Pain Resolution and Recurrent Prolapse Rates Following Vaginal Mesh Removal

Medium-Term Outcomes of Total Autologous Fascia Lata Anterior and Apical Pelvic Organ Prolapse Repair

PURPOSE

The recognition of synthetic vaginal mesh as a high-risk device in pelvic organ prolapse (POP) repair has led to a resurgence in the utilization of autologous graft and emphasizes the need for long-term studies into the use of autologous materials. In a 33-patient cohort, we highlighted our earliest results of a transvaginal repair for apical and anterior prolapse using a graft harvest of autologous fascia lata. In an updated cohort of 63 patients with up to 5 years of follow-up, we report our current findings.

METHODS

The Autologous Anterior and Apical Pelvic Organ Prolapse (AAA-POP) repair begins with a solitary, lateral 7-10 cm thigh incision, through which, a 4 × 14 cm segment of fascia lata is harvested. Transvaginal reconfiguration of the graft results in apical fixation to the sacrospinous ligaments and distal fixation to the obturator fascia. Concurrent procedures, including autologous pubovaginal sling, were performed as indicated. Several patient parameters were monitored including medical history, Visual Analog Pain (VAP) Score, SEAPI scores, POP-Q scores, and Baden-Walker grading. We defined a successful repair as absent symptomatic apical or anterior POP.

RESULTS

A total of 63 patients with an average age of 64 years underwent AAA-POP repair. Mean follow-up was 17 months (range 1-65); 18 patients had 24 months or more of follow-up. Complete POP symptom resolution was reported in 49 (78%) patients. In total, 11 patients (17%) experienced treatment failure; 5 of this subgroup (45%) underwent a uterine sparing procedure. Urinary retention postoperatively occurred in 20 patients and pubovaginal sling was concurrently performed in 18 of the patients in this subgroup (90%). Minor harvest site issues occurred and were managed expectantly. Nonbothersome thigh bulges occurred in 15 patients. Nine patients experienced a seroma at the harvest site, and five underwent aspiration. Mild paresthesia was reported by 37 patients. Mean VAP score of the fascia lata harvest site was 0.37.

CONCLUSION

The AAA-POP repair medium-term follow-up results reaffirm the procedure's efficacy as a transvaginal and nonmesh repair of POP. Patients should be advised of several precautions including the higher frequency of treatment failure with the uterine sparing approach, potential for urinary retention if pubovaginal sling placement is performed concurrently, and morbidities associated with the harvest site. Our results continue to uphold the AAA-POP repair and its role as a treatment option for patients desiring a nonmesh approach to POP repair.

Prediction of successful revision surgery for mesh-related complaints after inguinal hernia and pelvic organ prolapse repair

PURPOSE

With this retrospective case series, we aim to identify predictors for reduction of pain after mesh revision surgery in patients operated for inguinal hernia or pelvic organ prolapse with a polypropylene implant. Identifying these predictors may aid surgeons to counsel patients and select appropriate candidates for mesh revision surgery.

METHODS

Clinical records before and after mesh revision surgery from 221 patients with chronic postoperative inguinal pain (CPIP) and 59 patients with pain after pelvic organ prolapse (POP) surgery were collected at two experienced tertiary referral centers. Primary outcome was patient reported improvement of pain after revision surgery. A multivariable logistic regression model was used to specify predictors for pain reduction.

RESULTS

The multivariable logistic regression was performed for each patient group separately. Patients with CPIP had higher chances of improvement of pain when time between mesh placement and mesh revision surgery was longer, with an OR of 1.19 per year. A turning point in chances of risks and benefits was demonstrated at 70 months, with improved outcomes for patients with revision surgery ≥ 70 months (OR 2.86). For POP patients, no statistically significant predictors for reduction of pain after (partial) removal surgery could be identified.

CONCLUSION

A longer duration of at least 70 months between implantation of inguinal mesh and revision surgery seems to give a higher chance on improvement of pain. Caregivers should not avoid surgery based on a longer duration of symptoms when an association between symptoms and the location of the mesh is found.

How is pain associated with pelvic mesh implants measured? Refinement of the construct and a scoping review of current assessment tools

BACKGROUND

Recommendations for the management of pain related to pelvic mesh implants are still under development. One limitation that has impeded progress in this area is that mesh-related pain has not been consistently defined or measured. Here, we reviewed the ways in which pain associated with pelvic mesh implants has been measured, and mapped the ways in which these existing measures capture the construct.

METHODS

First, we reviewed existing accounts of the pain associated with pelvic mesh implants to develop a multifaceted construct definition, which includes aspects related to pain intensity, timing, body location, phenomenological qualities, impact/interference with daily living, and patient expectations and beliefs. Next, we reviewed the ways that the construct has been measured in the extant literature.

RESULTS

Within 333 eligible studies, 28 different assessments of pain associated with pelvic mesh were identified, and 61% of studies reported using more than one measurement tool. Questionnaire measures included measures designed to assess urological and/or pelvic symptoms, generic measures and unvalidated measures. We did not identify any validated questionnaire measures designed to assess pain associated with pelvic mesh implants. The phenomenological, location, and expectation/belief components of the construct were not captured well by the identified questionnaire measures, and there is no evidence that any of the identified measures have appropriate psychometric properties for the assessment of pain related to pelvic mesh implants.

CONCLUSIONS

We recommend further qualitative research regarding women's experiences of pelvic mesh-related pain assessment, and the development of a condition-specific patient reported outcome measure.

Long-Term Outcomes and Complications of Trans-Vaginal Mesh Removal: a 14-year Experience

OBJECTIVE

To assess the long-term patient outcomes, including the resolution of symptoms and need for subsequent procedures, after vaginal mesh removals (VMR) we evaluate our 14-year experience with VMR from a tertiary center with three FPMRS-trained surgeons. Although the use of transvaginal mesh (TVM) had decreased significantly before its ban in 2019, surgeons are still treating TVM complications and performing vaginal or open/robotic VMR for mesh-related complications.

METHODS

A retrospective review of women undergoing VMR with 6 months minimum follow-up was undertaken. The data abstracted included demographics, provider notes, operative reports, pathology findings, outside medical records, peri-operative information, and reoperations.

RESULTS

From 2006 to 2020, 133 patients were identified, and 113 patients met study criteria with at least 6 months follow-up. The most common presenting symptoms were dyspareunia (77%) and pain (71%). The majority of VMR were performed vaginally (84.5%). Vaginal mesh was removed from anterior (60%), posterior (11%), and anterior and posterior (10%) compartments. Two ureteral injuries and one rectal injury were repaired intraoperatively. VMR resulted in resolution of pain in 50% of patients. Some patients had persistent pain (21%) and a few developed de novo pain (4%). More than half of the patients had dyspareunia resolution (52%), but 12% had persistent dyspareunia and 2% developed de novo dyspareunia.

CONCLUSIONS

VMR complexity requires advanced surgical expertise. Most patients undergoing VMR had resolution of their presenting symptoms. However, outcomes for pain, sexual function, continence, and/or prolapse can be unpredictable, resulting in multiple surgeries.

Early Experience of Transabdominal and Novel Transvaginal Robot-Assisted Laparoscopic Removal of Transvaginal Mesh

Background: Mesh removal after 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 at determining the feasibility and safety of using robot-assisted laparoscopic surgery in the removal of pelvic mesh via the transabdominal and novel transvaginal 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 with pelvic mesh and a clinical indication for mesh removal if they were older than the age of 18. 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 preoperatively. 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 demonstrates the feasibility of removal of both retropubic and transobturator mid-urethral synthetic sling as well as transvaginal 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.