Management of vaginal mesh exposure: A systematic review

Midurethral Sling Mesh Exposure Confers a High Risk of Persistent Stress Urinary Incontinence

INTRODUCTION AND HYPOTHESIS

The objective was to investigate the relationship between mesh exposure and persistent stress urinary incontinence (SUI) post-midurethral sling (MUS) surgery.

METHODS

Extensive data collection including patient demographics, obstetric history, existing medical conditions, previous surgeries, and surgical outcomes, encompassing both perioperative and postoperative complications.

RESULTS

Out of 456 patients who underwent the MUS procedure within the specified period, the persistence of SUI was noted in 6.4% of cases. Mesh exposure was observed in 8.8% of these cases. Notably, 25% of patients with mesh exposure suffered from persistent SUI, in stark contrast to 4.6% of those without mesh exposure (p < 0.0001). Further, multivariate analysis indicated that patients with mesh exposure had an approximately 6.5-fold increased likelihood (95% CI: 2.71-15.44) of experiencing persistent SUI compared with those without mesh exposure.

CONCLUSIONS

Mesh exposure is a significant independent risk factor for persistent SUI post-MUS surgery. Patients with mesh exposure are about 6.5 times more prone to persistent SUI than those without. Although mesh exposure is typically managed with expectant measures, vaginal estrogen or mesh excision, current evidence does not support surgical revision of MUS affected by mesh exposure or additional incontinence procedures during mesh excision.

Quality of life outcomes after transobturator tape full removal surgeries: A monocentric experience

Objective

The objective of this study is to describe a standardised technique of full TOT removal with groin dissection and to report clinical improvement, satisfaction, safety and long-term functional, quality of life (QoL) and sexual QoL outcomes.

Materials and methods

A retrospective review enrolling all women who had full TOT removal, in a tertiary referral centre from May 2017 to November 2020. Functional outcomes, satisfaction and QoL were assessed using a bespoke composite questionnaire (UDI-6, EQ-5D-5L and ICIQ-S) with additional questions on sexual QoL. Secondary outcomes were post-operative recurrent stress urinary incontinence (SUI) and complication rate according to the Clavien-Dindo classification.

Results

Full TOT removal using a vaginal approach and bilateral groin/para-labial incisions was performed in 67 patients. Chronic pelvic pain was the main indication for mesh removal (51% of cases, n = 34). QoL questionnaires were answered by 43 patients. The satisfaction rate was high 86% (n = 37), and 81% (n = 35) of the patients considered the surgery successful. Seventy per cent (n = 30) of patients returned to having a sexual life after surgery. Recurrent SUI was reported in 32% (n = 14) of cases. The complication rate was 10% (7/67), all of them Clavien-Dindo ≤2.

Conclusion

Despite a high rate of postoperative bothersome SUI, full TOT removal with bilateral groin dissection improves pain and QoL. It is associated with a high overall satisfaction rate and an acceptable rate of complications.

Risk factors for stress urinary incontinence recurrence after midurethral sling revision

OBJECTIVES

The purpose of this study was to report the rate of stress urinary incontinence (SUI) recurrence after sling revision, and to determine predictive factors of SUI recurrence.

METHODS

We conducted a retrospective cohort study in a single academic center between 2005 and 2022, of patients who underwent sling revision. Four surgical techniques were used for sling revision (loosening, section, partial, and total excision). The primary endpoint was recurrence of SUI at 3 months postoperatively, and the other outcome of interest was the rate of subsequent anti-incontinence surgical procedure.

RESULTS

Sixty-nine patients were included for analysis. SUI recurred in 46.4% of patients. Fifteen patients underwent a subsequent anti-incontinence procedure (21.8%). The time to revision was significantly longer in the group with recurrent SUI (median: 84.5 vs. 44.8 months; p = 0.004). The recurrence rate differed significantly depending on the revision technique: 7.7% after sling loosening, 22.2% after sling section, 60% after partial excision, and 66.7% after complete sling removal (p = 0.001). The risk of SUI recurrence was lower for those whose indication of reoperation was voiding dysfunction (27.3% vs. 66.7%; p = 0.002), and was higher for those who underwent a trans-obturator tap rather than a tension-free vaginal tape revision (68.4% vs. 35.7%; p = 0.02). In multivariate analysis, only the revision technique remained significantly associated with the risk of recurrence of SUI (complete excision vs. section: odds ratio = 4.66; p = 0.04).

CONCLUSION

The risk of SUI recurrence may differ widely according to the techniques used, and it seems that the less extensive the surgical procedure is, the lower the risk is.

Clinical outcomes after total excision of transobturator tape inserted for treatment of stress urinary incontinence

INTRODUCTION

Midurethral tapes (MUTs) were the most common surgical treatment for stress urinary incontinence (SUI) between 2008 and 2017. Transobturator tapes were introduced as a novel way to insert MUTs. Some women have experienced life-changing complications, and opt to undergo a total excision of transobturator tape (TETOT). There is a paucity in evidence about the outcomes of TETOT, which is a complex operation. This study aims to report clinical outcomes of all women who underwent TETOT in a specialist mesh center.

METHODS

All women between 2017 and 2022 who underwent TETOT in one mesh center were reviewed. Background demographics and preoperative symptoms were recorded retrospectively. Outcome data were collected using patient global impression of improvement (PGI-I) scales via telephone review and analyzed using SPSS 25.

RESULTS

Forty-five women underwent telephone review in May 2022, on average 27.9 months (range: 3-60) after TETOT. Mean age was 55 and body mass index (BMI): 30; 82% were postmenopausal, 20% were smokers, and 73.3% had recurrent SUI before excision. Indications for excision were infection (4%), vaginal exposure (24%), urethral perforation (9%), and chronic pain not associated with other complications (60%). Two women with recurrent SUI opted for a concomitant fascial sling; both reported a PGI of "very much improved" regarding SUI postoperatively. Only 12 women (26.5%) did not have SUI before excision; of these 9 (75%) reported new SUI postoperatively. Pain improved for 57.8%, but worsened for 24.4%. Although not statistically significant (p = 0.055), more women who underwent TETOT for pain alone reported worsening pain than those with pain with an additional complication (37% vs. 5.55%). Overall, 62.2% women felt "better" after their excision, 17.8% felt "worse."

DISCUSSION

After TETOT, 62% of women felt better. Improvement in pain was reported by 58%-those with chronic pain without another complication reported improvement in pain less frequently (48% vs. 72%) and worsening pain more frequently (37% vs. 6%). Existing SUI worsened in 65% of women and 75% developed new SUI. There appears to be discordance between reporting global improvement with worsening of commonly measured clinical outcomes.

CONCLUSION

Outcome data are important for counseling women about the risks and benefits of TETOT. Women and clinicians may have different attitudes to the possible benefits of TETOT, as evidenced by women reporting feeling better despite continuing pain or SUI. Conventional outcome measures do not adequately capture all outcomes that are important to patients.

FIGO recommendations: Use of midurethral slings for the treatment of stress urinary incontinence

BACKGROUND

Stress urinary incontinence (SUI) is a global problem. It can significantly adversely impact a woman's quality of life. The use of synthetic mesh in vaginal surgery is controversial, especially when used for pelvic organ prolapse surgery. Although negative effects have been reported, the synthetic mesh midurethral sling (MUS) is considered to be safe and effective in the surgical treatment of SUI.

OBJECTIVES

To provide evidence-based data and recommendations for the obstetrician/gynecologist who treats women with SUI and performs or plans to perform MUS procedures.

METHODS

Academic searches of MEDLINE, the Cochrane Library, Embase, and Google Scholar articles published between 1987 and March 2020 were performed by a subgroup of the Urogynecology and Pelvic Floor Committee, International Federation of Gynecology and Obstetrics (FIGO).

SELECTION CRITERIA

The obtained scientific data were associated with a level of evidence according to the Oxford University Centre for Evidence-Based Medicine and GRADE Working Group system. In the absence of concrete scientific evidence, the recommendations were made via professional consensus.

RESULTS

The FIGO Urogynecology and Pelvic Floor Committee reviewed the literature and prepared this evidence-based recommendations document for the use of MUS for women with SUI.

CONCLUSIONS

Despite the extensive literature, there is a lack of consensus in the optimal surgical treatment of SUI. These recommendations provide a direction for surgeons to make appropriate decisions regarding management of SUI. The MUS is considered safe and effective in the treatment of SUI, based on many high-quality scientific publications and professional society recommendations. Comprehensive long-term data and systemic reviews are still needed, and these data will become increasingly important as women live longer. These recommendations will be continuously updated through future literature reviews.

[A CASE OF VAGINAL MESH EXPOSURE DIAGNOSED 15 YEARS AFTER TVT SURGERY FOR STRESS URINARY INCONTINENCE]

Midurethral sling procedures are regarded as standard therapies to treat female stress urinary incontinence. However, informed consent must be gained from the patients concerning the possibility of mesh complications. Furthermore, understanding of these complications is required by medical practitioners in general. A 59-year-old postmenopausal woman had undergone TVT surgery to treat stress urinary incontinence in our department 15 years ago. Due to genital bleeding which started 10 years later, she visited a gynecologist in another hospital and was referred to us due to vaginal erosion. During the pelvic examination, a cord-like structure was palpable on the right side of the anterior vaginal wall. Upon inspection of the vagina using a cystoscope, the foreign body attached to the anterior vaginal wall was clearly visible. After the diagnosis of vaginal mesh exposure, she underwent a transvaginal partial resection of the TVT tape. She had no recurrence of mesh exposure or stress urinary incontinence in a 6-month follow-up. Although infrequently reported in Japanese literature, medical practitioners must be cautious of mesh exposure that can occur long after midurethral sling procedures.

Perianal abscess as a manifestation of vaginocutaneous fistula after pelvic floor reconstruction

We present a case of vaginocutaneous fistula 10 years after pelvic floor reconstruction using transvaginal mesh implantation. The female patient in her mid-60s presented with typical symptoms of perianal abscess. After undergoing three surgical operations, the perianal infection was shown to be due to the implanted mesh as a late complication of the reconstruction. The patient was successfully managed with limited removal of the mesh tails. The case highlights one of the late complications of pelvic floor reconstruction using synthetic meshes.

Recurrent surgery in uterine prolapse: A nationwide register study

INTRODUCTION

One in three women with pelvic organ prolapse (POP) undergoing surgery have a relapse. Currently, no optimal surgical treatment has been identified for correcting a uterine prolapse. This population-based register study aims to compare the relapse rate in patients with uterine prolapse undergoing hysterectomy with suspension or uterine-sparing surgical procedures.

MATERIAL AND METHODS

All women with uterine prolapse undergoing prolapse surgery in Sweden from January 1, 2015 to December 31, 2018, were identified from the Gynecological Operation Register (GynOp). The primary outcome was the number of recurrent POP surgeries up to December 31, 2020.

RESULTS

Sacrospinous hysteropexy (SSHP) without graft and sacrohysteropexy (SHP) were associated with a significantly higher rate of recurrent POP surgery (SSHP without graft: adjusted odds ratio [aOR] 2.6, 95% CI 2.0-3.5; SHP aOR 2.6, 95% CI 1.8-3.7) and patients describing a sense of globe (SSHP without graft, aOR 2.0, 95% CI 1.6-2.6; SHP, aOR 1.8, 95% CI 1.1-3.1) compared with cervical amputation with uterosacral ligament fixation (Manchester procedure). There was no difference in the reoperation rate or sense of a globe between SSHP with graft and Manchester procedure. Patients undergoing SSHP without graft had a higher frequency of 1-year postoperative complications compared with Manchester procedure (aOR 2.0, 95% CI 1.6-2.6) and SHP (aOR 2.4, 95% CI 1.4-3.9). Moreover, the frequency of 1-year postoperative complications was higher in SSHP with graft (aOR 1.6, 95% CI 1.1-2.2) than in Manchester procedure.

CONCLUSIONS

The Manchester procedure was associated with a low rate of recurrent POP surgery, symptomatic recurrence and low surgical morbidity compared with other surgical methods in women with uterine prolapse.

Comparison of Two Single-Incision Mini-Slings for the Treatment of Incontinence

INTRODUCTION

This study aimed to compare the safety and efficacy of 2 single-incision mini-sling (SIMS) systems with different designs of anchoring mechanism.

METHODS

The records of patients who have been operated for the treatment of female stress urinary incontinence (SUI) with 2 different SIMS systems were retrospectively evaluated. Patient characteristics, physical examination results, and quality of life (QoL) questionnaires were used to evaluate the patients. Primary efficacy endpoints were the cure and failure rates. Secondary efficacy endpoints were complications and differences in QoL questionnaires.

RESULTS

Eighty-three patients from group 1 (Ophira SIMS system) and 77 patients from group 2 (Gallini SIMS system) were evaluated. There was no significant difference between the 2 groups regarding patient characteristics. The objective cure rates were found to be 83.1 and 79.2% in group 1 and group 2, respectively (p = 0.09). Mesh-related complications, such as anchor displacement, bladder erosion, vaginal erosion, and groin pain, were more common in group 1. No severe complications were observed. For both groups, a significant improvement in all scores of QoL questionnaires was observed after surgery; however, the differences between 2 groups were not significant.

CONCLUSIONS

The present study showed that the treatment of female SUI with 2 different SIMS systems had similar efficacy, complication rates, and scores in QoL questionnaires.

Mesh complications: best practice in diagnosis and treatment

Mesh was a promising, minimally invasive, and 'gold standard' treatment for urinary stress incontinence. Time has shown that complications from these devices can happen early, or even several years, after mesh placement and can be catastrophic. Pain, erosion, voiding dysfunction, infection, recurrent UTIs [urinary tract infections (UTIs)], fistulae, organ perforation, bleeding, vaginal scarring, neuromuscular alterations, LUTS (lower urinary tract symptoms), bowel complications and even immune disorders have been linked to mesh. Various tools, such as imaging, endoscopic and functional studies, are available for diagnosis of mesh complications. Since the spectrum of complications is wide, involvement of other specialties is usually beneficial in the diagnosis and management of these complications. There is still much to learn on the accuracy and utility of diagnostic studies in each type of complication. Evidence on the best diagnostic and treatment pathways for these complications is scarce but continuously growing as information is being reported, and we continue to gain expertise in dealing with patients affected by mesh. Treatment options include conservative and medical management initially and then open or minimally invasive surgical procedure approaches. This article will describe diagnostic and treatment pathways for mesh complications.

Historic transvaginal meshes and procedures: what did my patient have done?

PURPOSE OF REVIEW

Transvaginal mesh kits were widely used to treat pelvic organ prolapse for over a 10-year period in the early 2000s. Due to safety concerns and FDA regulations, these mesh kits are no longer available for use. Thus, current Obstetricians and Gynecologists are likely to encounter these meshes, but may have no previous experience or exposure to the devices making it difficult to adequately monitor, counsel, and care for patients that underwent these types of procedures. This review highlights the most commonly used transvaginal mesh kit types, provides insight into signs and symptoms related to transvaginal mesh complications, and provides guidance for management of mesh complications.

RECENT FINDINGS

Not all transvaginal mesh will give rise to a complication. If complications do occur, treatment options range from conservative observation to total mesh excision. Management must be customized to an individual patient's needs and goals.

SUMMARY

Transvaginal mesh kits promised increased durability of surgical repair for pelvic organ prolapse. Safety concerns over time caused these kits to no longer be available for use. Practicing Obstetricians and Gynecologists should be aware of the history of transvaginal mesh and the signs and symptoms of mesh complications.