lack of a standardized clinical pathway was noted, and the value of clinical investigations and surgical treatments was difficult to fully evaluate. The paucity of high-level evidence was a common factor in all discussions, and the difficulties with setting up relevant randomized-controlled trials were highlighted.

CONCLUSIONS

The outcome of the think-tank discussions is summarized with a set of recommendations designed to stimulate future research.

Endoscopic removal of intravesical polypropylene suture with plasmakinetic resection after abdominal hysterectomy

•

Insertion of polypropylene suture through the base of the bladder after abdominal hysterectomy was not reported yet.

•

Since the suture passed both through the base and dome of the bladder, the capacity was restricted and patient suffered from frequency and urgency.

•

Use of plasmakinetic energy for removal of intravesical suture was not also reported previously.

•

With the aid of plasmakinetic energy loop, bladder mucosa between suture entrance and exit sides was resected in both sides.

INTRODUCTION

Intravesical foreign substances such as mesh or suture are among the rare reasons of recurrent urinary tract infections. Anti-incontinence and prolapsus procedures are associated with mesh/suture extrusion into the bladder, however, this complication is uncommon with abdominal hysterectomy.

PRESENTATION OF CASE

A 61-year-old female, obese patient admitted to our clinic with recurrent urinary tract infections and voiding symptoms which were worsened after abdominal hysterectomy. Radiological evaluation revealed an intravesical foreign material within the bladder. The cytoscopy was performed and a polypropylene suture which was inserted from dome, passed through the base and exited from the dome of bladder during abdominal hysterectomy. Transurethral plasmakinetic resection of superficial layer of urothelium between suture entrance and exit sites was performed and suture was removed from the bladder.

DISCUSSION

Urogynecological procedures are associated with the increased risk of urethral or ureteral injury, intravesical mesh or suture erosion and fistulae formation. Many different techniques including open, laparoscopic and transvaginal approaches were described for the removal of intravesical mesh/suture extrusion in the literature. Transurethral approach with its minimally invasive and safe nature was used to remove suture in this patient. This technique with the use of plasmakinetic energy has the advantage of decreased risk of bleeding and urothelial injury when compared to monopolar cautery. It also avoids the need for open or extensive surgery which may have a high rate of complications.

CONCLUSION

Transurethral resection is the treatment of choice for the removal of intravesical foreign substances. Use of plasmakinetic energy will decrease the risk of complications and avoid the need for open interventions.

Transvaginal removal of mesh exposure involving the bladder

INTRODUCTION AND HYPOTHESIS

We present three cases of transvaginal removal of mesh exposure involving the bladder, including patient follow-up. Mesh exposure occurred secondary to placement of transvaginal mesh for management of pelvic organ prolapse.

METHODS

A pure transvaginal technique was performed to remove mesh exposure involving the bladder. Patient follow-ups were carefully recorded.

RESULTS

All operative steps were completed transvaginally. The duration of follow-up for the three cases was 6, 11, and 19 months. One patient experienced recurrence of mesh exposure during follow-up. The other two patients were symptom-free after surgery. There were no major postoperative complications and no recurrence of cystocele.

CONCLUSIONS

Transvaginal removal of mesh exposure involving the bladder is feasible. The pure transvaginal approach is applicable to various conditions with good outcomes, yet it cannot guarantee that exposure of residual fibers within the bladder will not recur.

Two-year outcomes after vaginal prolapse reconstruction with mesh pelvic floor repair system

OBJECTIVE

The aim of this study was to assess anatomical and functional outcomes 2 years after prolapse repair using vaginal mesh repair system.

METHODS

Women enrolled in a 12-month observational study of outcomes after transvaginal mesh-augmented prolapse repair were invited to participate in an extended follow-up. Subjects completed questionnaires assessing pelvic symptoms, quality of life, global satisfaction, and a pelvic examination for anatomical support and mesh complications.

RESULTS

Of 118 eligible women, 85 enrolled, 82 provided subjective data at 24 months, and pelvic examination/Pelvic Organ Prolapse Quantification data are available from 79 women. Total, anterior, and posterior Prolift kits were used in 47 (55%), 25 (29%), and 13 (15%), respectively. At baseline, most of the women had stage III prolapse (75%), with the anterior compartment constituting the leading edge in 71% of subjects. At 24 months, Pelvic Organ Prolapse Quantification measures were significantly improved from baseline in all compartments, with 51 (65%) stage 0/I, 25 (31%) stage II, 3 (4%) and stage III (P < 0.001), as were quality of life scores (P < 0.001), with the exception of sexual function. Symptomatic prolapse was reported by 7 (8.5%) women, of which 4 demonstrated prolapse in the nonoperated compartment. Three subjects (4%) reported persistent pelvic pain. The 2-year mesh exposure incidence was at least 13% (11/85). The proportion reporting dyspareunia was 28.9% (13/45) and was unchanged from baseline. The median global satisfaction was 9.3 (range 2.0-10.0).

CONCLUSIONS

Anatomical support, symptom relief, and satisfaction are high 24 months after mesh-augmented vaginal prolapse repair, although mesh exposure and new onset prolapse of the nonoperated compartment are not uncommon.

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.

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.

Transvaginal mesh for prolapse repair: what is all the controversy about?

The use of synthetic mesh for the management of pelvic organ prolapse has been embroiled in a contentious debate over the past decade, with only more partisanship among physicians strictly against its use versus those pelvic surgeons who believe it to be a useful tool in their armamentarium. At the heart of the controversy lies the concern, by its detractors, for complications related to mesh use outweighing the as yet not rigorously tested benefit of augmenting repairs with mesh. This article discusses, in detail, the current literature supporting the use of mesh in the management of pelvic organ prolapse repair. The rising concern for complications, both simple and complex, will be addressed. This review aims to narrow the divide between physicians and to address their discordant beliefs by objectively reporting the most up-to-date data on biologic and synthetic mesh use in pelvic organ prolapse repair.